Endoscopic assessment of morphological and histopathological upper gastrointestinal changes after endoscopic sleeve gastroplasty

BackgroundEndoscopic sleeve gastroplasty (ESG) is a promising bariatric endoluminal procedure. Restriction and shortening of the stomach are obtained by means of non-resorbable full-thickness sutures, thus inducing the formation of several endoluminal pouches in which food can stagnate. The effect of ESG on the upper gastrointestinal tract has never been investigated.ObjectivesThis study objectively evaluates endoscopic macroscopic and histopathologic changes within 12-month follow-up (FU) in patients who underwent ESG.SettingRetrospective study on a prospective database of patients who underwent ESG at our tertiary referral center between October 2016 and March 2019.MethodsAll consecutive patients undergoing upper endoscopy (EGD) preoperatively and 6 and 12 months after ESG were included. The upper gastrointestinal tract was evaluated for mucosal abnormalities and biopsies were systematically taken.ResultsEighty-six patients were included. EGD results were as follows: esophagitis decreased from 14% preoperatively to 3.6% and 1.2% at 6- and 12-month FU, respectively (P = .001); 19.8% of patients presented preoperatively a type I hiatal hernia <4 cm and showed no size increment or de novo hiatal hernia at 6- and 12-months. The rate of preoperative hyperemic (23.2%) and erosive (3.5%) gastropathy decreased to 9.5% and 1.2% at 6 months and 17.4% and 1.2% at 12 months, respectively. Gastric ulcer (4.7%), duodenal hyperemic mucosa (1.2%) and duodenal micro-ulcerations (2.3%) detected preoperatively were not present at 6- and 12-month EGD. The rate of histopathological disease, which was 68.1% preoperatively, dropped to 29.2% at 12 months, chronic gastritis decreased from 40.3% to 26.4%, acute gastritis from 9.7% to 0%, and acute inflammation on chronic gastritis from 18% to 2.8% (P < .001).ConclusionESG is a safe procedure that does not promote the new onset of macroscopic and histopathologic abnormalities within 1-year follow-up.     

Gastric adaptive changes following experimental gastroplasty

To study the adaptive response of the stomach secondary to partial obstruction imposed by gastroplasty, groups of rabbits with calibrated midgastric constrictions created as a stoma (unreinforced, Group II), as a short channel (Group III), or as a stoma reinforced with polypropylene mesh (Group IV), were compared to controls (Group I). It was found that the unreinforced stoma dilated rapidly while the pouch dilated moderately. In both the channel and reinforced stomas, the pouch dilated markedly. Increased fibrosis was found inside of the polypropylene banding, resulting in a significant incidence of luminal obstruction. The channel dilated in stages, affecting the proximal end first; but obstructive effect remained as long as part of the channel was undilated. We conclude that a narrow stoma is incompatible with a small pouch over time. Since anatomic specifications do not define function, both function (such as emptying) and adaptive changes should be studied in animal models before introduction of any new gastric limiting procedures into clinical practice.     

磨削术后皮肤组织变化的实验研究

为了解磨削术后皮肤组织结构的变化，选用小型猪为动物模型进行皮肤磨削术，术后对组织进行光镜、电镜的组织结构观察，并测定胶原含量变化和成纤维细胞中的ＳＤＨ及胶原纤维含量变化，以及用天狼猩红偏光法对Ⅰ、Ⅲ型胶原纤维进行分型观察。结果表明磨削术后皮肤细小皱纹消除，真皮浅层形成新的胶原带，胶原总量及Ⅰ型胶原纤维增多。磨削术不仅能消除细小皱纹，而且促进胶原代谢更新，使Ⅰ型胶原增多，故对改善皮肤的老化有一定的作用。     

Nutrition after vertical banded gastroplasty.

The authors assessed the nutritional status of 60 morbidly obese patients by determining body composition, using multiple isotope dilution at 13.6 +/- 0.4 months following operation. Body weight was followed for an additional 12.3 +/- 0.8 months. Twenty-four patients lost more than 25% of their preoperative weight and were within 30% of ideal weight (a "good" result). At 1 year they had lost 41.4 +/- 1.8% of preoperative weight and the body mass index (BMI) decreased from 46.7 +/- 1.2 to 27.0 +/- 0.6 kg/m2. Despite rapid weight loss, malnutrition did not develop and their body composition became indistinguishable from that of normally nourished volunteers. Twenty-nine patients had a "satisfactory" result with more than 25% weight loss but were not within 30% of ideal. Their weight decreased by 34.8 +/- 1.0% as their BMI decreased from 55.4 +/- 1.2 to 36.0 +/- 0.8 kg/m2. Seven patients lost less than 25% of their preoperative weight (an "unsatisfactory" result). Malnutrition did not develop in any patient. In the authors' experience, in contrast to other weight reducing operations, vertical banded gastroplasty (VBG) results in rapid weight loss without the concomitant development of malnutrition even in patients who return to normal weight.     

Development of a gastroplasty with variable diameter. Experimental study using artificial sphincters]

The vertical banded gastroplasty is currently the most popular technique in the surgical treatment of morbid obesity. This experimental study was aimed to create a gastroplasty with a variable stoma. The Marlex band was replaced by the cuff of an artificial sphincter to allow selective variation of the diameter of the stoma. The study was carried out on four mongrel dogs. The artificial sphincter was connected to a subcutaneous port. Injection of sterile fluid into the port inflates the cuff and decreases the surface of the stoma. The study was followed up for one year. Under gastroscopic control the system was regularly activated, the diameter and the surface of the stoma was measured and calculated. The sphincter allowed the surface of the stoma to decrease from 103 +/- 2.0 mm2 to 61 +/- 2.1 mm2. There was no significant variation of the surface for each volume unit injected into the system. After one year, the systems and stomachs were harvested and examined. It is possible to create a gastroplasty with a variable stoma. This system works without any technical problem. Microscopic examination of the stoma shows no peri-sphincteric fibrosis.     

Metabolic changes following gastroplasty in Prader-Willi syndrome--a case report

A vertical banded gastroplasty was performed in an adult female patient with Prader-Willi syndrome in an attempt to prevent the metabolic deterioration caused by polyphagia. After her operation, the patient felt satiated with the scheduled amount of food and one month later, her fasting blood sugar concentration (FBS) decreased from 521 to 125 mg/dl, and her urinary sugar excretion (US) from 257 to 9 g/day. Both glucose tolerance and insulin secretion were also improved. However, these parameters subsequently became worse after dietary control was lost since the surgical procedure alone was unable to continue to suppress the insatiable desire to eat food. Both her glucose tolerance and insulin secretion by the 31st postoperative month were better than before the surgery, but worse than at one month after the surgery. At the end of the surgery, but worse than at one month after the surgery. At the end of the 34th postoperative month, even under the temporary administration of 0.625 mg/day of glibenclamide, her FBS was 158 mg/dl and US, 38.1 g/day. Her body weight had also increased to over her preoperative value. Based on these results, we conclude that the effect of gastroplasty to prevent metabolic deterioration in our patient with Prader-Willi syndrome gradually diminishes.     

Tumour response and morphological changes of acoustic neurinomas after radiosurgery

Summary Twenty-seven of the 1560 patients treated by radiosurgery during the period 1984–1993 had acoustic neurinomas. Four cases were excluded from this study because they had a follow-up of less than 2 years. There were 24 neurinomas treated in 23 patients as one patient had a bilateral tumour. Seven patients underwent radiosurgery for a recurrent tumour (already operated on once or twice), while it was the first treatment for 16 patients. The tumour volume ranged from 1.99 cm³ to 18.30 cm³, and the patient follow-up was from 2 to 8 years.To determine the target on CT/NMR for linear accelerator stereotactic irradiation, the Greitz-Bergström non-invasive head fixation device was used. It was again adopted for subsequent serial imaging, and for repeat radiosurgery when necessary. The total peripheral tumour dose ranged from 12 to 45 Gy.In 9 patients there was a reduction in tumour volume varying from 39 to 100%, while 14 of the neurinomas appeared stable after an average follow-up of 3 years. In one patient there was an increase in size of the tumour. Variable morphological changes were present in 66% of the neurinomas treated.Radiosurgery is indicated as an alternative to microsurgery for inoperable patients and for those who refuse surgery, for recurrent tumours, and as a post-operative complementary treatment for partially removed tumours.A gradual approach to radiosurgery, depending on tumour response, allows a greater efficacy with minimal risk. In the present series no complications were observed. Hearing was preserved at almost the same level as that prior to radiosurgery in all patients.     

Meralgia paresthetica after gastroplasty for morbid obesity

In three morbidly obese patients (mean weight 169 kg), severe hip pain developed immediately after gastroplasty. The differential diagnosis included thrombophlebitis, osteoarthritis and lumbar disc protrusion. The pattern of pain and associated numbness was characteristic of compression of the lateral cutaneous nerve of the thigh, a condition known as meralgia paresthetica. The likely cause was compression of the thigh by the metal post of the Gomez retractor. Only the most obese patients suffered this syndrome and all symptoms resolved spontaneously within 3 months.     

Gastric emptying after gastroplasty for morbid obesity

Gastric emptying was studied in 11 patients who had undergone gastroplasty for morbid obesity 6 to 8 months previously and in 22 normal controls without gastrointestinal disease. A dual isotope technique for measuring solid and liquid emptying was used. Liquid emptying was slower in patients than controls. The emptying of solid was initially faster, but was followed by a prolonged slow rate of emptying indicating retention of solid food in the proximal partitioned pouch. There was no correlation between the weight loss produced by the operation and rates of solid or liquid emptying. Unlike gastric bypass, the changes in gastric emptying produced by gastroplasty were relatively small and gastric emptying rates in patients overlapped considerably with the range of emptying rates found in control subjects. The success of the procedure may depend on the induction of satiety by the filling of the partitioned pouch.     

快速扩张后皮肤生物力学特性的实验研究

本实验研究的目的在于观察皮肤软组织快速扩张后生物力学特性的改变,并与常规扩张、未扩张的皮肤进行对比研究,以了解扩张皮肤生物力学特性的改变与扩张速度的关系,即扩张皮肤24小时应力松弛的程度和应力状态的平衡与一周应力松弛和平衡的区别,为临床快速扩张提供生物力学的研究基础。取4只体重为15kg 左右的猪为实验动物,分为常规扩张组,快速扩张组和对照组;将容量为240ml 的矩形扩张器埋置于筋膜下,按分组要求定期给予扩张;扩张结束后取标本进行皮肤构关系、应力松弛特性、应变能密度和强度参数等生物力学指标的测定,结果表明扩张皮肤的粘弹性明显下降,有别于未扩张的皮肤,而快速扩张皮肤与常规扩张皮肤的粘弹性的下降则非常相似。因此,扩张可致皮肤粘弹性下降,但扩张皮肤粘弹性的下降除与扩张刺激的强度有明显的关系外,尚与扩张刺激的间隔时间有关,但后者的影响较小。临床上可以采用快速扩张的方法,以缩短疗程,提高疗效。     

快速扩张后皮肤生物力学特性的实验研究

本实验研究的目的在于观察皮肤软组织快速扩张后生物力学特性的改变，并与常规扩张、未扩张的皮肤进行对比研究，以了解扩张皮肤生物力学特性的改变与扩张速度的关系，即扩张皮肤２４小时应力松弛的程度和应力状态的平衡与一周应力松弛和平衡的区别，为临床快速扩张提供生物力学的研究基础。取４只体重为１５ｋｇ左右的猪为实验动物，分为常规扩张组，快速扩张组和对照组；将容量为２４０ｍｌ的矩形扩张器埋置于筋膜下，按分组要求定期给予扩张；扩张结束后取标本进行皮肤构关系、应力松弛特性、应变能密度和强度参数等生物力学指标的测定，结果表明扩张皮肤的粘弹性明显下降，有别于未扩张的皮肤，而快速扩张皮肤与常规扩张皮肤的粘弹性的下降则非常相似。因此，扩张可致皮肤粘弹性下降，但扩张皮肤粘弹性的下降除与扩张刺激的强度有明显的关系外，尚与扩张刺激的间隔时间有关，但后者的影响较小。临床上可以采用快速扩张的方法，以缩短疗程，提高疗效。     

High revision rates after laparoscopic vertical banded gastroplasty

BACKGROUND: To evaluate, in a surgical department at a university hospital in Stockholm, Sweden, the long-term results after laparoscopic vertical banded gastroplasty (VBG), with special emphasis on revisional surgery. Few studies are available with long-term results after laparoscopic VBG. Some short-term studies have shown results similar to gastric banding. METHODS: All consecutive patients who underwent attempted laparoscopic VBG between 1995 and 2005 were followed up regarding weight loss and the need for revisional surgery. Follow-up was from the date of surgery to the end of the observational period (December 2006). RESULTS: In 486 patients, laparoscopic VBG was attempted. Of the 486 cases, 64 were converted to open surgery. Conversions were common in the first patients, with a conversion rate of 4% during the last 100 patients. The mean body mass index at surgery was 42.4 kg/m2. The median follow-up was 3 years (range 0-11). All patients lost weight. A total of 104 patients (21%) required revisional surgery 114 times during the follow-up period, with food intolerance/vomiting and insufficient weight loss the most common reasons. Of the 104 patients, 31 underwent repeat VBG, of whom 10 needed a secondary revisional procedure, and 49 required conversion to gastric bypass, of whom none have required additional revisional surgery. CONCLUSION: Laparoscopic VBG is associated with high revisional rates. In the case of failed VBG, repeat VBG seems to be a poor option and conversion to gastric bypass yields better results. We have abandoned VBG as a surgical option in the treatment of obesity.     

Improvement of morphological changes after 70% hepatectomy with portocaval shunt: preclinical study in porcine model

BACKGROUND: After extensive hepatectomy, excessive portal venous flow (PVF) and elevated portal venous pressure (PVP) may lead to postoperative liver damage. We have evaluated the use of portocaval shunt (PCS) to control PVF and PVP following partial hepatectomy (PH) to reduce the postoperative liver damage. METHOD: Twenty-four pigs were divided into two Groups: Group C (n = 10) underwent 70% PH alone and Group S (n = 14) underwent 70% PH with PCS. The changes in PVF, PVP, serum liver function tests, and histology were evaluated. RESULTS: PVP and PVF per unit of remnant liver weight and serum total bilirubin levels in Group S were significantly lower than those in Group C postoperatively (P < 0.05). Histology showed that there were significant differences in hepatocyte ballooning, necrosis, and neutrophil aggregation between the two groups (P < 0.05). In particular, hepatic necrosis was observed in zone 3 of Group C as centrilobular necrosis. These results suggest that hepatic and sinusoidal damage after 70% PH were more severe in Group C than in Group S, with the latter group maintaining an almost normal ultrastructural appearance. Hepatocyte apoptotic index differed significantly between the two groups (P < 0.0001). CONCLUSION: After 70% PH, extensive centrolobular necrosis and neutrophil aggregation were present and may have caused liver damage, manifested as hyperbilirubinemia and coagulopathy. The delayed liver regeneration with PCS may reduce the postoperative liver damages rather than the rapid liver hypertrophy. The diversion of PVF with PCS to maintain adequate PVP is a very effective procedure for avoiding the postoperative liver failure after extensive hepatectomy.     

Adenocarcinoma of the pouch after silastic ring vertical gastroplasty

A 52-year-old woman was admitted because of epigastralgia, anorexia and recently increased vomiting, 2 years after silastic ring vertical gastroplasty. On gastroscopy, a tumor mass was visualized in the pouch near the "neo-pylorus". Biopsies confirmed adenocarcinoma. She underwent total gastrectomy, and has no evidence of recurrence at 1 year.The literature on gastric carcinoma after gastroplasty is reviewed.     

The significance of morphological changes in cerebral arteries after subarachnoid hemorrhage

A porcine model was developed to allow quantitative assessment of morphological changes in cerebral arteries after subarachnoid hemorrhage and to determine the significance of structural changes in producing arterial narrowing. Whole blood was selectively applied to the middle cerebral artery (MCA) of seven pigs. After 10 days, vessels were perfusion-fixed and examined by light and transmission electron microscopy and immunohistochemistry. The MCA's exposed to whole blood for 10 days showed prominent luminal narrowing associated with profound ultrastructural changes affecting all layers of the vessel wall. Morphometric analysis, however, demonstrated that significant reductions in the luminal cross-sectional area (-55.8% +/- 12.5%, p less than 0.005) and increases in radial wall thickness (75.1% +/- 10.5%, p less than 0.005) were associated with only minimal increase in the cross-sectional area of the vessel wall (12.5% +/- 15%, p less than 0.025). By stereological analysis, the volume density of individual components of the arterial wall was unchanged in MCA's exposed to blood. Vessels exposed to blood showed a 44% reduction in smooth-muscle cell immunoreactive actin and increased collagen in the extracellular matrix of the vessel wall. These data suggest that structural changes in cerebral arteries after subarachnoid hemorrhage do not directly contribute to vessel narrowing through increases in wall mass. Nevertheless, such changes may reflect pathological mechanisms which act to augment prolonged vasoconstriction or inhibit the maintenance of normal vascular tone.