A Novel Distal Very Long Roux-en Y Gastric Bypass (DVLRYGB) as a Primary Bariatric Procedure—Complication Rates, Weight Loss, and Nutritional/Metabolic Changes in the First 355 Patients

Proximal Roux-en Y gastric bypass (RYGB) representing the most frequently performed bariatric procedure yields a weight loss failure rate of around 20%. In order to reduce failure rates, we established a novel distal RYGB variant characterized by a very long alimentary (Roux) limb and a short common channel. Up to 5years, follow-up data (complication rates, weight loss, nutritional/metabolic changes) of the first 355 patients (mean ± SD preoperative age, 41.4 ± 10.8years; BMI, 48.5 ± 11.5kg/m2) who underwent the novel Distal Very Long Roux-en Y Gastric Bypass (DVLRYGB) were analysed. Overall follow-up rate was 98.9%, mean follow-up time 1.6 ± 1.4years. Limb lengths were as follows: common channel 76 ± 7cm, biliopancreatic limb 79 ± 14cm, and alimentary (Roux) limb 604 ± 99cm. The operation was performed laparoscopically in 95.2% of the cases. Thirty-day mortality was zero; major and minor complication rate was 4.5% and 10.4%, respectively. Average excess weight loss (EWL) was >74% 3, 4, and 5years after the operation and failure rate defined by an EWL < 50% remained < 6%. Annually blood measurements revealed a relatively low incidence rate of severe nutritional deficiencies, but mild anaemia and hypoproteinemia were frequently observed. Laparoscopic revision with a proximalization of the lower anastomosis was required in 4 (1.1%) patients. Data indicate that our DVLRYGB leads to excellent weight loss results. Furthermore, within the setting of a structured multidisciplinary follow-up program, the incidence of severe malnutrition states was relatively lo

C-Reactive Protein 2 Days After Laparoscopic Gastric Bypass Surgery Reliably Indicates Leaks and Moderately Predicts Morbidity

Background: The aim of the present study was to evaluate whether serum C-reactive protein (CRP) is a useful predictor of early post-operative complications, particularly of intestinal leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. Methods: The present study was a retrospective analysis of a prospectively maintained database with 809 patients who underwent LRYGB from 2002 until 2011. For 410 of these patients, at least one CRP measurement within the first seven post-operative days was available. The diagnostic value was determined by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. Results: Forty-nine of 410 patients (12.0%; 95% confidence intervals [95% CI], 9.2-15.5%) developed surgery-related complications. Leaks occurred in 17 patients (4.1%; 95% CI, 2.6-6.5%) at a median of 5days after surgery. CRP levels 2days after surgery showed the highest diagnostic value for post-operative complications (AUC, 0.74; 95% CI, 0.60-0.89). Sensitivity was 0.53 (95% CI, 0.31-0.74) and specificity was 0.91 (95% CI, 0.79-0.96) on day 2 (cutoff level, 229mg/l). The sensitivity for intestinal leaks was 1.00 (95% CI, 0.51-1.00). Conclusion: CRP on post-operative day 2 is a valuable predictor of post-operative complications, in particular intestinal leaks. Radiological imaging studies for intestinal leaks could be restricted to patients with CRP values exceeding 229mg/

Nocturnal Heart Rate and Cardiac Repolarization in Lowlanders With Chronic Obstructive Pulmonary Disease at High Altitude: Data From a Randomized, Placebo-Controlled Trial of Nocturnal Oxygen Therapy

Background: Chronic obstructive pulmonary disease (COPD) is associated with cardiovascular disease. We investigated whether sleeping at altitude increases nocturnal heart rate (HR) and other markers of cardiovascular risk or arrhythmias in lowlanders with COPD and whether this can be prevented by nocturnal oxygen therapy (NOT). Methods: Twenty-four COPD patients, with median age of 66 years and forced expiratory volume in 1 s (FEV1) 55% predicted, living <800 m underwent sleep studies at Zurich (490 m) and during 2 sojourns of 2 days each at St. Moritz (2,048 m) separated by 2-week washout at <800 m. During nights at 2,048 m, patients received either NOT (2,048 m NOT) or ambient air (2,048 m placebo) 3 L/min via nasal cannula according to a randomized, placebo-controlled crossover trial. Sleep studies comprised ECG and pulse oximetry to measure HR, rhythm, HR-adjusted QT interval (QTc), and mean oxygen saturation (SpO2). Results: In the first nights at 490 m, 2,048 m placebo, and 2,048 m NOT, medians (quartiles) of SpO2 were 92% (90; 94), 86% (83; 89), and 97% (95; 98) and of HR were 73 (66; 82), 82 (71; 85), and 78 bpm (67; 74) (P < 0.05 all respective comparisons). QTc increased from 417 ms (404; 439) at 490 m to 426 ms (405; 440) at 2,048 m placebo (P < 0.05) and was 420 ms (405; 440) at 2,048 m NOT (P = NS vs. 2,048 m placebo). The number of extrabeats and complex arrhythmias was similar over all conditions. Conclusions: While staying at 2,048 m, lowlanders with COPD experienced nocturnal hypoxemia in association with an increased HR and prolongation of the QTc interval. NOT significantly improved SpO2 and lowered HR, without changing QTc. Whether oxygen therapy would reduce HR and arrhythmia during longer altitude sojourns remains to be elucidated. Keywords: QTc prolongation; cardiac repolarisation; chronic obstructive pulmonary disease; heart rate; hypoxia

Effect of morbid obesity, gastric banding and gastric bypass on esophageal symptoms, mucosa and function

BACKGROUND: Obesity and gastroesophageal reflux disease (GERD) are commonly associated diseases. Bariatric surgery has been shown to have various impacts on esophageal function and GERD. Our aim was to evaluate changes in symptoms, endoscopic findings, bolus passage and esophageal function in patients after primary gastric bypass surgery as compared to patients converted from gastric banding to gastric bypass. METHODS: Obese patients scheduled for laparoscopic Roux-en-Y gastric bypass (naïve-to-bypass) and patients who previously underwent gastric banding and were considered for conversion from gastric banding to gastric bypass (band-to-bypass) were included. Patients rated esophageal and epigastric symptoms (100 point VAS) and underwent upper endoscopy, impedance-manometry, and modified "timed barium swallow" before/after surgery. RESULTS: Data from 66 naïve-to-bypass patients (51/66, 77 % females, mean age 41.2 ± 11.1 years) and 68 band-to-bypass patients (53/68, 78 % females, mean age 43.8 ± 10.0 years) were available for analysis. Esophageal symptoms, esophagitis, esophageal motility abnormalities and impaired esophageal bolus transit were more common in patients that underwent gastric banding compared to those that underwent gastric bypass. The majority of symptoms, lesions and abnormalities induced by gastric banding were decreased by conversion to gastric bypass. Esophagitis was present in 28/68 (41 %) and 13/47 (28 %) patients in the band-to-bypass group, pre- versus postoperatively, respectively, (p < 0.05). The percentage of swallows with normal bolus transit increased following transformation from gastric band to gastric bypass (57.9 ± 4.1 and 83.6 ± 3.4 %, respectively, p < 0.01). CONCLUSIONS: From an esophageal perspective, gastric bypass surgery induces less motility disorders and esophageal symptoms and should be therefore favored over gastric banding in difficult to treat obese patients at risk of repeated bariatric surgery

Effect of morbid obesity, gastric banding and gastric bypass on esophageal symptoms, mucosa and function

BACKGROUND: Obesity and gastroesophageal reflux disease (GERD) are commonly associated diseases. Bariatric surgery has been shown to have various impacts on esophageal function and GERD. Our aim was to evaluate changes in symptoms, endoscopic findings, bolus passage and esophageal function in patients after primary gastric bypass surgery as compared to patients converted from gastric banding to gastric bypass. METHODS: Obese patients scheduled for laparoscopic Roux-en-Y gastric bypass (naïve-to-bypass) and patients who previously underwent gastric banding and were considered for conversion from gastric banding to gastric bypass (band-to-bypass) were included. Patients rated esophageal and epigastric symptoms (100 point VAS) and underwent upper endoscopy, impedance-manometry, and modified "timed barium swallow" before/after surgery. RESULTS: Data from 66 naïve-to-bypass patients (51/66, 77 % females, mean age 41.2 ± 11.1 years) and 68 band-to-bypass patients (53/68, 78 % females, mean age 43.8 ± 10.0 years) were available for analysis. Esophageal symptoms, esophagitis, esophageal motility abnormalities and impaired esophageal bolus transit were more common in patients that underwent gastric banding compared to those that underwent gastric bypass. The majority of symptoms, lesions and abnormalities induced by gastric banding were decreased by conversion to gastric bypass. Esophagitis was present in 28/68 (41 %) and 13/47 (28 %) patients in the band-to-bypass group, pre- versus postoperatively, respectively, (p < 0.05). The percentage of swallows with normal bolus transit increased following transformation from gastric band to gastric bypass (57.9 ± 4.1 and 83.6 ± 3.4 %, respectively, p < 0.01). CONCLUSIONS: From an esophageal perspective, gastric bypass surgery induces less motility disorders and esophageal symptoms and should be therefore favored over gastric banding in difficult to treat obese patients at risk of repeated bariatric surgery