Both Roux-en-Y Fistulo-jejunostomy and Limited Proximal Gastrectomy with Esophago-jejunostomy Should be Considered as Treatment Modalities for Chronic Fistulous Tracts After Staple Disruption in Patients Who Have Undergone Laparoscopic Sleeve Gastrectomy

| June 11, 2014

Dear Readers of Bariatric Times:

By the time you receive this issue of Bariatric Times, we will probably be together in Miami, Florida, enjoying the American Society for Metabolic and Bariatric Surgery (ASMBS) 2014 Spring Event. The program will be excellent. Drs. Dan Herron and Rory Pryor have prepared excellent sessions with top-notch speakers and some new topics, such as medico legal cases in bariatric surgery.

In this issue of BT, Dr. Paul Wizman and Rita Wizman provide an overview on how to set up your bariatric center. This article is of unique value for those finishing their fellowships. I urge you to read this article and learn from the experts. Dr. Wizman is a terrific surgeon and has one of the most successful bariatric practices here in South Florida. In the article, the authors discuss a marketing strategy at an introductory level. They define the target client/patient, outline a system for tracking each patient, emphasize the importance of defining a budget, and discuss available tools best suited for your type of program. They also discuss important aspects of a bariatric practice, such as branding, reputation, and networking as well as traditional versus internet marketing for the bariatric professional.

In the third installment of “Obesity and Bariatric Surgery Trends Around the World,” Dr. Ahmed Ahmed from Imperial College in London, United Kingdom, gives us an excellent overview of the current situation of bariatric surgery and the obesity epidemic in the United Kingdom. Dr. Ahmed’s facility was the first Center of Excellence recognized by the Surgical Review Corporation (SRC) outside of the United States. Dr. Ahmed and his center continue to deliver excellent work as well as important literature. It is interesting to learn that the United Kingdom performs around 8,000 cases a year out of two million surgical candidates (5% of the population), suggesting that we in the United States are not alone in our fight against obesity through metabolic surgery.

In “The Medical Student Notebook,” we continue Lesson #1 with Part 2: Bariatric Surgery and Iron. Kyle Checchi reviews the normal physiology as well as the limiting effects of some bariatric procedures on iron absorption. This presents another good indication for laparoscopic sleeve gastrectomy (LSG) when compared to gastric bypass or biliopancreatic diversion with duodenal switch (BPD-DS), as LSG has limiting effect on iron absorption.

Also in this issue, Dr. Ellie Choulliard presents a brief report of his group’s results of Roux-en-Y fistulo-jejunostomy (RYFJ) as a treatment modality for chronic fistulous tracts after staple disruption in patients who have undergone LSG. This technique was originally described by Dr. Jacques Himpens and was adopted by many surgeons in Europe. Instead of this operation, I would prefer to do a limited proximal gastrectomy and esophago-jejunostomy. Our results using this technique, which were excellent, were recently published in Surgery for Obesity and Related Diseases. Nevertheless, it is important to have several options when dealing with this kind of complicated patient, and the fistulo-jejunostomy should be among them.

Wendy Scinta, MS, presents an interesting article addressing a difficult issue in medical weight loss and bariatric surgery: follow up and patient engagement. The use of online forums and wellness/fitness-ocused applications are some of the newest and most interesting approaches.

In this month’s “Checklists in Bariatric Surgery,” we review the important aspects in the diagnosis and treatment of thromboembolism. Pulmonary embolism (PE) is the number one reason for mortality in bariatric patients and because of that we felt compelled to add this topic to our collection of checklists. In a sad experience, a massive PE was the only reason for losing a patient after a primary procedure in 15 years of bariatric practice at the Cleveland Clinic Florida, Weston, Florida.

I read an interesting report published in the American Journal of Epidemiology. The study found that women who slept in a bedroom that was light enough to look across it at night had larger waistlines. One of the explanations given for this phenomenon was that light disrupts our body clocks. It has been well documented that light alters our mood, physical activity, and food digestion.[3] So, make sure you turn off the light when going to sleep. Another interesting article published in the BMJ, found that the clampdown on allowing fast food restaurants near working areas resulted in a decreased rate of obesity by 50 percent.[4] I was not surprised by these findings.

I hope you enjoy this issue of BT. Perhaps I will see you at the ASMBS Spring Event at the InterContinental hotel in Miami, Florida. There are a lot of great restaurants to explore around the area.

Sincerely,

Raul J. Rosenthal, MD, FACS, Clinical Editor, Bariatric Times; Interim Chief of Staff, Professor of Surgery and Chairman, Department of General Surgery; Director of Minimally Invasive Surgery and The Bariatric and Metabolic Institute; General Surgery Residency Program Director; and Director, Fellowship in MIS  and Bariatric Surgery, Cleveland Clinic Florida, Weston,  Florida 

References
1.    Thompson CE 3rd, Ahmad H1, Lo Menzo E, Szomstein S, Rosenthal RJ. Outcomes of laparoscopic proximal gastrectomy with esophagojejunal reconstruction for chronic staple line disruption after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis. 2013 Oct 19.
2.    McFadden E, Jones ME, Schoemaker MJ, Ashworth A, Swerdlow AJ. The relationship between obesity and exposure to light at night: cross-sectional analyses of over 100,000 women in the breakthrough generations study. Am J Epidemiol. 2014 May 29.
3.    Blue light has a dark side. Harvard Health Letter. May 2012. Accessed June 2, 2014. http://www.health.
harvard.edu/newsletters/Harvard_Health_Letter/2012/May/blue-light-has-a-darkside?utm_source=health&utm_medium=pressrelease&utm_campaign=health0512
4.    Burgoine T, Forouhi NG, Griffin SJ, Wareham NJ, Monsivais P. Associations between exposure to takeaway food outlets, takeaway food consumption, and body weight in Cambridgeshire, UK: population based, cross sectional study. BMJ. 2014;348:g1464.

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