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Is routine prophylactic cholecystectomy necessary at time of Roux-en-Y gastric bypass for morbid obesity?
Abstracts: Plenary Session/Surgery for Obesity and Related Diseases / 1 (2005) 222–283
Purpose: Gastric bypass is used to successfully treat the medical complications of morbid obesity. During the extensive preoperative evaluation and risk assessment, new medical conditions are often diagnosed. A four-year retrospective review of a single surgeon’s experience was used to determine the incidence of previously unidentified medical conditions and their relative frequencies. Methods: Between February 7, 2001 and October 31, 2004 the charts of 360 patients were reviewed. The presenting diagnoses were made by the primary care physicians and documented by the bariatric dietitians. These diagnoses were compared with those identified during the standard preoperative risk assessment. Sleep studies, cardiac, or pulmonary evaluations were conducted based on clinical indications. Results: On review of 360 charts, new medical diagnoses were obtained in 134 (37%) patients. Some patients had more than one new medical diagnosis. Obstructive sleep apnea was identified in 117 (32.5%) patients, hypertension in 7 (1.9%), diabetes mellitus in 7 (1.9%), cardiac disease in 4 (1.1%), thyroid disease in 7 (1.9%), gallstones in 3 (0.8%), hypercholesterolemia in 2 (0.6%), and GERD in 2 (0.6%). Conclusions: Previously undiagnosed medical conditions are commonly revealed in the extensive preoperative risk assessment for bariatric surgical candidates. Even diagnoses that are prevalent in the morbidly obese population are often not diagnosed by primary care physicians. This has a great health impact on whether or not patients undergo surgery. PII: S1550-7289(05)00225-X POSTOP
P38.
PREOPERATIVE RADIOLOGIC DIAGNOSIS OF INTERNAL HERNIA AFTER LAPAROSCOPIC ROUXEN-Y GASTRIC BYPASS Alexander Onopchenko, M.D., The Center for Surgical Weight Loss and Wellness at Atlantic City Medical Center, Atlantic City, NJ. Purpose: Internal hernia ia a known complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). Preoperative diagnosis may be difficult on the basis of history and physical examination. CT scanning is often performed as a diagnostic tool for patients with symptoms after LRYGB but is often read by the radiologist as non-specific or normal. Preoperative review of the study by the bariatric surgeon familiar with the neoanatomy can identify the internal hernia and its location. Methods: We retrospectively reviewed our first 205 patients undergoing LRYGB to identify all patients that developed an internal hernia. The patient’s symptoms, physical findings and CT scan fidings were reviewed. Time to presentation with the internal hernia was noted. Radiologic interpretation of the scans was recorded as well as the bariatric surgeon’s preoperative impression after review of the scans. Results: In our initial experience of 205 patients undergoing LRYGB, 5 patients presented at various times in their postoperative course with an internal hernia for an incidence of 2.4%. All patients underwent preoperative CT scanning. Radiological interpretation of the scans identified one internal hernia of the five
259
preoperatively. Preoperative review of the scans by the bariatric surgeon was not only highly suggestive of the diagnosis but of the location as well in all 5 cases. Conclusions: Preoperative diagnosis of an internal hernia in patients after LRYGB is often difficult. CT scanning has been found to be a very helpful diagnostic tool especially when reviewed preoperatively by the bariatric surgeon. PII: S1550-7289(05)00226-1
P39.
IS ROUTINE PROPHYLACTIC CHOLECYSTECTOMY NECESSARY AT TIME OF ROUX-EN-Y GASTRIC BYPASS FOR MORBID OBESITY? Jerome D. Taylor, M.D., I. Michael Leitman, M.D., Peter K. Hon, B.S., Michael Horowitz, M.D., Lenox Hill Hospital, New York, NY. Purpose: Morbid obesity is associated with an increased incidence of gallstones. Rapid weight loss, such that occurs after gastric bypass surgery may also increase the incidence of gallstone development. Standard surgical treatments for gallbladder disease and its complications might be more difficult after gastric bypass surgery. Controversy exists whether prophylactic cholecystectomy is necessary at the time of Roux-en-Y gastric bypass (RGB). Methods: Retrospective analysis was performed on a database of 535 patients undergoing Roux-en-Y gastric bypass surgery for morbid obesity during a 5.5-year period. Patients were followed and medical records were reviewed. Ursodeoxycholic acid (Actigall) was not prescribed for any patient after surgery. Results: Eight percent of patients had cholecystectomy before RGB. 75 of 492 patients (15%) were found the have gallstones at RGB and cholecystectomy was performed at the same time. Three of these patients had bile leaks but only one required further intervention (percutaneous transhepatic drainage for 3 weeks). After RGB, 14 patients (3%) required cholecystectomy for symptomatic cholelithiasis in the postoperative period. All were performed laparoscopically and without complication. Conclusions: Gallbladder disease after gastric bypass surgery does occur but is not frequent. Prophylactic cholecystectomy for a normal gallbladder is not necessary at the time of gastric bypass surgery. Patients without biliary tract symptoms may not require routine preoperative sonogram. If an abnormal gallbladder or gallstones are found at the time of gastric bypass surgery, then prophylactic cholecystectomy should be considered. PII: S1550-7289(05)00227-3
P40.
READMISSIONS AFTER BARIATRIC SURGERY: OPEN VERSUS LAPAROSCOPIC Pratibha Vemulapalli, M.D., Glenn J. Forrester, M.D., Larry F. Griffith, M.D., Babak Moeinolmolki, M.D., Karen E. Gibbs, M.D., Julio Teixeira, M.D., Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY. Purpose: Emergency room visits and early readmission after bariatric surgery (⬍30 days) occur at an unknown frequency. We sought to determine how often patients returned to the emergency department (ED) after undergoing bariatric surgery for the treatment of morbid obesity.
Purpose: Gastric bypass is used to successfully treat the medical complications of morbid obesity. During the extensive preoperative evaluation and risk assessment, new medical conditions are often diagnosed. A four-year retrospective review of a single surgeon’s experience was used to determine the incidence of previously unidentified medical conditions and their relative frequencies. Methods: Between February 7, 2001 and October 31, 2004 the charts of 360 patients were reviewed. The presenting diagnoses were made by the primary care physicians and documented by the bariatric dietitians. These diagnoses were compared with those identified during the standard preoperative risk assessment. Sleep studies, cardiac, or pulmonary evaluations were conducted based on clinical indications. Results: On review of 360 charts, new medical diagnoses were obtained in 134 (37%) patients. Some patients had more than one new medical diagnosis. Obstructive sleep apnea was identified in 117 (32.5%) patients, hypertension in 7 (1.9%), diabetes mellitus in 7 (1.9%), cardiac disease in 4 (1.1%), thyroid disease in 7 (1.9%), gallstones in 3 (0.8%), hypercholesterolemia in 2 (0.6%), and GERD in 2 (0.6%). Conclusions: Previously undiagnosed medical conditions are commonly revealed in the extensive preoperative risk assessment for bariatric surgical candidates. Even diagnoses that are prevalent in the morbidly obese population are often not diagnosed by primary care physicians. This has a great health impact on whether or not patients undergo surgery. PII: S1550-7289(05)00225-X POSTOP
P38.
PREOPERATIVE RADIOLOGIC DIAGNOSIS OF INTERNAL HERNIA AFTER LAPAROSCOPIC ROUXEN-Y GASTRIC BYPASS Alexander Onopchenko, M.D., The Center for Surgical Weight Loss and Wellness at Atlantic City Medical Center, Atlantic City, NJ. Purpose: Internal hernia ia a known complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). Preoperative diagnosis may be difficult on the basis of history and physical examination. CT scanning is often performed as a diagnostic tool for patients with symptoms after LRYGB but is often read by the radiologist as non-specific or normal. Preoperative review of the study by the bariatric surgeon familiar with the neoanatomy can identify the internal hernia and its location. Methods: We retrospectively reviewed our first 205 patients undergoing LRYGB to identify all patients that developed an internal hernia. The patient’s symptoms, physical findings and CT scan fidings were reviewed. Time to presentation with the internal hernia was noted. Radiologic interpretation of the scans was recorded as well as the bariatric surgeon’s preoperative impression after review of the scans. Results: In our initial experience of 205 patients undergoing LRYGB, 5 patients presented at various times in their postoperative course with an internal hernia for an incidence of 2.4%. All patients underwent preoperative CT scanning. Radiological interpretation of the scans identified one internal hernia of the five
259
preoperatively. Preoperative review of the scans by the bariatric surgeon was not only highly suggestive of the diagnosis but of the location as well in all 5 cases. Conclusions: Preoperative diagnosis of an internal hernia in patients after LRYGB is often difficult. CT scanning has been found to be a very helpful diagnostic tool especially when reviewed preoperatively by the bariatric surgeon. PII: S1550-7289(05)00226-1
P39.
IS ROUTINE PROPHYLACTIC CHOLECYSTECTOMY NECESSARY AT TIME OF ROUX-EN-Y GASTRIC BYPASS FOR MORBID OBESITY? Jerome D. Taylor, M.D., I. Michael Leitman, M.D., Peter K. Hon, B.S., Michael Horowitz, M.D., Lenox Hill Hospital, New York, NY. Purpose: Morbid obesity is associated with an increased incidence of gallstones. Rapid weight loss, such that occurs after gastric bypass surgery may also increase the incidence of gallstone development. Standard surgical treatments for gallbladder disease and its complications might be more difficult after gastric bypass surgery. Controversy exists whether prophylactic cholecystectomy is necessary at the time of Roux-en-Y gastric bypass (RGB). Methods: Retrospective analysis was performed on a database of 535 patients undergoing Roux-en-Y gastric bypass surgery for morbid obesity during a 5.5-year period. Patients were followed and medical records were reviewed. Ursodeoxycholic acid (Actigall) was not prescribed for any patient after surgery. Results: Eight percent of patients had cholecystectomy before RGB. 75 of 492 patients (15%) were found the have gallstones at RGB and cholecystectomy was performed at the same time. Three of these patients had bile leaks but only one required further intervention (percutaneous transhepatic drainage for 3 weeks). After RGB, 14 patients (3%) required cholecystectomy for symptomatic cholelithiasis in the postoperative period. All were performed laparoscopically and without complication. Conclusions: Gallbladder disease after gastric bypass surgery does occur but is not frequent. Prophylactic cholecystectomy for a normal gallbladder is not necessary at the time of gastric bypass surgery. Patients without biliary tract symptoms may not require routine preoperative sonogram. If an abnormal gallbladder or gallstones are found at the time of gastric bypass surgery, then prophylactic cholecystectomy should be considered. PII: S1550-7289(05)00227-3
P40.
READMISSIONS AFTER BARIATRIC SURGERY: OPEN VERSUS LAPAROSCOPIC Pratibha Vemulapalli, M.D., Glenn J. Forrester, M.D., Larry F. Griffith, M.D., Babak Moeinolmolki, M.D., Karen E. Gibbs, M.D., Julio Teixeira, M.D., Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY. Purpose: Emergency room visits and early readmission after bariatric surgery (⬍30 days) occur at an unknown frequency. We sought to determine how often patients returned to the emergency department (ED) after undergoing bariatric surgery for the treatment of morbid obesity.