Dexmedetomidine in Bariatric Surgery: A Systematic Review and Meta-Analysis of Its Effects on Postoperative Pain and Postoperative Nausea and Vomiting

Background: Bariatric surgery is associated with significant postoperative challenges, including pain and nausea. Dexmedetomidine (Dex), an alpha-2 adrenergic agonist, is commonly used to manage pain and postoperative nausea and vomiting (PONV) in various surgical settings. This meta-analysis evaluates the efficacy of Dex in bariatric surgery patients, focusing on postoperative pain intensity, opioid consumption, and PONV. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) published between 2010 and 2023, assessing Dex use during or after bariatric surgery. Studies comparing Dex to placebo or standard care were included. Data extraction was performed independently by two reviewers, and statistical analysis was conducted using a random-effects model. Study quality was assessed using the Cochrane Risk of Bias tool. Results: Six RCTs (485 participants) met the inclusion criteria. Dex significantly reduced intraoperative fentanyl use (SMD -1.33, 95% CI [-2.19, -0.47], p = 0.002). Pain scores showed mixed results, with some studies reporting lower pain intensity in the Dex group, while others found no significant difference compared to morphine or placebo. PONV scores were generally lower in the Dex group (p = 0.01) compared to placebo and morphine. No significant differences were found in morphine consumption (SMD -1.13, 95% CI [-2.24, 0.01], p = 0.05) or recovery time. Conclusions: Dexmedetomidine appears to reduce opioid requirements and postoperative nausea in bariatric surgery patients. However, the variability in pain management outcomes suggests that further well-designed RCTs are needed to confirm its overall efficacy. The findings are based on moderate-quality evidence, and further research should aim to standardize dosing protocols and patient populations.

Gastrointestinal complaints after Roux-en-Y gastric bypass surgery. Impact of microbiota and its metabolites

Unexplainable gastrointestinal complaints occasionally occur after Roux-en-Y Gastric Bypass (RYGB) surgery. We therefor investigated the impact of microbiota composition and metabolites on gastrointestinal complaints after RYGB. In the BARICO study (Bariatric surgery Rijnstate and Radboudumc neuroimaging and Cognition in Obesity), microbiota and metabolites were measured before surgery, and 6, and 24 months after surgery. Gastrointestinal complaints were assessed with the Irritable Bowel Syndrome Severity Scoring System (IBS-SSS) questionnaire 24 months after surgery. 65 participants (86.2 % female) with a mean age of 46.2 ± 6.0 years, and mean BMI of 41.2 ± 3.6 kg/m2 were included. According to the IBS-SSS questionnaire, 32.3 % had moderate/severe gastrointestinal complaints 24 months after surgery. Microbiota alpha diversity remained stable, while beta diversity significantly changed over time. Bile acids and short-chain fatty acids were significantly higher, and inflammatory markers significantly lower after surgery. Barnesiella sp., Escherichia/Shigella sp., and Faecalibacterium prausnitzii correlated positively, while Akkermansia sp correlated inversely with gastrointestinal complaints. Patients with mild and moderate/severe gastrointestinal complaints showed higher levels of GLC-3S. These findings suggest involvement of microbiota and metabolite changes in gastrointestinal complaints after surgery. However, it remains unclear whether bacteria influence gastrointestinal complaints directly or indirectly. Further exploration is required for development of interventions against gastrointestinal symptoms after surgery.

An Unusual Complication of Internal Hernia Post-laparoscopic Sleeve Gastrectomy: A Video Case Report

Internal hernia is a well-recognized complication after laparoscopic Roux-En-Y gastric bypass. Recently, it has been recognized after laparoscopic one-anastomosis gastric bypass. Alteration of bowel anatomy was put as the cause of internal hernia after these procedures.  Laparoscopic sleeve gastrectomy (SG) is one of the most commonly performed bariatric procedures worldwide; it was hypothesized that internal hernia could not occur after sleeve gastrectomy. We report in a video a case of internal hernia that occurred post laparoscopic sleeve gastrectomy and its concomitant management. Data on the case of post-SG internal hernia were collected retrospectively and reported in a video with its intra-operative findings and concomitant management. The patient is a 35-year-old male. He underwent laparoscopic sleeve gastrectomy, which was complicated by a leak. It was managed conservatively with optimal clinical response. He presented seven years after his surgery to the emergency department with a history of multiple episodes of severe left upper abdominal pain. a CT scan was performed, showing suspicion of an internal hernia. The patient was taken for emergency laparoscopic exploration.  Intra-operatively, there was a band of adhesion from a previous leak site connecting a loop of proximal jejunum to the anterior abdominal wall, forming a 5 cm defect. Through it, a loop of bowel was found herniating with partial twisting of its mesentery and engorgement of its vessels. In addition, there were multiple adhesions between bowel loops. The herniated bowel loop was reduced with no evidence of ischemia. The adhesive band was resected using a laparoscopic linear stapler. The bowel was fully inspected from the ileocecal valve up to the duodenojejunal (DJ) flexure, and a full adhesiolysis was performed. The patient recovered well. He was discharged on day one postoperatively. He was followed up with a complete resolution of his symptoms and no complications. We conclude that an internal hernia could occur as a long-term complication of sleeve gastrectomy leaks. A high index of suspicion should be applied when dealing with vague abdominal pain post-bariatric surgery. The laparoscopic approach was safe and feasible.

Postbariatric hypoglycemia, abdominal pain and gastrointestinal symptoms after Roux-en-Y gastric bypass explored by continuous glucose monitoring

BACKGROUND

Abdominal pain and postbariatric hypoglycemia (PBH) are common after bariatric surgery.

OBJECTIVES

This study aimed to explore the potential relationship between abdominal pain, gastrointestinal symptoms, and PBH more than a decade after Roux-en-Y gastric bypass (RYGB) and whether continuous glucose monitoring (CGM) with dietary intervention has an educational role in reducing symptoms.

SUBJECTS

At two public hospitals in Norway (one University Hospital) 22 of 46 invited patients who reported abdominal pain more than weekly took part. Recruited from a prospective follow-up study of 546 patients 14.5 years after RYGB.

METHODS

They used a CGM for two 14-day periods, with a dietary intervention between periods. The Gastrointestinal Symptom Rating Scale (GSRS) and the Dumping Severity Score (DSS) questionnaires were completed at the start and end of the study.

RESULTS

The 22 women had preoperative age 39.6 ± 7.7 years and body mass index (BMI) 42.0 ± 4.0 kg/m2, present age 54.6 ± 7.7 years and BMI 29.8 ± 4.8 kg/m2. The total GSRS score and DSS of early dumping decreased after the diet intervention. The number of events with Level 1 (<3.9 mmol/L) or Level 2 (<3.0 mmol/L) hypoglycemia did not change in the second period. Half of the patients had fewer, three had unchanged, and eight had more frequent events with Level 1 hypoglycemia after the intervention. Ten patients had Level 2 hypoglycemia.

CONCLUSION

Though inconclusive findings, a personalized dietary intervention reduces GSRS. This intervention was accompanied by lower mean absolute glucose in patients with recurrent abdominal pain after bariatric surgery. However, further studies are needed to explore the benefits of CGM in this setting.

Long-Term Follow-up and Risk of Recurrence of Internal Herniation after Roux-en-Y Gastric Bypass

PURPOSE

Internal herniation (IH) is the most common complication after Roux-en-Y gastric bypass surgery (RYGB). Although primary closure has reduced the incidence, recurrences are a continued problem. This study aimed to investigate long-term follow-up and recurrence risk of IH surgery.

METHODS

A retrospective cohort study of laparoscopic RYGB operated patients operated for a first IH between April 2012 and April 2015 at Skåne University Hospital in Malmö, Sweden. Status of primary closure of mesenteric gaps, time since RYGB, and findings at IH surgery were retrieved from medical records. Follow-up until December 31st, 2019, included recurrences of IH, number of computed tomography (CT) scans, emergency visits, readmissions, and other acute surgeries.

RESULTS

IH (n = 44) occurred almost equally in Petersen's space (n = 24) and beneath the jejunojejunostomy (n = 20). Long-term follow-up (median 75 months) of 43 patients registered an IH recurrence rate of 14% (n = 6). All recurrences occurred in the other mesenteric gap. One patient suffered a third IH, and one patient had four IH events. During follow-up, 56% (n = 24) had ER visits for abdominal pain, 47% (n = 20) had ≥ 1 abdominal CT scan, and 40% (n = 17) were readmitted. A third of readmitted (6/17) patients suffered a recurrence of internal herniation. Two other patients were readmitted ≥ 10 times for chronic abdominal pain.

CONCLUSION

Surgery for IH had a low risk of recurrence at the treated mesenteric gap, but a 14% recurrence risk at the other mesenteric gap, emphasizing the importance of carefully investigating weaknesses or gaps at the other mesenteric defect during surgery for IH.

Factors predictive of persistent fistulas in EUS-directed transgastric ERCP: a multicenter matched case-control study

BACKGROUND AND AIMS

EUS-directed transgastric ERCP (EDGE) is an established method for managing pancreaticobiliary pathology in Roux-en-Y gastric bypass patients, with high rates of technical success and low rates of serious adverse events (AEs). However, widespread adoption of the technique has been limited because of concerns about the development of persistent gastrogastric or jejunogastric fistulas. Gastrogastric and jejunogastric fistulas have been reported in up to 20% of cases in some series, but predictive risk factors and long-term management and outcomes are lacking. Therefore, our aims were to assess factors associated with the development of persistent fistulas and the technical success of endoscopic fistula closure.

METHODS

This is a case-control study involving 9 centers (8 USA, 1 Europe) from February 2015 to September 2021. Cases of persistent fistulas were defined as endoscopic or imaging evidence of fistula more than 8 weeks after lumen-apposing metal stent (LAMS) removal. Control subjects were defined as endoscopic or imaging confirmation of no fistula more than 8 weeks after LAMS removal. AEs were defined and graded according to the American Society for Gastrointestinal Endoscopy lexicon.

RESULTS

Twenty-five patients identified to have evidence of a persistent fistula on follow-up surveillance (cases) were matched with 50 patients with no evidence of a persistent fistula on follow-up surveillance (control subjects) based on age and sex. Mean LAMS dwell time was 74.7 ± 106.2 days. After LAMS removal, argon plasma coagulation (APC) ablation of the fistula was performed in 46 patients (61.3%). Primary closure of the fistula was performed in 26.7% of patients (20: endoscopic suturing in 17, endoscopic tacking in 2, and over-the-scope clips + endoscopic suturing in 1). When comparing cases with control subjects, there was no difference in baseline demographics, fistula site, LAMS size, or primary closure frequency between the 2 groups (P > .05). However, in the persistent fistula group, the mean LAMS dwell time was significantly longer (127 vs 48 days, P = .02) and more patients had ≥5% total body weight gain (33.3% vs 10.3%, P = .03). LAMS dwell time was a significant predictor of persistent fistula (odds ratio, 4.5 after >40 days in situ, P = .01). The odds of developing a persistent fistula increased by 9.5% for every 7 days the LAMS was left in situ. In patients with a persistent fistula, endoscopic closure was attempted in 19 (76%) with successful resolution in 14 (73.7%).

CONCLUSIONS

Longer LAMS dwell time was found to be associated with a higher risk of persistent fistulas in EDGE patients. APC or primary closure of the fistula on LAMS removal was not found to be protective against developing a persistent fistula, which, if present, can be effectively managed through endoscopic closure in most cases.

Cross-sectional E-survey on the Incidence of Pre- and Postoperative Chronic Pain in Bariatric Surgery

BACKGROUND

To assess the prevalence, incidence, location, and behavior of chronic pre- and postoperative pain in bariatric surgery, and the use of analgesics.

METHODS

A cross-sectional e-survey was conducted on 3928 post-bariatric patients and four-time points for pain assessment were evaluated: preoperative, on the ward, day 1 at home postoperatively, and present time (at the time of the e-survey). A numerical rating scale (NRS) was used to assess the level of pain (0 to 10). The general incidence of chronic pain was calculated, as also, subgroups were defined as group A (pre and postoperative chronic pain), B (preoperative pain, and no longer postoperative), and C (preoperative painless, postoperative chronic pain). Besides the pain intensity, location of pain, and the use of analgesics were investigated.

RESULTS

A total of 3279 patients (83.9%) responded to the survey. Preoperative and postoperative chronic pain was found in 343 (10.5%) and 264 (8.1%) patients, respectively. In group A, chronic pain was present in 4.8% of the patients; in group B, it was present in 5.7%; and in group C in 3.3% of the patients. Furthermore, in 4.5% of patients pain was located in the abdomen, which was higher as compared to before surgery (+ 2.3%, p < 0.001). The ORs for present postoperative chronic pain were OR 1.45, 1.7, and 1.71 (p = 0.002, 0.003, 0.003) compared to respectively preoperative chronic pain, pain at the ward, and pain at day 1 after surgery. Among all participants, 4.6% consumed chronic analgesics. Of these, paracetamol was used most frequently (3.8%), followed by tramadol (1.3%) and oxycodone (0.5%).

CONCLUSIONS

In this e-survey, chronic postoperative abdominal pain was prominent in patients after bariatric surgery. Of patients, 3.3% that were without preoperative chronic pain developed chronic pain after surgery. Opioid consumption in the queried population was relatively low.

The Multiple Etiologies of Abdominal Pain Post Roux-en-Y Gastric Bypass: A Case Series and Review of Management Strategies

Roux-en-Y gastric bypass (RYGB) is one of the most common bariatric surgeries performed and has aided many people with their weight loss efforts. However, manipulating the gastrointestinal anatomy may have numerous consequences. Various complications of RYGB can occur during the early to late post-op periods, and abdominal pain is the most common symptom reported. The etiologies that present as abdominal pain are heterogeneous in anatomical origin, onset, severity, and management; therefore, differentiating diagnoses is crucial. The physical exam, inciting triggers, and alleviating factors can direct diagnostic measures accordingly. Prompt recognition and identification of these patients' underlying causes of abdominal pain are vital for accurate diagnosis and treatment. Methods can range from conservative management to surgical intervention, depending on the severity of the complication. In this report, we recount the cases of two patients who underwent elective RYGB and presented to the emergency department (ED) months later with abdominal pain. After the labs were taken and diagnostic tests were conducted, it was discovered that both patients had multiple underlying factors that could have contributed to their pain. This study aims to describe the diverse etiologies of abdominal pain encountered in these bariatric patients and explore the appropriate management strategies utilized for each case.

Intussusception After Roux-en-Y Gastric Bypass: Correlation Between Radiological and Operative Findings

INTRODUCTION

Intussusceptions diagnosed on computed tomography (CT) scans in Roux-en-Y gastric bypass (RYGB) patients could cause serious small bowel obstruction (SBO) or be an incidental finding. The objective of this study was to correlate radiological findings with clinical outcomes to differentiate intussusceptions requiring emergent surgery for SBO.

METHODS

A search for acute abdominal CT scans reporting intussusceptions in RYGB patients between 2012 and 2019 at Skåne University Hospital, Malmö, Sweden, retrieved 35 scans. These were independently reevaluated by two radiologists for the length and location of the intussusception, whether oral contrast passed through, proximal bowel dilatation, and signs of internal herniation. Clinical outcome in terms of emergency surgery and the diagnosis was determined through chart review.

RESULTS

Out of 35 acute patients, 9 patients required emergency surgery within 24 h. Intussusception caused SBO in five patients, and one patient had an internal herniation, while three patients had unremarkable findings. Eight patients were evaluated for intermittent pain with five unremarkable laparoscopies, while 18 patients had intussusceptions as incidental findings. Intussusception length on CT as measured by radiologists O.E. and D.L. predicted acute bowel obstruction (p = .014 and p < .001). A 100 mm threshold predicted bowel obstruction with a sensitivity of 80% and 100% and a specificity of 93% and 86% by radiologists O.E. and D.L., respectively. Proximal bowel dilatation predicted SBOs of any cause as well as SBO caused by an intussusception (all p < .05).

CONCLUSION

Intussusception length > 100 mm on CT in RYGB patients is an easy and valuable sign indicating SBO that may require emergent surgery.

Operative management of acute abdomen after bariatric surgery in the emergency setting: the OBA guidelines

BACKGROUND

Patients presenting with acute abdominal pain that occurs after months or years following bariatric surgery may present for assessment and management in the local emergency units. Due to the large variety of surgical bariatric techniques, emergency surgeons have to be aware of the main functional outcomes and long-term surgical complications following the most performed bariatric surgical procedures. The purpose of these evidence-based guidelines is to present a consensus position from members of the WSES in collaboration with IFSO bariatric experienced surgeons, on the management of acute abdomen after bariatric surgery focusing on long-term complications in patients who have undergone laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

METHOD

A working group of experienced general, acute care, and bariatric surgeons was created to carry out a systematic review of the literature following the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) and to answer the PICO questions formulated after the Operative management in bariatric acute abdomen survey. The literature search was limited to late/long-term complications following laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

CONCLUSIONS

The acute abdomen after bariatric surgery is a common cause of admission in emergency departments. Knowledge of the most common late/long-term complications (> 4 weeks after surgical procedure) following sleeve gastrectomy and Roux-en-Y gastric bypass and their anatomy leads to a focused management in the emergency setting with good outcomes and decreased morbidity and mortality rates. A close collaboration between emergency surgeons, radiologists, endoscopists, and anesthesiologists is mandatory in the management of this group of patients in the emergency setting.

The Diagnostic Accuracy of Abdominal Computed Tomography in Diagnosing Internal Herniation Following Roux-en-Y Gastric Bypass Surgery: A Systematic Review and Meta-analysis

OBJECTIVE

To analyze the diagnostic accuracy of abdominal computed tomography (CT) in diagnosing internal herniation (IH) following Rouxen-Y gastric bypass (RYGB) surgery.

SUMMARY OF BACKGROUND DATA

IH is one of the most important and challenging complications following RYGB. Therefore, early and adequate diagnosis of IH is necessary. Currently, exploratory surgery is considered the gold standard in diagnosing IH. Although CT scans are frequently being used, the true diagnostic accuracy in diagnosing IH remains unclear.

METHODS

PubMed, Embase, and Cochrane databases were systematically searched for relevant articles describing the diagnostic accuracy of abdominal CT in diagnosing IH after RYGB. Data were extracted, recalculated, and pooled to report on the overall diagnostic accuracy of CT in diagnosing IH, and the diagnostic accuracy of specific radiological signs.

RESULTS

A total of 20 studies describing 1637 patients were included. seventeen studies provided data regarding the overall diagnostic accuracy: pooled sensitivity of 82.0%, specificity of 84.8%, positive predictive value of 82.7%, and negative predictive value of 85.8% were calculated. Eleven studies reported on specific CT signs and their diagnostic accuracy. The radiological signs with the highest sensitivity were the signs of venous congestion, swirl, and mesenteric oedema (sensitivity of 78.7%, 77.8%, and 67.2%, respectively).

CONCLUSIONS

This meta-analysis demonstrates that CT is a reliable imaging modality for the detection of IH. Therefore, abdominal CT imaging should be added to the diagnostic work-up for RYGB patients who present themselves with abdominal pain suggestive of IH to improve patient selection for explorative surgery.

The Jejunojejunostomy: an Achilles Heel of the Roux-en-Y Gastric Bypass Construction

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (RYGB) has for long been the gold standard technique in bariatric surgery, especially in the Scandinavian countries. In a tertiary hospital setting, we observed an increasing number of patients with postprandial abdominal pain and nausea, often associated with complex hypoglycemia.

OBJECTIVES

The present study aimed to characterize the clinical patterns, patient characteristics, and clinical outcomes after surgical revision of dysfunctional RYGB at Sahlgrenska University Hospital in Gothenburg, Sweden.

METHODS

This cohort study included patients with RYGB who underwent revision of the jejunojejunostomy (JJ) after 2013. Information was obtained by reviewing medical records and performing complementary interviews.

RESULTS

Laparoscopic revisional surgery was performed in 115 cases with either adhesiolysis or total revision of the JJ (mean age 41 years, range 19-67 years; 90% women). The median time to assessment after the last revision was 33 months (range 12-75 months). Forty-four (38%) patients reported that they were symptom-free long-term after the intervention, and 32 (28%) patients experienced an improvement in the symptoms that were the indication for revision. However, 31 (27%) patients reported no long-term improvement, and half of them (n = 16) subsequently had a reversal of the anatomy. Eight (7%) patients were lost to follow-up.

CONCLUSIONS

Dysfunction of the JJ appears to be a relatively common cause of postprandial pain and nausea after ante-colic/ante-gastric RYGB. Most patients with symptoms of dysfunction experienced partial or total relief following revisional surgery, but a substantial minority had persistent problems, with one in five eventually undergoing reversal of the anatomy.

A prospective longitudinal study of chronic abdominal pain and symptoms after sleeve gastrectomy

BACKGROUND

Sleeve gastrectomy (SG) is widely applied. Few studies have evaluated patient-reported abdominal symptoms after SG.

OBJECTIVE

To evaluate the prevalence of chronic abdominal pain (CAP) and symptom characteristics after SG.

SETTING

Oslo University Hospital and Voss Hospital.

METHODS

We performed a longitudinal prospective cohort study of patients operated on with SG at two tertiary referral centers. For broad assessments of abdominal pain and symptoms, consultations were performed and questionnaires retrieved before and 2 years after SG. The definition of CAP or recurrent abdominal pain lasting for more than 3 months was sustained. Preoperative predictors of CAP were explored.

RESULTS

Of 249 patients at baseline, 207 (83.1%) had follow-up consultations. Mean preoperative body mass index was 43.9 (6.0) kg/m², and 181 patients (72.7%) were female. Total weight loss was 31.9% (10.4%). CAP was reported in 32 of 223 patients (14.3%) before and in 50 of 186 patients (26.9%) after SG (P =.002). All mean gastrointestinal symptoms rating scale questionnaire scores increased after SG, and they were higher in patients with CAP. Symptoms of depression decreased but were more prevalent in patients with CAP at follow-up. Most quality-of-life scores increased after SG. However, patients with CAP had lower scores (except for physical functioning). Preoperative bothersome Gastrointestinal Symptom Rating Scale reflux symptoms, study center, and younger age seemed to predict CAP after SG.

CONCLUSION

The prevalence of patient-reported CAP increased after SG. Patients reporting CAP had reduced quality-of-life scores.

Self-Reported Gastrointestinal Symptoms Two To Four Years After Bariatric Surgery. A Cross-Sectional Study Comparing Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy

BACKGROUND

Roux-en-Y gastric bypass (RYGBP) and laparoscopic sleeve gastrectomy (LSG) are efficient methods for weight loss (WL) and WL maintenance in severe obesity. However, the knowledge of gastrointestinal (GI) symptoms after surgery is limited. This study aimed to compare the severity of GI symptoms, pain, and self-rated health 2 to 4 years after RYGBP and LSG surgery.

METHODS

In this cross-sectional study, RYGBP and LSG patients answered a questionnaire including the Gastrointestinal Symptom Rating Scale (GSRS), questions from the Brief Pain Inventory (BPI), and self-rated health (SRH).

RESULTS

A total of 172/303 (57%) responded, RYGBP (n=73) and LSG (n=99). The mean age was 45.3 (SD 11.1) years (74% females). There was no evidence of a difference in total GSRS scores between the surgical methods (p=0.638). There were higher scores of reflux symptoms in LSG vs. RYGBP (both median 1, 75-percentile 2.5 vs. 1.0, p <0.001) and higher consumption of acid-reducing medication after LSG (32% vs. 12%, p <0.001). Pain scores were low in both groups; however, average abdominal pain was higher for RYGBP, median 2 (IQR 0-4) vs. median 1 (IQR 0-3) for LSG (p = 0.025). There was no significant difference in SRH.

CONCLUSIONS

Patients undergoing RYGBP and LSG surgery reported similar total GSRS scores and low pain scores 2 to 4 years after surgery. However, reflux symptoms and use of acid-reducing medication occurred more frequently after LSG surgery, while abdominal pain was more frequent in RYGBP surgery. These findings are important for surgical decision-making and follow-up.

Endoscopic Evaluation and Management of Late Complications After Bariatric Surgery: a Narrative Review

Despite ongoing evolution in technique and a low mortality rate, clinicians may care for patients who suffer late complications (> 90 days of surgery) after bariatric surgery. Endoscopic techniques are used to identify and manage many of the late complications of the two most commonly performed bariatric surgeries: sleeve gastrectomy and Roux-en-Y gastric bypass. Stenosis at the incisura angularis and gastroesophageal reflux disease may occur in patients who have undergone a sleeve gastrectomy. Patients who underwent a Roux-en-Y gastric bypass can suffer marginal ulceration, gastrojejunal anastomotic stricture, and gastro-gastric fistula. Clinicians may also encounter biliary pathologies such as choledocholithiasis, chronic abdominal pain, and weight regain. This narrative review provides an update on the endoscopic evaluation and management of patients with late complications after sleeve gastrectomy or Roux-en-Y gastric bypass.

Long-term Emergency Department Visits and Readmissions After Laparoscopic Roux-en-Y Gastric Bypass: a Systematic Review

PURPOSE

There is considerable evidence on short-term outcomes after laparoscopic Roux-en-Y gastric bypass (LRYGB), but data on long-term outcome is scarce, especially on postoperative emergency department (ED) visits and readmissions. We aim to systematically review evidence on the incidence, indications, and risk factors of ED visits and readmissions beyond 30 days after LRYGB.

MATERIALS AND METHODS

A systematic search in PubMed, Scopus, Embase.com , Cochrane Library, and PsycINFO was performed. All studies reporting ED visits and readmissions > 30 days after LRYGB, with ≥ 50 patients, were included. PRISMA statement was used and the Newcastle-Ottawa Scale for quality assessment.

RESULTS

Twenty articles were included. Six studies reported on ED visits (n = 2818) and 19 on readmissions (n = 276,543). The rate of patients with an ED visit within 90 days after surgery ranged from 3.9 to 32.6%. ED visits at 1, 2, and 3 years occurred in 25.6%, 30.0%, and 31.1% of patients. Readmissions within 90 days and at 1-year follow-up ranged from 4.1 to 20.5% and 4.75 to 16.6%, respectively. Readmission was 29% at 2 years and 23.9% at 4.2 years of follow-up. The most common reason for ED visits and readmissions was abdominal pain.

CONCLUSION

Emergency department visits and readmissions have been reported in up to almost one in three patients on the long-term after LRYGB. Both are mainly indicated for abdominal pain. The report on indications and risk factors is very concise. A better understanding of ED visits and readmissions after LRYGB is warranted to improve long-term care, in particular for patients with abdominal pains.

The role of citrulline, intestinal fatty acid-binding protein, and D-dimer as potential biomarkers in the diagnosis of internal herniation after Roux-en-Y gastric bypass

BACKGROUND

Diagnosing internal herniation (IH) in Roux-en-Y gastric bypass (RYGB) patients with acute abdominal pain poses a diagnostic challenge. Diagnostic laparoscopy is often required for a definitive diagnosis. We hypothesized that intestinal ischemia biomarkers would aid in the diagnosing of IH.

OBJECTIVES

To explore intestinal ischemia biomarkers in diagnosing IH.

SETTING

University Hospital, Sweden.

METHODS

Prospective inclusion of 46 RYGB patients admitted for acute abdominal pain between June 2015 and December 2017. Blood samples for analysis of citrulline, intestinal fatty acid-binding protein (I-FABP), and D-dimer were drawn <72 hours from admission and compared between patients with IH (n = 8), small bowel obstruction (SBO) (n = 5), other specified diagnoses (n = 12), or unspecified abdominal pain (n = 21). Levels of white blood cell count (WBC), C-reactive protein (CRP), and lactate at admission were compared. A prospective pain questionnaire for time of pain onset and level of pain at onset and at admission was analyzed.

RESULTS

None of the investigated biomarkers differed significantly between diagnosis categories. Most patients with IH had normal CRP, WBC, and D-dimer levels while their lactate levels were significantly lower (P = .029) compared with the rest of the cohort. Neither pain level nor pain duration differed between the groups.

CONCLUSION

This study shows that citrulline, I-FABP, and D-dimer cannot be used to diagnose IH and indicates that CRP, D-dimer, and lactate are rarely elevated by an IH. Furthermore, pain intensity and duration cannot differentiate patients with IH. A diagnostic laparoscopy remains the gold standard to diagnose and rule out an IH.

GERD after Bariatric Surgery. Can We Expect Endoscopic Findings?

Background and Objectives: Bariatric surgery remains the gold standard treatment for morbidly obese patients. Roux-en-y gastric bypass and laparoscopic sleeve gastrectomy are the most frequently performed surgeries worldwide. Obesity has also been related to gastroesophageal reflux disease (GERD). The management of a preoperative diagnosis of GERD, with/without hiatal hernia before bariatric surgery, is mandatory. Endoscopy can show abnormal findings that might influence the final type of surgery. The aim of this article is to discuss and review the evidence related to the endoscopic findings after bariatric surgery. Materials and Methods: A systematic review of the literature has been conducted, including all recent articles related to endoscopic findings after bariatric surgery. Our review of the literature has included 140 articles, of which, after final review, only eight were included. The polled articles included discussion of the endoscopy findings after roux-en-y gastric bypass and laparoscopic sleeve gastrectomy. Results: We found that the specific care of bariatric patients might include an endoscopic diagnosis when GERD symptoms are present. Conclusions: Recent evidence has shown that endoscopic follow-up after laparoscopic sleeve gastrectomy could be advisable, due to the pathological findings in endoscopic procedures in asymptomatic patients.

Gastrointestinal quality of life before and short- and long-term after Roux-en-Y gastric bypass for severe obesity

BACKGROUND

Overall quality of life (QoL) is generally improved after bariatric surgery. Gastrointestinal (GI) symptoms including abdominal pain have been reported in up to >30% of patients after Roux-en-Y gastric bypass (RYGB), and may negatively influence QoL, especially GI-QoL.

OBJECTIVES

To evaluate the evolution of GI symptoms and GI-QoL short- and long-term after RYGB.

SETTING

Two public hospitals METHODS: Candidates for bariatric surgery (n = 128, BMI = 44.2 ± 7.4) or patients who had undergone RYGB 2-4 years (n = 161, BMI = 29.3 ± 15.9) and 5-10 years (n = 121, BMI = 31.3 ± 6.5) before were invited to complete a questionnaire combining 3 validated questionnaires (GIQLI, GSRS, and PCS) specifically designed to evaluate GI-QoL. Scores were compared between the preoperative, early, and late postoperative periods.

RESULTS

The GIQLI score improved from 88.1 before surgery to 118.6 (P < .0001) and 109.7 (P < .0001) in the early and late postoperative periods respectively. GSRS score improved from 15.6 to 10.1 (P = .0001) and 12.8 (P = .012), and PCS-score improved from 19 to 4.5 (P = .0001) and 8.3 (P = .0001), respectively. The GI subscore of the GIQLI improved from 57.4 to 62.1 (P = .007) in the early period but was not significantly different in the late period (59.3 versus 57.4, P = .3). The psychological impact of GI symptoms decreased at both postoperative time points.

CONCLUSION

GI-QoL is markedly improved after RYGB, and this improvement persists up to 10 years. GI symptoms decrease early after surgery and do not worsen in the longer term. Their psychological impact is markedly reduced.

The Phantom Satiation Hypothesis of Bariatric Surgery

The excitation of vagal mechanoreceptors located in the stomach wall directly contributes to satiation. Thus, a loss of gastric innervation would normally be expected to result in abrogated satiation, hyperphagia, and unwanted weight gain. While Roux-en-Y-gastric bypass (RYGB) inevitably results in gastric denervation, paradoxically, bypassed subjects continue to experience satiation. Inspired by the literature in neurology on phantom limbs, I propose a new hypothesis in which damage to the stomach innervation during RYGB, including its vagal supply, leads to large-scale maladaptive changes in viscerosensory nerves and connected brain circuits. As a result, satiation may continue to arise, sometimes at exaggerated levels, even in subjects with a denervated or truncated stomach. The same maladaptive changes may also contribute to dysautonomia, unexplained pain, and new emotional responses to eating. I further revisit the metabolic benefits of bariatric surgery, with an emphasis on RYGB, in the light of this phantom satiation hypothesis.

Small Intestinal Bacterial Overgrowth: Clinical Presentation in Patients with Roux-en-Y Gastric Bypass

BACKGROUND

Small intestinal bacterial overgrowth (SIBO) is defined by an increased number of bacteria measured via exhaled hydrogen and/or methane gas following the ingestion of glucose. This condition is prevalent following abdominal surgery, including Roux-en-Y gastric bypass (RYGB), and associated with a variety of non-specific abdominal symptoms, often requiring an extensive diagnostic work-up.

AIM

To assess the frequency that individuals with RYGB anatomy are diagnosed with SIBO and if they are more likely to report specific gastrointestinal (GI) symptoms compared to individuals with native anatomy.

METHODS

This large matched cohort study evaluated patients with GI symptoms who underwent a glucose breath test (GBT) for SIBO evaluation, utilizing 1:2 matching between RYGB and native anatomy. Patients with positive GBT were included in univariate and multivariate analyses to distinguish the presence of ten specific GI symptoms between RYGB and native anatomy.

RESULTS

A total of 17,973 patients were included, where 271 patients with RYGB were matched to 573 patients with native anatomy that underwent GBT. Patients with RYGB anatomy and a positive GBT (199; 73.4%) as compared to those with native anatomy and a positive GBT (209; 36%) more often reported nausea, vomiting, bloating, and diarrhea. There were no differences between the two groups in the report of heartburn, regurgitation, chest pain, gas, or constipation.

CONCLUSIONS

SIBO is common in patients with RYGB and more commonly report nausea, vomiting, bloating, and diarrhea. The results of this study suggest that the report of these symptoms in RYGB should prompt early evaluation for SIBO.

Chronic abdominal pain and persistent opioid use after bariatric surgery

Background and aims Bariatric surgery remains a mainstay for treatment of morbid obesity. However, long-term adverse outcomes include chronic abdominal pain and persistent opioid use. The aim of this review was to assess the existing data on prevalence, possible mechanisms, risk factors, and outcomes regarding chronic abdominal pain and persistent opioid use after bariatric surgery. Methods PubMed was screened for relevant literature focusing on chronic abdominal pain, persistent opioid use and pharmacokinetic alterations of opioids after bariatric surgery. Relevant papers were cross-referenced to identify publications possibly not located during the ordinary screening. Results Evidence regarding general chronic pain status after bariatric surgery is sparse. However, our literature review revealed that abdominal pain was the most prevalent complication to bariatric surgery, presented in 3-61% of subjects with health care contacts or readmissions 1-5 years after surgery. This could be explained by behavioral, anatomical, and/or functional disorders. Persistent opioid use and doses increased after bariatric surgery, and 4-14% initiated a persistent opioid use 1-7 years after the surgery. Persistent opioid use was associated with severe pain symptoms and was most prevalent among subjects with a lower socioeconomic status. Alteration of absorption and distribution after bariatric surgery may impact opioid effects and increase the risk of adverse events and development of addiction. Changes in absorption have been briefly investigated, but the identified alterations could not be separated from alterations caused solely by excessive weight loss, and medication formulation could influence the findings. Subjects with persistent opioid use after bariatric surgery achieved lower weight loss and less metabolic benefits from the surgery. Thus, remission from comorbidities and cost effectiveness following bariatric surgery may be limited in these subjects. Conclusions Pain, especially chronic abdominal, and persistent opioid use were found to be prevalent after bariatric surgery. Physiological, anatomical, and pharmacokinetic changes are likely to play a role. However, the risk factors for occurrence of chronic abdominal pain and persistent opioid use have only been scarcely examined as have the possible impact of pain and persistent opioid use on clinical outcomes, and health-care costs. This makes it difficult to design targeted preventive interventions, which can identify subjects at risk and prevent persistent opioid use after bariatric surgery. Future studies could imply pharmacokinetic-, pharmacodynamics-, and physiological-based modelling of pain treatment. More attention to social, physiologic, and psychological factors may be warranted in order to identify specific risk profiles of subjects considered for bariatric surgery in order to tailor and optimize current treatment recommendations for this population.

Laparoscopy as a Diagnostic and Therapeutic Modality for Chronic Abdominal Pain of Unknown Etiology: A Literature Review

BACKGROUND

Investigate the diagnostic and therapeutic utility of laparoscopy in the management of patients with chronic abdominal pain of unknown origin.

METHODS

Ovid MEDLINE, PubMed, and SCOPUS databases were queried to identify relevant published studies. Data on the diagnostic and therapeutic utility of laparoscopy were abstracted and summarized.

RESULTS

Laparoscopy achieved a diagnosis in 65% to 94% of patients with chronic abdominal pain of unknown origin. Common intraoperative findings included adhesions, chronic appendicitis, hernias, and enlarged mesenteric lymph nodes. These findings corresponded with the therapeutic procedures that were performed, including laparoscopic adhesiolysis, appendectomy, and hernia repair. Therapeutic utility of laparoscopy based on pain relief, patient satisfaction, and quality of life ranged from 63% to 94%.

CONCLUSIONS

Based on current available evidence, diagnostic laparoscopy (DL) is a safe and effective method for identifying organic causes of chronic abdominal pain. Laparoscopic treatment also resulted in substantial pain relief for a majority of patients. However, the efficacy of laparoscopic adhesiolysis remains controversial. We would recommend the use of DL as an early diagnostic tool, but more robust studies are needed to establish the breadth of its therapeutic utility in clinical practice.

Associations between perceived somatic symptoms and mental health after Roux-en-Y gastric bypass: a 3-year prospective cohort study

BACKGROUND

Attention to and interpretation of symptoms are influenced by psychologic and contextual factors. Preoperative anxiety, and to some extent depression, has been found to predict the perceived impact of somatic symptoms 1 year after Roux-en-Y gastric bypass. Postoperative changes in negative affect may possibly both influence and be influenced by the perception of somatic symptoms.

OBJECTIVES

This study aimed to explore whether preoperative anxiety and depressive symptoms correlated with perceived impact of somatic symptoms 3 years after Roux-en-Y gastric bypass. Second, we aimed to examine the 3-year trajectory of depressive and anxiety symptoms, and their interaction with perceived somatic symptoms postoperatively.

SETTING

University hospital.

METHODS

Presurgery, 1-, and 3-year postsurgery data were collected from 169 participants (62.4% follow-up). Anxiety and depressive symptoms were assessed at all time points. The participants reported the degree of perceived impact of various somatic symptoms 1 and 3 years after surgery. A cross-lagged, autoregressive regression analysis was employed to examine the mutual interaction of trajectories over the follow-up period.

RESULTS

Fatigue (30.8%) and dumping (23.7%) were common high-impact symptoms 3 years postoperatively. Higher baseline anxiety was associated with higher impact of fatigue, pain, and diarrhea, while depressive mood was related to higher impact of diarrhea at 3-year follow-up. Higher anxiety/depression symptoms were bidirectionally related to higher perceived total symptom impact at both 1 and 3 years postoperatively, controlling for percent total weight loss. Higher perceived impact of somatic symptom burden at 1 year after surgery predicted a significant increase in depressive symptoms the next 2 years.

CONCLUSION

Baseline anxiety was associated with higher perceived impact of several somatic symptoms 3 years after Roux-en-Y gastric bypass. Higher total symptom burden (pain, fatigue, dumping, diarrhea, and vomiting) at 1 year after surgery predicted increase in depression over the next 2 years. The results underscore the importance of managing somatic symptoms after surgery to prevent patients' distress.

What Is Known About the Nutritional Intake of Women during Pregnancy Following Bariatric Surgery? A Scoping Review

Optimising the diet and weight of women prior to and during pregnancy is of paramount importance to both maternal and offspring health. In women who become pregnant after bariatric surgery, evidence suggests a better overall obstetric outcome in comparison to women with severe obesity managed conservatively. Historically, most studies in this population group have monitored supplement adherence or serum concentrations of micronutrients, rather than dietary intake. The aim of this study was to synthesise current knowledge of the dietary intake of women during pregnancy following bariatric surgery. A systematic search of search engines was conducted using the following databases: MEDLINE, Embase, CINAHL, Cochrane database, Scopus, Trip, NHS Evidence, UK Clinical Trials, ClinicalTrials.gov, Prospero, Epistemonikos and Open Grey. Titles and abstracts were screened independently by two reviewers against predefined inclusion and exclusion criteria. After removal of duplicates, 1594 titles were identified, of which 1586 were initially excluded. Following full-text review, four articles were included. In total, across all four studies, data from only 202 bariatric surgery participants were included, the majority of whom had had one type of surgery. Just one study included a control group. Reporting of nutritional outcomes was heterogenous, with none of the studies including complete macro and micronutrient intake results in their articles. An insufficient intake of protein was noted as a concern in two studies and associated with poor fetal growth in one study. Overall, this review has identified a paucity of data about the dietary intake of women during pregnancy after bariatric surgery.

Possible relation between partial small bowel obstruction and severe postprandial reactive hypoglycemia after Roux-en-Y gastric bypass

BACKGROUND

Although dietary treatment ameliorates symptoms in most patients with postbariatric hypoglycemia (PBH), there is a subgroup with severe symptoms that do not respond sufficiently to either diet or drugs. A clinical observation showed that those patients additionally experienced postprandial abdominal discomfort or pain.

OBJECTIVES

This report describes patients with severe PBH following laparoscopic Roux-en Y gastric bypass undergoing corrective surgery to alleviate partial small bowel obstruction (kink, adhesions, dysfunctional anastomosis) and the subsequent outcome regarding symptoms of PBH.

SETTING

Sahlgrenska University Hospital, Sweden.

METHODS

Retrospective analysis regarding hypoglycemic symptoms from medical records and a complementary telephone interview.

RESULTS

Out of 80 patients treated for severe PBH at our tertiary academic surgical unit over the last 4 years, 38 underwent corrective surgery (adhesiolysis and/or a reconstructed jejuno-jejunostomy). Out of 21 patients using medications to control hypoglycemia before corrective surgery, 19 (90.5%) discontinued the medication, and 5 of 19 (26%) no longer needed to use a blood glucometer or a continuous glucose monitor. Although patients after surgical correction still could experience PBH, symptoms were less frequent and less severe. Postprandial abdominal symptoms decreased, and patients reported improved eating quality. Patient interviews revealed that 8% became entirely free of PBH symptoms after surgery and 71% experienced significant relief.

CONCLUSIONS

We propose a possible association between severe hypoglycemic symptoms after laparoscopic Roux-en Y gastric bypass and partial small bowel obstruction. Patients with PBH not responding adequately to diet and drug treatment may benefit from assessment and intervention for partial small bowel obstruction.

Abdominal pain and symptoms before and after Roux-en-Y gastric bypass

Background

Despite increased emphasis on patient‐reported outcomes, few studies have focused on abdominal pain symptoms before and after Roux‐en‐Y gastric bypass (RYGB). The aim of this study was to quantify chronic abdominal pain (CAP) in relation to RYGB.

Methods

Patients with morbid obesity planned for RYGB were invited to participate at a tertiary referral centre from February 2014 to June 2015. Participants completed a series of seven questionnaires before and 2 years after RYGB. CAP was defined as patient‐reported presence of long‐term or recurrent abdominal pain lasting for more than 3 months.

Results

A total of 236 patients were included, of whom 209 (88·6 per cent) attended follow‐up. CAP was reported by 28 patients (11·9 per cent) at baseline and 60 (28·7 per cent) at follow‐up (P < 0·001). Gastrointestinal Symptom Rating Scale (GSRS) scores (except reflux scores) and symptoms of anxiety increased from baseline to follow‐up. Most quality of life (QoL) scores (except role emotional, mental health and mental component scores) also increased. At follow‐up, patients with CAP had higher GSRS scores than those without CAP, with large effect sizes for abdominal pain and indigestion syndrome scores. Patients with CAP had more symptoms of anxiety, higher levels of catastrophizing and lower QoL scores. Baseline CAP seemed to predict CAP at follow‐up.

Conclusion

The prevalence of CAP is higher 2 years after RYGB compared with baseline values.

Surgical management of obesity

Weight loss surgery is the most effective intervention for addressing obesity and related metabolic disorders such as diabetes. We describe common surgical procedures as well as emerging and investigational procedures in terms of their capacity to induce weight reduction and their risk profiles. We then discuss the impact of weight loss surgery on important obesity related disorders including diabetes, cardiovascular disease, and non-alcoholic fatty liver disease. The question of operative choice is discussed with respect to benefits and risks of common procedures. Reoperative weight loss surgery, an increasingly common element of weight loss surgical practice, is reviewed. We briefly discuss the metabolic mechanism of action of weight loss surgery. Lack of access to and under-utilization of weight loss surgery represent important challenges to adequate obesity treatment, and we review these topics as well.