Background: Iron deficiency is a major postoperative complication of Roux-en-Y gastric bypass surgery. Oral replacement can fail to correct the deficiency. Thus, recourse to parenteral iron administration might be necessary. Our objective was to evaluate the effectiveness and safety of a standardized 2 g intravenous iron dextran infusion in the treatment of iron deficiency after Roux-en-Y gastric bypass surgery. The setting was a university-affiliated community hospital in the United States.Methods: We reviewed the medical records of 23 patients at our institution who had received 2 g of iron dextran intravenously for recalcitrant iron deficiency after Roux-en-Y gastric bypass surgery. We obtained the demographic data and the complete blood count and serum iron studies obtained before treatment and at outpatient visits after infusion.Results: Before treatment, all 23 patients were iron deficient (average ferritin 6 ng/mL) and anemic (average hemoglobin 9.4 g/dL). By 3 months, the average ferritin and hemoglobin had increased to 269 ng/mL and 12.3 g/dL, respectively. The hemoglobin levels remained stable throughout the follow-up period. The iron stores were adequately replaced in most patients. Four patients required a repeat infusion by 1 year, because the ferritin levels had decreased to <15 ng/mL. The probability of remaining in an iron replete state was 84.6% (95% confidence interval 78-91.2%). One patient required warm compresses for superficial phlebitis. No other significant adverse events were reported.Conclusion: Intravenous administration of 2 g of iron dextran corrects the anemia and repletes the iron stores for >= 1 year in most patients. This therapy is safe, tolerable, efficient, and effective. (Surg Obes Relat Dis 2013;9:129-132.) (C) 2013 American Society for Metabolic and Bariatric Surgery. All rights reserved.

BACKGROUND:There have been decreasing pass rates recently on the American Board of Surgery Certifying Examination (ABSCE). General surgery residents from the University of Pittsburgh Medical Center, the West Penn Allegheny Health System, the Conemaugh Health System, and Mercy Hospital participate in a mock oral board examination, which is similar to the ABSCE. The aims of the study are to compare examinee performance on the mock oral boards with the ABSCE and to evaluate the interrater reliability of examiner pairs. METHODS:In this retrospective study from 2003 to 2010, outcomes on the mock oral boards and the first attempt of the ABSCE for chief residents were compared for the 4 regional residency programs. Interrater reliability for examiner pairs was evaluated with agreement and kappa statistics. Nonparametric statistics were performed, with α = 0.05. RESULTS:A total of 32 of 38 (84.2%) chief residents passed the mock oral boards. The median score for each of the 3 rooms was 6 (clear pass). A total of 37 of 38 (97.4%) residents passed the ABSCE. The sensitivity of the mock oral boards was 83.8%, with a positive predictive value of 96.9%, and an accuracy of 81.6%. A total of 25 of 47 (53.2%) examiner pairs were from the same residency institution, whereas 22 of 47 (46.8%) were from different institutions. The median agreement was 100% (interquartile range (IQR) [100% - 100%]). The median kappa statistic was 1.00 (IQR [0.38-1.00]). The Mann-Whitney U tests showed no difference in agreement or kappa for examiner pairs from the same or from different institutions (p> 0.05). CONCLUSIONS:The mock oral boards have substantial sensitivity and positive predictive value in relation to the ABSCE. There are also very high levels of interrater agreement and interrater reliability. This regional mock oral board examination is valuable for ABSCE preparation.

Spilled gallstones have emerged as a new issue in the era of laparoscopic cholecystectomy. We treated a 77-year-old woman who underwent laparoscopic cholecystectomy. Subsequently, a right flank abscess developed. During the cholecystectomy, the gallbladder was perforated and stones were spilled. After a failed attempt to drain the abscess percutaneously, the patient required open drainage, which revealed retained gallstones in the right flank. The abscess resolved, although the patient continued to have intermittent drainage without evidence of sepsis. Review of the literature revealed 127 cases of spilled gallstones, of which 44.1% presented with intraperitoneal abscess, 18.1% with abdominal wall abscess, 11.8% with thoracic abscess, 10.2% with retroperitoneal abscess, and the rest with various clinical pictures. In case of gallstone spillage during laparoscopic cholecystectomy, every effort should be made to locate and retrieve the stones.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most common surgical procedures for severe obesity. Incidental findings at the time of surgery may alter the planned procedure. Malrotation of the bowel is a rare condition that may be present at the time of surgery.

BACKGROUND:Cervical esophagogastric anastomotic disruption following transhiatal esophagectomy (THE) is a significant problem. Gastric tip ischemia is a primary cause of anastomotic failure. We examined gastric tip blood flow when laparoscopic "ischemic preconditioning" was attempted by selectively ligating the short gastric (SG) vessels or both the left and short gastric (LG/SG) vessels prior to THE.METHODS:Seventeen (25 kg) mongrel dogs underwent laparoscopy followed 3 weeks later by THE. Three groups were studied: control group = laparoscopy only, no preconditioning (n = 6); SG group = laparoscopic ligation of SG vessels only (n = 5); and LG/SG group = laparoscopic ligation of LG and SG vessels (n = 6). Tissue blood flow was assessed using the fluorescent microsphere method. The initial microsphere injections occurred prior to pneumoperitoneum and upon completion of the laparoscopy. At the second operation, transhiatal esophagectomy was performed and microsphere blood flow assessment occurred after induction of anesthesia, after mobilization of the stomach, and after completion of the cervical esophagogastric anastomosis. The animals were euthanized and regional gastric tissue was analyzed for microsphere estimates of blood flow. Differences in blood flow were evaluated using Student's t test.RESULTS:The mean baseline gastric blood flow was 0.58 ml/min/g. After THE, the proximal gastric blood flow fell to 16% of baseline in control and 22% in SG, but was reduced to only 60% of baseline in LG/SG. This relative preservation of blood flow among the LG/SG group approached significance compared with the laparoscopy-only (control) group (P = 0.07). Ligation of SG vessels alone provided no preservation of proximal gastric blood flow following THE.CONCLUSION:Preoperative "ischemic preconditioning" through ligation of both the short and left gastric vessels may achieve preservation of blood flow to the gastric tip. Preconditioning during laparoscopic staging of esophageal carcinoma may be considered to reduce anastomotic complications following esophagectomy.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is 1 of the most common procedures performed for severe obesity. Incidental anatomic abnormalities found at surgery are uncommon and can require an alternative operative approach. We present a video case report of a patient incidentally found to have midgut congenital malrotation at LRYGB.

Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric surgical procedure in the United States. Many of these patients will develop complications, experience inadequate weight loss, or weight regain. We describe our experience with patients undergoing laparoscopic revision of RYGB.

Improvement and resolution of type 2 diabetes occurs in the majority of patients that undergo Roux-en-Y gastric bypass. Some patients with severe obesity and Type I1 (T1DM) require increasing doses of insulin and are at risk for DM related complications. We describe our experience with patients with T1DM undergoing bariatric surgery and review the safety, efficacy, results, and outcomes.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is 1 of the most common procedures performed for severe obesity. Complications are not uncommon, and the evaluation for symptoms of abdominal pain and dysphagia can be difficult. Extensive evaluation can require upper gastrointestinal (GI) radiologic series, endoscopy, and abdominal computed tomography to help in the diagnosis. Some of these patients could require revisional procedures to alleviate their symptoms. We present a video case report of a patient with chronic abdominal pain, dysphagia, and vomiting due to a hiatal hernia, bile reflux, and a poorly emptying pouch. The video demonstrates the laparoscopic revision of the gastric pouch and gastrojejunal anastomosis, revision of the Roux limb, hiatal hernia repair, and gastrostomy tube placement.

Although vertical banded gastroplasty (VBG) was endorsed by the 1991 NIH Consensus Conference for the treatment of morbid obesity, it has largely been abandoned due to poor long-term weight loss and band-related complications. We present our experience with laparoscopic revision of VBG to Roux-en-Y Gastric Bypass (RYGB) and review the safety, efficacy, results, and outcomes.

Background: Although vertical banded gastroplasty (VBG) was endorsed by the 1991 National Institutes of Health Consensus Conference for the treatment of morbid obesity, it has largely been abandoned owing to the poor long-term weight loss and band-related complications. The objective of the present study was to review the outcomes of patients who had undergone laparoscopic conversion of VBG to Roux-en-Y gastric bypass (RYGB) for weight loss or dysphagia and gastroesophageal reflux.Methods: A retrospective review of prospectively collected data from all patients who had undergone revision of VBG to RYGB was performed. The data on the symptoms, weight loss, co-morbidities, and complications were collected.Results: From July 1999 to April 2010, 2397 bariatric procedures were performed. Of these, 105 (4.4%) were laparoscopic revisions of previous VBG to RYGB. Of the 105 patients, 103 had undergone open VBG and 2 laparoscopic VBG. Of the 105 patients, 97 were women and 8 were men. The average patient age was 49 years (range 23-71). The median preoperative body mass index was 42 kg/m(2) (range 20-72). Short- and long-term complications occurred in 40 patients (38%). No patients died. The median length of stay was 2 days. At an average follow-up of 31 months (range 1-96), the median percentage of excess weight loss was 47% (range -24% to 138%). The median decrease in body mass index was 8 kg/m(2) (range -6 to 30). Dysphagia had improved or resolved in 100%. Gastroesophageal reflux disease had improved or resolved in 95%. Diabetes had improved or went into remission in 90%. Hypertension had improved or resolved in 62%. Obstructive sleep apnea had improved or resolved in 96%.Conclusion: The results of our study have shown that laparoscopic revision of VBG to RYGB is a feasible procedure that can provide acceptable weight loss and reversal of weight-related co-morbidities. Complications were common after revisional bariatric surgery. (Surg Obes Relat Dis 2011;7:493-499.) (c) 2011 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Selection of candidates for surgical fellowships has traditionally been based on subjective evaluations by the program directors and references from previous positions. The introduction of well-validated objective methods of assessment has allowed us to evaluate candidates’ technical skills and base the selection process on objective, reliable, and transparent criteria. The aim of the study was to assess the applicability of such methods in current practice.

Abdominal pain during pregnancy is common and may be due to surgical causes such as appendicitis and diseases of the gallbladder. Women that have undergone Roux-en-Y gastric bypass (RYGB) for morbid obesity are at risk for internal hernias.

BACKGROUND:Obesity is a risk factor for cancer and is associated with increased mortality from a number of malignancies. We describe our experience with bariatric surgery patients with a history of malignancy and review the safety and outcomes of bariatric surgery in patients with a history of cancer.METHODS:We performed a retrospective review of prospectively collected data from all patients diagnosed with a malignancy before, during, or after bariatric surgery. Data on weight loss, co-morbidities, and recurrence were collected.RESULTS:From July 1999 to February 2008, 1566 patients underwent bariatric surgery. Of these 1566 patients, 36 (2.3%) had a history of malignancy before they underwent bariatric evaluation and surgery, 4 (0.26%) were diagnosed with a malignancy during their preoperative evaluation, 2 of whom subsequently underwent bariatric surgery, and 2 had intraoperative findings suspicious for malignancy; bariatric surgery was completed in both cases. The evaluation revealed renal cell carcinoma and low-grade lymphoma, respectively. No procedures were aborted because of a suspicion of malignancy. Postoperatively, 16 patients (0.9%) were diagnosed with cancer, 3 of whom had a history of malignancy: 1 with metastatic renal cell, 1 with recurrent melanoma, and 1, who had had prostate cancer, with bladder cancer.CONCLUSION:A history of malignancy does not appear to be a contraindication for bariatric surgery as long as the life expectancy is reasonable. Screening for bariatric surgery might reveal the malignancy. Bariatric surgery does not seem to have a negative effect on the treatment of malignancies that are discovered in the postoperative period.

Immunosuppression is considered by some surgeons to be a relative contraindication for weight loss surgery. We describe our experience with immunosuppressed patients undergoing weight loss surgery.

Patients undergoing bariatric surgery while on anticoagulation are considered high risk. We describe our experience with bariatric surgery on patients on active anticoagulation.

Obesity is associated with increased mortality from a variety of malignant diseases. We describe our experience with bariatric surgery and malignant diseases.