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The presentation of gastroesophageal reflux ranges from asymptomatic patients to incapacitating symptoms and can even promote the development of adenocarcinoma of the esophagus. In order to understand the correct management of gastroesophageal reflux disease (GERD), it is important to understand the anatomical and pathophysiological changes that lead to its development.

Management of post-bariatric surgery emergencies is common practice in the USA and the world. Due to the popularity and widespread use of bariatric procedures to treat obesity and its comorbidities, emergency physicians and general surgeons will be challenged with the treatment of short- and long-term complications of bariatric procedures. In this article, we evaluate the most common long-term complications of the most commonly performed bariatric interventions.

Bariatric surgery emerged as an effective way to treat morbid obesity, and it was rapidly recognized to have the capability to improve diabetes mellitus type 2 (T2DM), reduce cardiovascular events, and improve survival (Buchwald et al. Am J Med 122: 248, 2009; Sjostromk et al. JAMA 307: 56–65, 2012; Adams et al. N Engl J Med 357: 741–752, 2007; Halperin and Goldfine. Curr Opin Endocrinol Diabetes Obesity 20: 98–105, 2013). It has been suggested that 84 % of the patients with diabetes will undergo long-term remission after RYGB (Jurowich et al. Obes Surg 22: 1521–1526, 2012). The bariatric procedures most commonly performed are Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric band (LAGB), laparoscopic sleeve gastrectomy (LSG), and biliopancreatic diversion (BPD), each with different magnitude in the excess weight loss, but with sustainable long-term results compared with medical group alone.

Limited information is available regarding reversal of gastric bypass. While reversal will lead to weight regain and return of comorbid conditions, procedure reversal is sometimes necessary due to complications. The decision to reverse versus revise is difficult; currently, there are no established guidelines. The objective was to review one center's experience with reversals of gastric bypass and jejunoileal bypass procedures and identify potential indications as well as technical feasibility and short-term outcomes. A retrospective review of a prospectively collected database from 1999 to 2010 was conducted; 12 patients who underwent reversal of non-banding bariatric procedures were included. There was no major perioperative morbidity in elective patients; one patient whose reversal was part of a second-look operation had massive intestinal necrosis. There was one (8.3 %) non-procedure-related postoperative death. No leaks were identified in any of the reversals. Leak rates were compared with other revisional procedures such as reversals, revisions, and conversions, with no statistical significance regarding leak rates between all three groups; however, revisions and conversions were performed via open or laparoscopic approach, while reversals were performed exclusively via open approach. Reversals of bariatric (non-banding) procedures, either combined or purely malabsorptive, are technically challenging. Indications remain poorly defined. In our experience, short gut syndrome, renal failure, marginal ulceration, and malnutrition were the most common indications for reversal, differing from previously published data. Indications can depend on patient and surgeon preferences, but primarily on surgeon experience and type of complications. Based on this initial experience, these operations can be performed using the open approach with good outcomes.

Introduction Superior mesenteric artery syndrome is a clearly defined and uncommon medical condition. Surgical intervention is needed for failed long-term medical management. Material and methods We report a series of 3 cases, a 17-year-old woman, a 23-year-old man, and a 50-year-old woman that were successfully treated by Roux-en-Y duodenojejunal bypass using a laparoscopic approach. Technique A 5-trocar laparoscopic approach was used for the surgery. A 75 cm long Roux limb was used in all cases. Results The postoperative period was unremarkable and symptoms of obstruction subsided in all 3 cases. Conclusions Laparoscopic duodenojejunal bypass seems to be a feasible and safe treatment option for superior mesenteric artery syndrome.

The surgical treatment of morbid obesity and the numerous medical conditions associated with obesity has evolved over the past 58 years since the first operation specifically designed to create weight loss was performed and reported. Many different procedures and innumerable variations of procedures have since come and gone. The transition to laparoscopic procedures has dramatically improved recovery time, discomfort, cosmesis, and many complications. Lessons learned during the evolution of bariatric and metabolic surgery are important to remember in order to continue to improve safety and efficacy.

Laparoscopic adhesiolysis is a valuable tool for the surgeon performing complex minimally invasive procedures. It can be used for the management of intestinal obstruction and chronic abdominal pain syndromes. It is also an essential skill when performing laparoscopic surgery on patients who had prior abdominal operations. The use of laparoscopy for patients with an intestinal obstruction was once considered an absolute contraindication. With the advancement in optics and increasing experience, more and more surgeons are turning to laparoscopy as a useful diagnostic and therapeutic tool in more complex situations.

Many diseases in the obese population have been found to improve after weight loss. A 56-year-old female with a long history of myasthenia gravis (MG) and morbid obesity is reported. Preoperatively, she presented with a BMI of 46.5 kg/m2, and was on three medications and IV immunoglobulin every 5 weeks. After the surgical procedure, she improved and required less medication. Because MG and morbid obesity require careful perioperative management in order to avoid complications, a multidisciplinary approach is recommended.

Laparoscopic gastric banding is a popular method for treating morbid obesity. One of the most serious complications is band erosion into the gastric lumen. We present the case of a patient who underwent gastric banding and presented with symptoms of gastrointestinal reflux and mild-to-moderate hypertension, fever, and pain. UGI revealed stomach wall erosion and partial migration of the band into the gastric lumen. The band was laparoscopically removed without any further complications. Migration after laparoscopic gastric banding must be immediately addressed to prevent infection. Close monitoring of the band location during adjustments as well as a high index of suspicion is necessary.

Background: The authors reviewed the benefits of routine placement of closed drains in the peritoneal cavity following laparoscopic Roux-en-Y gastric bypass (LRYGBP). The purpose of the study was to determine whether routine closed abdominal drainage provides diagnostic and therapeutic advantages in the presence of complications such as bleeding and leaks. Materials and Methods: The medical records of 593 consecutive patients who had undergone LRYGBP from July 2001 through May 2003 were retrospectively reviewed. In all cases, antecolic antegastric LRYGBP was performed. Two 19-Fr Blake closed suction drains were left in place, one at the gastrojejunostomy and the other at the jejunojejunostomy. The incidence of bleeding and leaks was reviewed, and the utility of the drains relative to diagnosis and management was evaluated. Results: Bleeding presented in 24 patients (4.4%); in 8, the diagnosis was based on increased sanguinous output from the drain and decreased hematocrit. None of the patients with intraabdominal bleeding required reoperation. Of the 10 patients (1.68%) who presented with leaks, the diagnosis was made within 48 hours postoperatively in 5 patients (50%), based on the characteristics of the drain output. Nonoperative management with drainage and total parenteral nutrition was accomplished in 5 (50%) of the 10 patients with leaks. There was no mortality in the series. Conclusion: The routine use of abdominal drains after LRYGBP appears to be beneficial. Drains allowed early diagnosis of complications and in most cases, the successful treatment of leaks. When bleeding is suspected or documented, appropriate volume replacement therapy is mandatory to maintain adequate hemodynamic parameters. Drain output may orient the surgeon to take preventive measures such as discontinuing anticoagulation and early fluid resuscitation. In this series, in most cases the bleeding spontaneously stopped and no further surgical management was required.

data base (7F, mean age 457y, BMI 518 kg/m 2 , HbA1c: 8.31%). 16 LRYGB Obese Diabetics with similar pre-operative features (Group2), were identified (7F; mean age 458y; BMI 484 kg/m2, HbA1c: 8.51%). LRGBP alimentary limb was 150 cm and bilio-pancreatic limb was 50 cm from Treitz ligament. SG vertical transection was calibrated on a 40F oro-gastric bougie. Data were analyzed at 15 days, 6 months, 1 year according weight loss and diabetes resolution (fasting glucose 126 mg/dl without hypoglycemic drugs). Data were reported as meanSD, statistical analysis was by Fisher’s exact test (p0.05 was significant). Results: Group1 and Group2 BMI were comparable at 15 days: 467 and 445 kg/m2, respectively (p0,479). BMI was significantly lower in Group2 (354 and 325 kg/m 2 ) vs. Group 1 (426 and 385 kg/m 2 ) at 6 months and 1 year respectively (P0.02). Diabetes resolution occurred in 66, 77and 77% of Group1 patients and in 94, 100, 94% of Group2 at 15 days, 6 months and 1 year, respectively (pns). Conclusion: In spite of its statistically significant inferiority regarding weight loss in comparison with LRYGB, SG is equally effective for the diabetes resolution.