Linear or circular: Anastomotic ulcer after gastric bypass surgery

Background After laparoscopic Gastric Bypass Procedure (GBP), anastomotic ulcers (AU) at the gastrojejunostomy (GJ) occur in up to 16% of the patients. Surgical techniques seem to influence the development of AU, but this is still a matter of discussion. This study aims to compare the incidence of AU in circular-stapled (CS) versus linear-stapled (LS) gastrojejunostomy. Methods Single-centre retrospective analysis of 241 (m 77 /f 164) consecutive patients (126 CS, 115 LS) with primary or revisional GBP including Roux-Y-Gastric Bypass (RYGB) and One-Anastomosis Gastric Bypass (OAGB) between 01/2014 and 01/2018. Follow-up with oesophagogastroduodenoscopy was only performed in symptomatic patients. Age, body mass index (BMI), comorbidities, smoking and medication were analyzed in both groups. The data are reported as total numbers (%) and mean ± standard deviation. Results AU occurred significantly more often in the CS group than in the LS group (p = 0.0034). Moreover, refractory AU and the need for revisional surgery were higher in the CS group. Smoking correlates significantly with the development of AU, whereas other risk factors had no impact on its incidence. Conclusion Linear-stapled gastrojejunostomy with a long and narrow pouch should be the preferable procedure for reducing AU development risk. Smoking cessation minimizes the risk for AU and is a necessary part of the treatment.

Multi-task temporal convolutional networks for joint recognition of surgical phases and steps in gastric bypass procedures

Purpose Automatic segmentation and classification of surgical activity is crucial for providing advanced support in computer-assisted interventions and autonomous functionalities in robot-assisted surgeries. Prior works have focused on recognizing either coarse activities, such as phases, or fine-grained activities, such as gestures. This work aims at jointly recognizing two complementary levels of granularity directly from videos, namely phases and steps. Methods We introduce two correlated surgical activities, phases and steps, for the laparoscopic gastric bypass procedure. We propose a multi-task multi-stage temporal convolutional network (MTMS-TCN) along with a multi-task convolutional neural network (CNN) training setup to jointly predict the phases and steps and benefit from their complementarity to better evaluate the execution of the procedure. We evaluate the proposed method on a large video dataset consisting of 40 surgical procedures (Bypass40). Results We present experimental results from several baseline models for both phase and step recognition on the Bypass40. The proposed MTMS-TCN method outperforms single-task methods in both phase and step recognition by 1-2% in accuracy, precision and recall. Furthermore, for step recognition, MTMS-TCN achieves a superior performance of 3-6% compared to LSTM-based models on all metrics. Conclusion In this work, we present a multi-task multi-stage temporal convolutional network for surgical activity recognition, which shows improved results compared to single-task models on a gastric bypass dataset with multi-level annotations. The proposed method shows that the joint modeling of phases and steps is beneficial to improve the overall recognition of each type of activity.

A qualitative study exploring patient suggestions for the design, functionality and implementation of digital health technologies before and after bariatric surgery

Introduction Health behaviour changes made during the pre-operative period can positively impact on post-operative outcomes and the success of bariatric surgery.(1) Digital technologies present an opportunity to support patients with this. Currently, little is known about the optimal design or delivery of digital technologies for this patient cohort. In order to develop useful and effective digital strategies for this unique patient cohort, it is important to first understand how bariatric surgery patients want to be supported.(2) Aim To understand how digital technologies could be designed and delivered to better support patients with surgical health behaviour changes, specifically: 1) what do patients want from technologies, 2) how do they want to use them, and 3) when should they be implemented? Methods According to the EQUATOR guidelines, the consolidated criteria for reporting qualitative research (COREQ) checklist was followed. Pre- and post-operative patients attending bariatric surgery clinics within one large teaching hospital in the North of England were invited to take part. Purposive sampling was employed to recruit a representative sample of patients. Participants received an information sheet detailing the study purpose and aims. Written informed consent was obtained before conducting semi-structured interviews. Semi-structured interviews took place between February-March 2020 and were audio-recorded and transcribed verbatim. Interviews included questions on participant surgical experience, health behaviour change and perspectives on digital technologies. A reflexive thematic analysis approach enabled the development of themes from the data. NVivo 12 software assisted data organisation. Results Eighteen patients were recruited and interviewed. The average age of participants was 46-years. 55% (n=10) of participants had or were undergoing a gastric bypass procedure. The data analysis enabled the development of four themes which highlighted specific participant desires relating to the design, functionality and implementation of optimal digital technologies to best support them during the pre- and post-operative periods. Specifically, the themes related to an intervention’s ability to: 1) provide structured content and support, 2) facilitate self-monitoring and goal-setting, 3) deliver information in an accessible, trusted and usable manner, and 4) meet patient information-seeking and engagement needs (Figure 1). “In the first couple of weeks (following surgery), we need to be told what to do by the technology” Participant 9. Conclusion This patient-informed research highlighted how interventions could be designed, what functionality would be most useful and when they should be implemented within the NHS pathway for bariatric surgical patients. This study is one of the first in this patient cohort to involve pre- and post-operative participants and provides key insights to fill knowledge gaps relating to the design and optimisation of person-centred digital interventions. We acknowledge some limitations with our work. Whilst we did not sample participants by socioeconomic status, it is possible that different socioeconomic classes may have varied experiences with technologies. Our focus was solely bariatric surgery and thus findings may not be generalisable to other elective surgical procedures. These findings have the potential to shape and influence future work on the co-design and optimisation of person-centred digital health technologies in modern healthcare settings. References 1. Michie S, Abraham C, Whittington C, McAteer J, Gupta S. Effective techniques in healthy eating and physical activity interventions: a meta-regression. Health Psychology. 2009;28(6):690. 2. Donetto S, Pierri P, Tsianakas V, Robert G. Experience-based Co-design and Healthcare Improvement: Realizing Participatory Design in the Public Sector. The Design Journal. 2015;18(2):227–48.

Perforated One Anastomosis Gastric Bypass, How We Managed and Review of Literature

: Marginal ulcer formation remains a common complication of the one anastomosis gastric bypass procedure, the ulcer can further perforate and present as peritonitis and although this is uncommon, it is considered one of the life threatening sequela associated with this surgery, we report here 2 different cases of perforated marginal ulcers that presented months after the procedure with acute abdomen, and discuss the surgical management using the laparoscopic approach to repair the perforation.

Gastric Bypass and Absorption of Antihypertensive Medications

Little is known about the effects of gastric bypass on the absorption of prescription medications in the post-operative state. This poses a considerable clinical dilemma especially that the prevalence of morbid obesity continues to escalate in the United States of America, and as a result the number of gastric bypass procedures performed each year has similarly increased dramatically. The author presented a case of a 45-year-old male with refractory hypertension, secondary to mechanical complications after a Roux-en-Y gastric bypass procedure due to anatomical alteration contributing to pill retention and change in medications' pharmacokinetics. Investigations for secondary causes of hypertension were made, patient’s blood pressure had become exceedingly difficult to control after his Roux-en-Y gastric bypass procedure and had only been controlled with IV medications. Further investigations confirmed the diagnosis of a mechanical gastrointestinal complication.

LONG-TERM POSTOPERATIVE ENDOSCOPIC FINDINGS AFTER GASTRIC BYPASS PROCEDURE: a co-occurrence analysis

ABSTRACT Background A multitude of endoscopic findings post-gastric bypass procedures have been previously reported in the literature, but to our knowledge, no present rules exist that could guide clinicians regarding which findings should be actively sought, once an initial finding is identified. Objective To identify co-occurrence patterns among endoscopic findings of patients having undergone past gastric bypass procedure. Methods Our registry involves all consecutive patients undergoing an upper endoscopic evaluation after a gastric bypass procedure. We collected information on the presence of the endoscopic findings in post-gastric bypass surgery patients. Co-occurrence evaluation involved the use of intersection, cluster and item factor analyses. Results A total of 396 endoscopic evaluations were made on 339 patients. Most patients were female (81.1%), with an average BMI of 31.88±6.7 at the time of endoscopy. Esophagitis was the most common isolated finding (35.3%). Endoscopic findings clustered around two groups, (1) the ring-related complications involving ring displacement, ring slips and gastric pouch, while (2) stenosis-related findings involved dilation and stenosis (P<0.01). Conclusion While most endoscopic findings after gastric bypass endoscopic procedures are isolated, ring and stenosis-related clusters should be used as a set of rules by clinicians, as it might enhance their probability of finding co-occurring conditions.