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Obesity is a well-established risk factor for endometrial cancer and is thought to adversely affect outcomes. The impact of significant and sustained weight loss as achieved by bariatric surgery for women with endometrial cancer is not well understood. We performed an institutional retrospective review of patients who underwent bariatric surgery and were diagnosed with premalignant or malignant uterine disease from 1989 to 2019 (n=171). We compared tumor characteristics and cancer-specific outcomes in patients diagnosed with uterine disease before (“PRE” group) or after (“POST” group) undergoing bariatric surgery and in a BMI- and age-matched cohort who did not undergo bariatric surgery. Of the 171 patients, 120 were in the PRE group and 51 in the POST group. The POST group was more likely to have adenocarcinoma (68.6 vs 45.0%, p=0.012) and more likely to have a minimally invasive hysterectomy (80.9 vs 46.2%, p

Bariatric surgery is associated with a reduced risk of developing certain malignancies, particularly in women. However, the impact of bariatric surgery on tumor characteristics, cancer treatment, and oncologic outcomes is unknown. In a retrospective cohort study, 42 subjects diagnosed with breast cancer after bariatric surgery (1989–2014) were matched to 84 subjects with breast cancer (1984–2012) who did not undergo bariatric surgery, based on age, body mass index (BMI), and menopausal status at the time of breast cancer diagnosis, as well as the date of cancer diagnosis. Medical records were reviewed for cancer and bariatric endpoints. Statistical analysis was performed using mixed effects regression models, generalized estimating equation, conditional logistic regression, and Fisher’s exact tests. Women who developed breast cancer after bariatric surgery presented at an earlier stage compared to non-operated, obese controls. In the bariatric surgery group, there were fewer tumors with human epidermal growth factor receptor 2 overexpression (HER2+) (OR 0.16 (0.03–0.76); p = 0.02), with no significant differences seen in estrogen and progesterone receptor positivity. No HER2+ cancers were found in patients who underwent Roux-en-Y gastric bypass (OR 0.00 (0.00–0.43); p = 0.002). On multivariate analysis, bariatric surgery status remained associated with reduced HER2+ breast cancers (OR 0.18 (0.03–0.99); p

The metabolic and immunologic properties of adipose tissue are linked to the pathogenesis of type 2 diabetes mellitus. Lipomatous tumors, such as liposarcomas, are rare but can reach significant size. We hypothesized that some lipomatous tumors are metabolically active and can alter systemic glucose homeostasis.We performed a retrospective study of patients who underwent resection of a lipomatous tumor at a tertiary cancer referral center (2004-2015). We divided patients into nondiabetics, well-controlled diabetics (hemoglobin A1c [HbA1c] 7), and poorly controlled diabetics (HbA1c ≥ 7). We compared patient demographics, tumor characteristics, and measures of glycemic control among these groups before and after tumor resection.We reviewed 217 operations for lipomatous tumors. No differences were observed in tumor characteristics in patients with and without diabetes. However, tumor characteristics differed significantly between the well-controlled and poorly controlled diabetics groups. Patients with poorly controlled diabetes had larger tumors that were more likely to be malignant, retroperitoneal, and well-differentiated. Tumor resection had no detectable impact on diabetes, as assessed by HbA1c, and requirement for diabetic medications.Poorly controlled diabetes was linked to the presence of large, malignant, and retroperitoneal lipomatous tumors. However, in limited follow-up, no detectable impact of tumor resection was apparent on glycemic control. These data suggest that most lipomatous tumors do not exert a clinically relevant impact on glucose homeostasis.

Gastroesophageal reflux disease (GERD) and hiatal hernia (HH) are common problems more frequently found in the obese. Growing experience indicates that bariatric surgery can lead to significant weight loss and, in many cases, improvement in GERD. Laparoscopic Roux-en-Y gastric bypass in particular is a highly effective therapy for GERD and can be safely performed in conjunction with repair of an HH. Laparoscopic sleeve gastrectomy (LSG) has rapidly become the most commonly performed bariatric procedure; however, one major drawback of LSG is the potential for development of GERD postoperatively. The indications for LSG in the setting of GERD and HH remain incompletely defined. This chapter highlights aspects of evaluation and management of the obese pre- or postop bariatric surgery patient with GERD and/or HH, including areas of controversy.

Background Retrograde intussusception (RI) at the jejunojejunostomy can occur after Roux-en-Y gastric bypass (RYGB). Although this complication is rare, it has been encountered more frequently as the number of bariatric procedures have increased. Little data is available to assist surgeons with the optimal management of this condition. Our objectives were to identify the risk factors for RI after RYGB and report on outcomes after surgical intervention at a tertiary academic surgical unit. Methods We used our prospective longitudinal institutional bariatric surgical database to identify patients with post-RYGB RI from 1996 to 2011. Results We identified 28 post-RYGB RI cases. The median interval between RYGB and RI was 52 months, and the median percentage of excess weight loss was 75%. Patients presented with acute symptoms in 36% of the cases. All patients underwent surgical exploration, including resection and revision of the jejunojejunostomy (46%) or operative reduction with or without enteropexy (54%). Those undergoing resection had a longer hospital stay but similar 30-day complication rates. At a median follow-up of 9 months, only 1 recurrence was documented. Conclusions RI is a rare and late complication of RYGB and typically occurs after significant weight loss. In the presence of ischemia or nonreducible RI, resection and revision of the jejunojejunostomy is recommended. In less acute patients, laparoscopic management with reduction and/or enteropexy offers a reduced hospital length of stay while maintaining equivalent morbidity and low recurrence compared with resection.

Laparoscopic adjustable gastric band (LAGB) has gone through major design modifications to improve clinical endpoints and reduce complications. Little is known, however, about the effects of LAGB size on clinical outcomes, or whether outcomes differ based on gender. We set out to examine the impact of band size on surgical weight loss, reoperations, comorbidity resolution, and compare outcomes within gender.We reviewed our prospectively collected longitudinal bariatric database between 2008 and 2010, and compared patients with BMI 35-50 kg/m(2) who had undergone LAGB with the LAP-BAND® APS to those who had the larger APL. Those patients with initial BMI 50 kg/m(2) were excluded to reduce any possible selection bias which favors larger band use in such subjects.Three hundred ninety-four patients met our inclusion criteria; 230 (58 %) in the APS group and 164 (42 %) in the APL group. Female patients in APS group experienced significantly higher percentage excess body weight loss at 6 months, 1 year, and 2 years in comparison to female patients in APL group (p 0.001 for all time points). In contrast, a reverse pattern was observed for male patients. No significant differences were observed between the groups regarding frequency of band adjustments, complications, or comorbidity resolution.Male patients might benefit from APL bands, in contrast to female patients who appear to experience superior weight loss with the smaller APS bands. This study provides the first set of evidence to facilitate surgical decision making for band size selection and highlights differences between genders.

Alanine aminotransferase (ALT) is used to detect non-alcoholic fatty liver disease and has been associated with increased risk of metabolic syndrome and type II diabetes mellitus (T2DM). Bariatric procedures result in significant weight loss and a rapid resolution of T2DM. We aimed to study the impact of bariatric interventions on ALT levels in patients with or without T2DM and compare this effect between different types of weight-loss procedures.We reviewed 756 patients undergoing bariatric surgery. Demographics, co-morbidities, baseline and post-operative ALT and HbA1C levels, weight-loss data, and diabetes status were recorded. ALT levels were compared between different procedures and between diabetic and non-diabetic patients. Chi-square test, ANOVA, and t test were used to evaluate outcomes.Males and diabetics had significantly higher ALT at baseline. Both Roux-en-Y gastric bypass surgery (RYGB) and laparoscopic adjustable gastric banding (LAGB) resulted in significant reduction in ALT levels beginning at the third post-operative month (20 and 17 %, respectively, compared to baseline, p 0.001). ALT remained at the new low level up to year 3 after surgery. The degree of reduction was similar for both procedures and was independent of the degree of weight loss. In diabetics, ALT reduction was associated with improvement in disease; but in T2DM patients who remained on insulin, ALT remained elevated.RYGB and LAGB decrease ALT levels to the same degree and independent of weight loss. Our data confirm higher ALT in diabetics and demonstrate a rapid normalization after bariatric surgery with a simultaneous decrease in HbA1C. These results suggest that ALT may be used as a marker of metabolic improvement after bariatric surgery.

OBJECTIVE The impact of bariatric surgeries on insulin-treated type 2 diabetes (I-T2D) in the general population is largely undocumented. We assessed changes in insulin treatment after bariatric surgery in a large cohort of I-T2D patients, comparing Roux-en-Y gastric bypass surgery (RYGB) with laparoscopic adjustable gastric banding (LAGB), controlling for differences in weight loss between procedures. RESEARCH DESIGN AND METHODS Of 113,638 adult surgical patients in the Bariatric Outcomes Longitudinal Database (BOLD), 10% had I-T2D. Analysis was restricted to 5,225 patients with I-T2D and at least 1 year of postoperative follow-up. Regression models were used to identify factors that predict cessation of insulin therapy. To control for differences in weight loss patterns between RYGB and LAGB, a case-matched analysis was also performed. RESULTS Of I-T2D patients who underwent RYGB (n = 3,318), 62% were off insulin at 12 months compared with 34% (n = 1,907) after LAGB (P < 0.001). Regression analysis indicated that RYGB strongly predicted insulin cessation at both 1 and 12 months postoperatively. In the case-matched analysis at 3 months, the proportion of insulin cessation was significantly higher in the RYGB group than in the LAGB group (P = 0.03), and the diabetes remission rate was higher at all time points after this surgery. RYGB was a weight-independent predictor of insulin therapy cessation early after surgery, whereas insulin cessation after LAGB was linked to weight loss. CONCLUSIONS I-T2D patients have a greater probability of stopping insulin after RYGB than after LAGB (62% vs. 34%, respectively, at 1 year), with weight-independent effects in the early months after surgery. These findings support RYGB as the procedure of choice for reversing I-T2D.

Although laparoscopic splenectomy (Lap-Spleen) has become the standard surgical approach for normal-sized spleens, open splenectomy (Open-Spleen) is still recommended by many in the setting of splenomegaly. We set out to compare the impact of spleen size on Lap-Spleen and Open-Spleen outcomes using a national database.We reviewed the American College of Surgeons' National Surgical Quality Improvement Program database to identify patients who had undergone non-emergency splenectomy during 2005-2010. To evaluate the impact of spleen size on outcomes, we considered patients with diagnoses of splenomegaly and hypersplenism as those having large spleens (Large-Sp group) and those with diagnoses of primary thrombocytopenia and immune thrombocytopenic purpura as having normal spleens (Normal-Sp group). Patients were also categorized based on surgical approach into Lap-Spleen and Open-Spleen groups.We identified 639 patients in the Large-Sp group and 879 patients in the Normal-Sp group. During 2005-2010 laparoscopy was used in 84.2% of cases in the Normal-Sp group (annual range, 77.8%-90.8%). However, the rate of laparoscopy in the Large-Sp group remained consistently below 50% with an average of 41.8% (annual range, 20%-47%). In the Lap-Spleen group, those with Large-Sp had longer operative time and length of stay and higher blood transfusion and morbidity compared with the Normal-Sp group. However, when looking specifically at the Large-Sp group, patients with Open-Spleen had more transfusion requirements, longer length of stay, and higher morbidity, compared with those with Lap-Spleen.Lap-Spleen leads to significant improvement in outcomes. These advantages were believed to be limited to normal-sized spleens, but this study demonstrates that laparoscopy can still be advantageous in patients with splenomegaly. We hope such data encourages wider utilization of laparoscopy in the setting of splenomegaly, especially among surgeons who are experienced with the technique.

The role of adrenalectomy in management of isolated metastatic adrenal tumors is increasingly established. Laparoscopy is becoming the preferred approach for these resections. We evaluated surgical and oncological outcomes of patients who underwent laparoscopic versus open adrenal metastasectomy and assessed the effect of such surgery on postoperative adjuvant therapy and survival. We reviewed our institutional experience with adult patients who underwent an adrenal metastasectomy from 1997 to 2013. We assessed preoperative tumor size, operating room (OR) time, status of resection margin, and length of stay (LOS), as well as oncological outcomes including the use of adjuvant chemotherapy and radiotherapy within 1 year of surgery and 5-year survival. The χ 2 test, Mann–Whitney U test, and Kaplan–Meier curve were used for statistical analysis. Thirty-eight patients were identified. Lung was the primary site of malignancy (52.6 % of cases). Of the metastasectomies, 55.2 % (n = 21) were performed laparoscopically and 44.7 % (n = 17) were open. In the laparoscopic group, median tumor size was 2.6 cm versus 4.8 cm in the open group (p = 0.09). Median OR time and complication rates were similar between the 2 groups. The laparoscopic group, however, trended toward a shorter LOS (3 days laparoscopic vs. 4 days for open; p = 0.07). At 1 year, 37 % of all patients had not required any adjuvant chemotherapy or adjuvant radiotherapy. This series confirms that adrenal metastasectomy leads to favorable oncological outcomes in select patient groups, with over one-third of patients not requiring adjuvant therapy for at least 1 year after their resection. Laparoscopic approach leads to excellent oncological resection margins without increasing OR time and with a possible reduction in LOS.

Surgical resection is often recommended in adults with intestinal intussusception (AI) because of its potential association with malignancy. We provide a contemporary algorithm for managing AI by focusing on the probability of discovering a lead point.This is a retrospective study of adult patients with computed tomography (CT)-confirmed intussusception who underwent operative management of AI between 1996 and 2011 at a single academic institution.Sixty-four patients were diagnosed with AI by CT scan and then managed operatively. The incidence of colonic (CI), small bowel (SBI), and retrograde intussusception (RI) was 14, 55, and 31 %, respectively. All patients with CI had a lead point, whereas none were found among patients with RI. Some 46 % of patients with SBI had a lead point. The probability of discovering a lead point in SBI was increased by past history of malignancy (RR, 3.7, p0.001), a mass seen on preoperative CT scan (RR, 2.9, p = 0.005), and age over 60 years (RR, 2.2, p = 0.07).A pathologic lead point is likely with CI but not with RI. Patients with SBI who are over the age of 60 years and have a history of malignancy or a mass noted on CT scan have a higher likelihood of harboring a pathologic lead point.

Background With the increasing popularity of laparoscopic adjustable banding (LAGB), reoperations to treat band complications have become increasingly more common. Few studies, however, have documented the outcomes of such revisional procedures. The purpose of the present study was to compare the different reoperative approaches after LAGB placement. The present study was conducted at a tertiary referral academic medical center in the United States. Methods We reviewed our bariatric database to identify patients who had undergone LAGB from 2004 to 2007 and had undergone either revision of their original band or conversion to Roux-en-Y gastric bypass. Results Of the 66 patients who met our inclusion criteria, 47 (71.2%) had undergone revision and 19 (28.8%) conversion. The patient demographics were similar between the 2 groups. The interval to revision or conversion was 22 and 28 months, respectively. Band slippage was the most common surgical indication in the revision group, and inadequate weight loss was the most common in the conversion group. Although patients in the revision group had experienced good weight loss before their reoperation, the conversion group had not. However, the conversion group experienced good weight loss after their reoperation, with an average excess body weight loss of 48%. Conclusion Patients who have experienced successful weight loss with LAGB and experience band complications will have satisfactory outcomes with band revision, maintaining their excess body weight loss. These data suggest that patients with inadequate weight loss after LAGB can do well after conversion to Roux-en-Y gastric bypass.