Biliopancreatic Diversion-Duodenal Switch: Independent Contributions of Sleeve Resection and Duodenal Exclusion

Background

The choice of first-stage operation in bilio-pancreatic diversion with duodenal switch (BPD-DS) is controversial. There are no published long-term comparisons of one- and two-stage BPD-DS outcomes.

Methods

During 2001–2009, among 1,762 patients scheduled for BPD-DS 48 had duodenal switch (DS) and 53 sleeve gastrectomy (SG) as first-stage procedures. We compared prospectively updated outcomes of 42 DS (100 % open) and 49 SG (88 % laparoscopic), 13 of whom completed their second stage, to a control group of 91 patients with open one-stage BPD-DS.

Results

One-year mean percent excess weight loss (%EWL) was greater after SG than DS (47?±?19 vs. 39?±?13 SD; p?=?0.01) with earlier nadir (16?±?10 vs. 45?±?30 months; p?p?p?p?p?p?Dyslipidemia was cured in 41, 82, and 100 %, respectively. Systolic and diastolic blood pressure decreased only after DS (12 %; p?p?=?0.04).

Conclusions

SG and DS independently contribute to beneficial metabolic outcomes after BPD-DS. Long-term weight loss and correction of metabolic abnormalities were better after DS favoring its use as first stage in BPD-DS; one-stage BPD-DS outcomes were superior to two-staged.     

Changes in Bone Mineral Density After Sleeve Gastrectomy or Gastric Bypass: Relationships with Variations in Vitamin D,Ghrelin, and Adiponectin Levels

Background

A major long-term concern after gastric bypass (GBP) is the risk of osteoporosis; however, little is known about this complication in patients undergoing sleeve gastrectomy (SG).

Objective

To evaluate changes in bone mineral density (BMD) after GBP and SG, and its relationship with changes in vitamin D, parathyroid hormone (PTH), ghrelin, and adiponectin.

Methods

Twenty-three women undergoing GBP (BMI 42.0?±?4.2 kg/m²; 37.3?±?8.1 years) and 20 undergoing SG (BMI 37.3?±?3.2 kg/m²; 34.2?±?10.2 years) were studied before and 6 and 12 months after surgery. BMD was measured by dual-energy X-ray absorptiometry. Plasma PTH, 25-hydroxyvitamin D (25-OHD), ghrelin, and adiponectin concentrations were determined. Food as well as calcium and vitamin D supplement intake was recorded.

Results

Excess weight loss (mean?±?SE), adjusted by baseline excess weight, was 79.1±3.8 % and 74.9?±?4.1 % 1 year after GBP and SG, respectively (p?=?0.481). Significant reduction in BMD for total body (TB), lumbar spine (LS), and femoral neck (FN) was observed after GBP. In the SG group, reduction in BMD was significant only for TB. Adjusted by baseline BMD, the difference between change in BMD for GBP vs. SG was not significant for TB, LS, or FN. Percent reduction in ghrelin concentration was a main factor related to total BMD loss (GBP group) and LS BMD loss (GBP and SG groups).

Conclusions

One year after gastric bypass, bone mineral density was significantly affected, mainly at the femoral neck. Decreases in bone mineral density were more dramatic among patients who had greater baseline BMD and greater reduction in ghrelin concentrations.     

Significant Weight Loss and Rapid Resolution of Diabetes and Dyslipidemia During Short-Term Follow-Up After Laparoscopic Sleeve Gastrectomy

Background

Bariatric surgery has been established as the best option of treatment for morbid obesity. Recently, laparoscopic sleeve gastrectomy (SG) has become very popular because of good postoperative weight loss and low morbidity. The aim of this study was to report our single-center experience with SG regarding feasibility, morbidity, and outcome.

Methods

From January 2006 to December 2011, 93 patients (68 female) with a median age of 46 years underwent laparoscopic SG at our department. Thirteen patients had a history of gastric banding with insufficient weight loss or band-related complications. Clinical outcome and laboratory findings were analyzed.

Results

The mean preoperative and postoperative body mass index (BMI) was 44.1?±?6.9 and 33.4?±?6.8 kg/m², respectively (p?<?0.001). The mean excessive body weight loss after a median follow-up of 11.9 months was 55.7 %?±?24.9 %. Three bleedings, two staple line leakages, and a deep wound infection required conversion to laparotomy (n?=?1), reoperation (n?=?4), or endoscopic stent implantation (n?=?2). Resolution of diabetes and dyslipidemia was seen in 85 and 50 % of patients, respectively. Blood test results of HbA1c, cholesterols, triglycerides, and leptin showed significant postoperative improvement.

Conclusions

Laparoscopic SG represents a feasible bariatric procedure with good short-term weight loss, low morbidity rate, and efficient resolution of diabetes and dyslipidemia, especially in patients with lower BMI. The significant decrease of leptin necessitates further studies to understand the ambiguous role of leptin in bariatric surgery.     

Sleeve Gastrectomy Induces Weight Loss in Diet-Induced Obese Rats Even if High-Fat Feeding Is Continued

Background

Sleeve gastrectomy (SG) has been used for the surgical treatment of morbid obesity as a first or definitive procedure with satisfactory results. The objective of this study in rats was to establish the effects of SG on weight loss depending on the post-surgical type of diet followed.

Methods

Thirty male Wistar rats were fed ad libitum during 3 months on a high-fat diet (HFD) to induce obesity. After this first phase, rats were subdivided in three groups of ten rats each and underwent a sham intervention, an SG, or no surgery but were pair-fed to the amount of food eaten by the animals of the SG group. At this time point, half of the animals in each group continued to be fed on the HFD, while the other half was switched to a normal chow diet (ND). Thus, the following subgroups were established: sham-ND, sleeve-ND, pair-fed-ND as well as sham-HFD, sleeve-HFD, and pair-fed-HFD. Body weight and food intake were recorded daily for 4 weeks. The feed efficiency rate (FER) was determined from weekly weight gains and caloric consumption during this period.

Results

Statistically significant (P?<?0.05) differences in body weight were observed between the six experimental groups after 4 weeks of the interventions with rats in the sleeve-ND group experimenting the highest weight loss (?78.2?±?10.3 g) and animals in the pair-fed-HFD group exhibiting the lowest weight reduction (?4.0?±?0.1 g). Interestingly, the FER value of rats that underwent the SG and continued to be fed on a HFD was significantly (P?<?0.05) lower than that of sham operated and pair-fed animals on the same diet.

Conclusion

The positive effects of SG on weight reduction are observed in obese rats submitted to the intervention and subsequently following an ND or even an HFD.     

Effect of Sleeve Gastrectomy Plus Side-to-Side Jejunoileal Anastomosis for Type 2 Diabetes Control in an Obese Rat Model

Background

Sleeve gastrectomy plus side-to-side jejunoileal anastomosis (JI-SG), a relatively new approach to bariatric surgeries, has shown promising results for treating obesity and metabolic comorbidities. This study investigated the feasibility and safety of JI-SG in weight loss and diabetes remission compared with sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB).

Methods

Forty 10-week-old male Zucker diabetic fatty rats were randomly assigned to four groups: control, SG, JI-SG, and RYGB. Their body weights, food intake, and levels of gut hormones (ghrelin, insulin, and glucagon-like peptide-1 (GLP-1)) and lipids were measured.

Results

Rats in the SG, JI-SG, and RYGB groups demonstrated lower food intake and more weight loss 2 weeks postoperatively compared with control rats. Furthermore, rats in the JI-SG group achieved more weight loss (mean 242.7?±?11.2 g) compared with those in the SG and RYGB groups (SG, 401.4?±?15.1 g and RYGB, 298?±?12 g, both P?<?0.01). All surgery groups demonstrated a decreased fasting insulin, serum glucose, lipid levels, and increased GLP-1 postoperatively. The JI-SG group had lower fasting ghrelin levels than the RYGB group (168?±?19.8 ng/L vs. 182?±?16.7 ng/L, P?<?0.01) and higher fasting GLP-1 levels than the SG group (1.99?±?0.11 pmol/L vs. 1.71?±?0.12 pmol/L, P?<?0.01) at 12 weeks postoperatively. Over the experimental period, the ghrelin levels slowly increased in all surgical groups but remained lower than the preoperative and control levels.

Conclusions

JI-SG induced higher ghrelin and GLP-1 levels and improved glycemic control in Zucker diabetic fatty rats. Compared with SG and RYGB, JI-SG appeared to be a simple, relatively safe, and more effective procedure for treating type 2 diabetes and obesity in this animal model.

     

Comparison of Gastrojejunal Anastomosis Techniques in Laparoscopic Roux-en-Y Gastric Bypass: Gastrojejunal Stricture Rate and Effect on Subsequent Weight Loss

Background

Different gastrojejunal anastomotic (GJA) techniques have been described in laparoscopic Roux-en-Y gastric bypass (LRYGB). There is conflicting data on whether one technique is superior to the other. We aimed to compare hand-sewn (HSA), circular-stapled (CSA) and linear-stapled (LSA) anastomotic techniques in terms of stricture rates and their impact on subsequent weight loss.

Methods

A prospectively collected database was used to identify patients undergoing LRYGB surgery between March 2005 and May 2012. Anastomotic technique (HSA, CSA, LSA) was performed according to individual surgeon preference. The database recorded patient demographics, relevant comorbidities and the type of GJA performed. Serial weight measurements and percentage excess weight loss (%EWL) were available at defined follow-up intervals.

Results

Included in the data were 426 patients, divided between HSA (n?=?174, 40.8 %), CSA (n?=?110, 25.8 %) and LSA (n?=?142, 33.3 %). There was no significant difference in the stricture rates (HSA n?=?17, 9.72 %; CSA n?=?9, 8.18 %; LSA n?=?8, 5.63 %; p?=?0.4006). Weight loss was similar between the three techniques (HSA, CSA and LSA) at 3 months (40.6 %?±?16.2 % vs 35.92 %?±?21.42 % vs 48.21 %?±?14.79 %; p?=?0.0821), 6 months (61.48 %?±?23.94 % vs 58.16 %?±?27.31 % vs 60.18 %?±?22.26 %; p?=?0.2296), 12 months (72.94 %?±?19.93 % vs 69.72?±?21.42 % vs 66.05 %?±?17.75 %; p?=?0.0617) and 24 months (73.29 %?±?22.31 % vs 68.75 %?±?24.71 % vs 69.40 %?±?23.10 %; p?=?0.7242), respectively. The stricture group lost significantly greater weight (%EWL) within the first 3 months compared to the non-stricture group (45.39 %?±?16.82 % vs 39.22 %?±?21.93 %; p?=?0.0340); however, this difference had resolved at 6 months (61.29 %?±?18.50 % vs 59.79 %?±?23.03 %; p?=?0.8802) and 12 months (71.59 %?±?18.67 % vs 68.69 %?±?22.19 %; p?=?0.5970).

Conclusions

There was no significant difference in the rate of strictures between the three techniques, although the linear technique appears to have the lowest requirement for post-operative dilatation. The re-intervention rate will, in part, be dictated by the threshold for endoscopy, which will vary between units. Weight loss was similar between the three anastomotic techniques. Surgeons should use techniques that they are most familiar with, as stricture and weight loss rates are not significantly different.     

Baseline Abdominal Lipid Partitioning Is Associated with the Metabolic Response to Bariatric Surgery

Background

The purpose of this study was to compare the effects of two bariatric procedures on abdominal lipid partitioning and metabolic response.

Methods

Fifty-one patients (RYGB 31(11 M/20 F); (SG) 20(8 M/12 F)) who met the criteria of metabolic syndrome before the operation were followed following Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Visceral and subcutaneous abdominal fat depots were assessed by CT before, 6 months, and 12 months following the operation.

Results

Patients undergoing both procedures did not differ in baseline body mass index (BMI) (42.84?±?4.65 vs. 41.70?±?4.68 kg/m²) or abdominal lipid depots. BMI at 12 months post-op was similar (29.44?±?3.35 vs 30.86?±?4.31 kg/m² for RYGB and SG, respectively). Both procedures led to a significant reduction in visceral and subcutaneous fat at 6 months (p?p?p?Conclusions RYGB and SG induce a similar effect on abdominal fat mobilization. The metabolic effects in individual patients are mostly determined by their baseline abdominal lipid partitioning.     

Outcomes of Laparoscopic Sleeve Gastrectomy in Patients Older than 60 Years

Background

Morbidity and mortality following laparoscopic sleeve gastrectomy (LSG) occur at acceptable rates, but its safety and efficacy in the elderly are unknown.

Methods

A retrospective review was performed of all patients aged >60 years who underwent LSG from 2008 to 2012. These patients were 1:2 matched, by gender and body mass index (BMI) to young patients, 18?<?age?<?50. Data analyzed included demographics, preoperative and postoperative BMI, postoperative complications, and improvement or resolution of obesity-related comorbidities.

Results

Fifty-two morbid obese patients older than 60 years underwent LSG (mean age, 62.9?±?0.3 years). These were matched to 104 young patients, age 18–50 years (mean age, 35.7?±?0.8 years). Groups did not differ in male gender (44 vs. 43 %, p?=?0.9), preoperative BMI (42.6?±?0.7 vs. 42.6?±?0.6, p?=?0.97), and length of follow-up (17?±?2 vs. 22?±?1.4 months, p?=?0.06). Obesity-related comorbidities were significantly higher in the older group (96 vs. 65 %, p?<?0.001). Excess weight loss (EWL) was higher in the younger group (75?±?2.4 vs. 62?±?3 %, p?=?0.001). Older patients had a significantly higher rate of a concurrent hiatal hernia repair (23 vs. 1.9 %, p?<?0.001). Overall postoperative minor complication rate was higher in the older group (25 vs. 4.8 %, p?<?0.001). This included atrial fibrillation (9.5 %), urinary tract infection (7 %), trocar site hernia (4 %), dysphagia, surgical site infection, bleeding, bowel obstruction, colitis, and nutritional deficiency (2 %, each). No perioperative mortality occurred. Comorbidity resolution or improvement was comparable between groups (88 vs. 80 %, p?=?0.13).

Conclusions

LSG is safe and very efficient in patients aged >60, despite higher rates of perioperative comorbidities.     

How do risk factors for mortality and overall complication rates following laparoscopic and open colectomy differ between inpatient and post-discharge phases of care? A retrospective cohort study from NSQIP

Background

Risk factors for complications differ between laparoscopic (LC) and open colectomy (OC) patients, given the selection bias between these groups. How risk factors for these outcomes differ between inpatient and post-discharge phases of care requires further study.

Methods

A retrospective cohort study (2005–2010) using NSQIP data was performed comparing OC and LC patients. Multivariable logistic regression was used to compare covariates associated with mortality and overall complication rates both before and after hospital discharge.

Results

Patients in the LC cohort were younger (64.2 vs. 62.5 years; P < 0.0001) with a lower incidence of comorbidities. OC was associated with a higher incidence of mortality compared to LC among inpatients (3.3 vs. 0.61 %, P < 0.0001) and following discharge (0.88 vs. 0.29 %, P < 0.0001). OC also demonstrated a higher incidence of overall complication rates for both inpatients (22.32 vs. 9.36 %, P < 0.0001) and following discharge (8.83 vs. 7.24 %, P < 0.0001). Risk factors (P < 0.05) for mortality following LC included age and emergency procedures for inpatients; pre-operative SIRS was associated with mortality occurring after discharge. For the OC cohort, risk for mortality was increased with smoking and contaminated/dirty wounds for inpatients; pre-operative weight loss was associated with death following discharge. Factors associated with increased risk of morbidity following LC included smoking history for inpatients and pre-operative steroid therapy following discharge. Following OC, morbidity was strongly associated with ASA scores for inpatients; pre-operative steroid therapy was a risk factor following discharge. Obesity was strongly associated with non-mortal complications in both cohorts following discharge.

Conclusions

(1) LC is associated with a lower incidence of post-operative mortality and complications. (2) Risk factors associated with adverse post-operative outcomes change during the post-operative period; surveillance for these outcomes should be tailored by operative technique and phase of post-operative care (3) Obesity is an underappreciated risk for complications following discharge for both LC and OC.     

A Randomized Clinical Trial of Laparoscopic Roux-en-Y Gastric Bypass and Sleeve Gastrectomy for the Treatment of Morbid Obesity in China: a 5-Year Outcome

Background

No randomized comparative trials have presented long-term outcomes for laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). The present study was designed to compare the efficacy and safety of these two procedures.

Methods

From January 2007 to July 2008, 64 eligible patients were randomly assigned to LSG or LRYGB. During the 5-year follow-up, we compared morbidity rate, body mass index (BMI), percent of excess weight loss (%EWL), Moorehead-Ardelt (M-A) II quality of life, and resolution or improvement rate of obesity-related comorbidities between the groups.

Results

Both groups were matched with respect to age, gender, and BMI. Slightly more major complications were observed in patients undergoing LRYGB (P?>?0.05). Weight loss was significantly better with LRYGB except during the first postoperative year. At 5 years, %EWL for LSG and LRYGB was 63.2?±?24.5 % and 76.2?±?21.7 % (P?=?0.02), respectively. No statistical difference was observed in quality of life between the groups at all intervals (P?>?0.05). At the last follow-up, most comorbidities in both groups were resolved or improved, with no difference between the groups (P?>?0.05).

Conclusion

LRYGB and LSG are equally safe and effective in quality of life and improvement or resolution of comorbidities, and LRYGB possesses the superiority in terms of weight loss. Further studies are needed to evaluate micronutrient deficiencies of these procedures.     

A Prospective Randomized Study Comparing Patients with Morbid Obesity Submitted to Sleeve Gastrectomy With or Without Omentectomy

Background

Increased visceral adipose tissue is a risk factor for the metabolic complications associated with obesity and promotes a low-grade chronic inflammatory process. Resection of the great omentum in patients submitted to a bariatric procedure has been proposed for the amelioration of metabolic alterations and the maximization of weight loss. The aim of the present study was to investigate the impact of omentectomy performed in patients with morbid obesity undergoing sleeve gastrectomy (SG) on metabolic profile, adipokine secretion, inflammatory status, and weight loss.

Methods

Thirty-one obese patients were randomized into two groups: SG alone or with omentectomy. Adiponectin, omentin, interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), high-sensitivity C-reactive protein (hs-CRP), blood lipids, fasting glucose, insulin, and insulin resistance were measured before surgery and at 7 days, and 1, 3 and 12 months after surgery.

Results

During the 1-year follow-up, body mass index (BMI) decreased markedly and comparably in both groups (p?<?0.001). Insulin, IL-6, and hs-CRP levels decreased significantly compared to baseline (p?<?0.05) in both groups with no significant difference between groups. Adiponectin and high-density lipoprotein cholesterol levels were significantly and similarly increased compared to baseline (p?<?0.001) in both groups. Omentin levels increased significantly (p?<?0.05) in the control group and decreased in the omentectomy group 1 year postoperatively. There was no significant change in TNF-α levels in either group.

Conclusions

The theoretical advantages of omentectomy in regard to weight loss and obesity-related abnormalities are not confirmed in this prospective study. Furthermore, omentectomy does not induce important changes in the inflammatory status in patients undergoing SG.     

Gastric Bypass for Obesity in the Elderly: Is It as Appropriate as for Young and Middle-Aged Populations?

Background

Obesity prevalence increases in elderly population. Bariatric surgery has been underused in patients over 60 because of fears of complications and lower weight loss. We postulated worse outcomes in the elderly in comparison to young and middle-aged population 1 year after gastric bypass.

Methods

We retrospectively analyzed gastric bypass outcomes in young (<40 years), middle-aged (40 to 55 years), and elderly (>60 years) patients between 2007 and 2013. Each subject over 60 (n?=?24) was matched with one subject of both the other groups according to gender, preoperative body mass index (BMI), surgical procedure, and history of previous bariatric surgery (n?=?72).

Results

Older subjects demonstrated higher prevalence of preoperative metabolic comorbidities (70 vs 30 % in the <40-year-old group, p?p?=?0.69). Age was not predictive of weight loss failure 1 year after surgery. Remission and improvement rates of comorbidities were similar between age groups 6 months after surgery.

Conclusions

Our study confirms weight loss efficacy of gastric bypass in the elderly with acceptable risks. Further studies evaluating the benefit-risk balance of bariatric surgery in the elderly population will be required so as to confirm the relevance of increasing age limit.     

Lower Glycemic Fluctuations Early After Bariatric Surgery Partially Explained by Caloric Restriction

Background

We assessed the acute impact of laparoscopic Roux-en-Y gastric bypass (GBP) or sleeve gastrectomy (SG) compared to caloric-matched control group without surgery on glucose excursion in obese patients with type 2 diabetes, and examined if this was mediated by changes in insulin resistance, early insulin response or glucagon-like peptide (GLP)-1 levels.

Methods

Six-day subcutaneous continuous glucose monitoring (CGM) recordings were obtained from patients beginning 3 days before GBP (n?=?11), SG (n?=?10) or fasting in control group (n?=?10). GLP-1, insulin and glucose were measured during 75 g oral glucose tolerance testing at the start and end of each CGM.

Results

Post-operative hyperglycaemia occurred after both surgeries in the first 6 h, with a more rapid decline in glycaemia after GBP (p?<?0.001). Beyond 24 h post-operatively, continuous overlapping of net glycaemia action reduced from baseline after GBP (median [interquartile range]) 1.6 [1.2–2.4] to 1.0 [0.7–1.3] and after SG 1.4 [0.9–1.8] to 0.7 [0.7–1.0]; p?<?0.05), similar to controls (2.2 [1.7–2.5] to 1.3 [0.8–2.8] p?<?0.05). Higher log GLP-1 increment post-oral glucose occurred after GBP (mean ± SE, 0.80?±?0.12 vs. 0.37?±?0.09, p?<?0.05), but not after SG or control intervention. Among subgroup with baseline hyperglycaemia, a reduction in HOMA-IR followed GBP. Reduction in time and level of peak glucose and 2-h glucose occurred after both surgeries but not in controls.

Conclusions

GBP and SG have a similar acute impact on reducing glycaemia to caloric restriction; however, with a superior impact on glucose tolerance.     

Laparoscopic Sleeve Gastrectomy Versus Single Anastomosis (Mini-) Gastric Bypass for the Treatment of Type 2 Diabetes Mellitus: 5-Year Results of a Randomized Trial and Study of Incretin Effect

Background

Bariatric surgery may be beneficial in mildly obese patients with poorly controlled diabetes. The optimal procedure to achieve diabetes remission is unknown. In 2011, we published the short-term results of a pilot study designed to evaluate the efficacy of diabetic control and the role of duodenal exclusion in mildly obese diabetic patients undergoing laparoscopic sleeve gastrectomy (SG) vs. a laparoscopic single anastomosis (mini-) gastric bypass (SAGB). This study analyzes the 5-year results and evaluates the incretin effect.

Methods

A double-blind randomized trial included 60 participants with a hemoglobin A1c (HbA1c) level higher than 7.5 %, a body mass index (BMI) between 25 and 35 Kg/m², a C-peptide level ≥1.0 ng/mL, and a diagnosis of type 2 diabetes mellitus (T2DM) for at least 6 months. A SAGB with duodenal exclusion or a SG without duodenal exclusion was performed.

Results

The 5-year results of the primary outcome were as an intention-to-treat analysis for HbA1c ≤6.5 % without glycemic therapy. Assessments of the incretin effect and β cell function were performed at baseline and between 36 and 60 months. The patients were randomly assigned to SAGB (n?=?30) and SG (n?=?30). At 60 months, 18 participants (60 %; 95 % confidence interval (CI), 42 to 78 %) in the SAGB group and nine participants (30 %; 95 % CI, 13 to 47 %) in the SG group achieved the primary end points (odds ratio (OR), 0.3; 95 % CI, 0.1 to 0.8 %). The participants assigned to the SAGB procedure had a similar percentage of weight loss as the SG patients (22.8?±?5.9 vs. 20.1?±?5.3 %; p?>?0.05) but achieved a lower level of HbA1c (6.1?±?0.7 vs. 7.1?±?1.2 %; p?Conclusions In mildly obese patients with T2DM, SG is effective at improving glycemic control at 5 years, but SAGB was more likely to achieve better glycemic control than SG and had a higher incretin effect compared to SG.     

Internalized Weight Bias in Weight-Loss Surgery Patients: Psychosocial Correlates and Weight Loss Outcomes

Purpose

In this study, we examined the relationship between pre-operative internalized weight bias and 12-month post-operative weight loss in adult bariatric surgery patients.

Methods

Bariatric surgery patients (n?=?170) from one urban and one rural medical center completed an internalized weight bias measure (the weight bias internalization scale, WBIS) and a depression survey (Beck depression inventory-II, BDI-II) before surgery, and provided consent to access their medical records.

Results

Participants (BMI?=?47.8 kg/m2, age?=?45.7 years) were mostly female (82.0 %), White (89.5 %), and underwent gastric bypass (83.6 %). The average WBIS score by item was 4.54?±?1.3. Higher pre-operative WBIS scores were associated with diminished weight loss at 12 months after surgery (p?=?0.035). Pre-operative WBIS scores were positively associated with depressive symptoms (p?Conclusion Greater internalized weight bias was associated with more depressive symptoms before surgery and less weight loss 1 year after surgery.     

Is laparoscopy a safe approach for diffuse appendicular peritonitis? Feasibility and determination of risk factors for post-operative intra-abdominal abscess

Background

Several studies have assessed feasibility and early outcomes of the laparoscopic approach for complicated appendicitis (CA). However, these studies suffer from limitations due to the heterogeneous definitions used for CA. No studies have assessed feasibility and early post-operative outcomes of the laparoscopic approach in the specific management of diffuse appendicular peritonitis (DAP). Consequently, outcomes of the laparoscopic approach for the management of DAP are poorly documented.

Methods

The laparoscopic approach is the first-line standardised procedure used by our team for the management of DAP. All patients (aged >16 years) who underwent laparoscopy for DAP (CA with the presence of purulent fluid with or without fibrin membranes in at least a hemi abdomen) between 2004 and 2012 were prospectively included. Post-operative outcomes were analysed according to the Clavien–Dindo classification.

Results

Laparoscopy for DAP was performed for 141 patients. Mean age was 39.6 ± 20 (16–92) years. A total of 45 patients (31.9 %) had pre-operative contracture. The mean pre-operative leukocyte count was 14,900 ± 4,380 mm^?3. The mean pre-operative C-reactive protein (CRP) serum concentration was 135 ± 112 (2–418) mg/dl. The conversion rate was 3.5 %. The mean operative time was 80 ± 27 (20–180) min. There were no deaths. The rate of grade III morbidity was 6.5 %. Ten patients (7.1 %) experienced intra-abdominal abscess (IAA); seven of these cases were treated conservatively. The mean length of hospital stay was 6.9 ± 5 (2–36) days. A pre-operative leukocyte count >17,000 mm^?3, and CRP serum concentration >200 mg/dl were significant predictive factors for IAA in multivariate analyses [odds ratio (OR) 25.0, 95 % confidence interval (CI) 2.4–250, p = 0.007 and OR 16.4, 95 % CI 1.6–166, p = 0.02, respectively].

Conclusion

The laparoscopic approach for DAP is a safe and feasible procedure with a low conversion rate and an acceptable rate of IAA in view of the severity of the disease. Pre-operative leukocyte counts >17,000 mm^?3 and pre-operative CRP serum concentrations >200 mg/dl indicate a high risk of IAA.     

Sleeve Gastrectomy Improves Glucose Homeostasis in Zucker Diabetic Fatty Rats

Background

Bariatric surgery improves glucose homeostasis, but the mechanism of action is poorly understood. The aim of this study was to assess the effect of sleeve gastrectomy (SG) on glucose homeostasis in two obese populations of rats.

Methods

Two strains of rats [Zucker fatty (ZF) and Zucker diabetic fatty (ZDF)] were each divided into two groups: sham and SG. Food intake was measured daily, and weight was measured bi-weekly. Oral glucose tolerance testing (OGTT) was performed before and 45?days after surgery.

Results

In both strains of rats, there was no statistical difference in food intake and weight gain between the sham and SG rodents before and after surgery. In ZF rats, there was no change in fasting glucose or OGTT area under the curve (AUC) before or 45?days after surgery. In the ZDF rodents, the mean preoperative fasting glucose and OGTT AUC was 204?±?25 and 25,441?±?2,648, respectively. At 45?days after surgery, mean fasting glucose significantly increased in the sham (sham?=?529?±?26, p?=?0.0003) but not in the SG rodents (SG?=?289?±?46, p?=?0.1113). In ZDF sham animals, OGTT at 45?days showed a higher AUC compared to before surgery (44,983?±?6,338, p?=?0.006), whereas in ZDF SG rodents, the increase in AUC glucose approached but did not reach statistical significance (35,553?±?3,925, p?=?0.06).

Conclusions

In ZF and ZDF rodents, SG did not influence food intake and weight evolution. In ZDF rodents, diabetes progressed in the sham group but not in the SG group.     

Racial Disparity in Short-Term Outcomes after Gastric Bypass Surgery

Background

Roux-en-Y gastric bypass procedure is the most frequently performed bariatric surgery for the extremely obese in USA. However, the information about the effects of racial/ethnic differences, comorbidities, and medication use on weight loss outcomes is limited. The objectives of this study were to investigate if race/ethnicity, comorbidities, and medication use affect weight loss effectiveness after the surgery.

Methods

This is a retrospective observational study conducted at one teaching hospital at Houston metropolitan area, TX, USA. Patients between 18 and 64 years, with body mass index (BMI) of ≥40 or BMI of ≥35 with comorbidities, who had completed medical evaluations/consultations and met insurance policy requirements, were included in the study.

Results

From a total of 40 patients in the study (40 % African Americans, 35 % Caucasians, 17.5 % Hispanics, 7.5 % others), the weight loss was significantly greater in Caucasian patients at 6 months after the surgery, with mean percentage excess weight loss (%EWL) of 40.6?±?17.3, as compared to all other racial groups combined at %EWL of 30.9?±?11.5 (p value 0.04). No association was found between the 6-month weight loss and other variables including age, gender, BMI prior to surgery, comorbidities, and total number of medications taken before the surgery.

Conclusions

This study found that Caucasian patients had a significantly greater %EWL at 6 months post-op as compared to their African-American and Hispanic counterparts. No other variables exhibited significant impact on the weight loss. Further studies with a larger sample size are needed to confirm the results from this study.     

Laparoscopic Sleeve Gastrectomy for Morbid Obesity: 5 Years Experience from an Asian Center of Excellence

Background

Laparoscopic sleeve gastrectomy (LSG) is emerging as a popular “stand-alone” bariatric procedure. We report our 5 years experience with LSG as a single-stage bariatric procedure with which to study the technical progress, learning curve, complications, and follow-up results.

Methods

Prospectively collected data of 228 patients (145 females and 83 males), who underwent LSG for morbid obesity, from February 2007 to March 2012, was retrospectively analyzed.

Results

The mean age was 34.68 years (range, 18–62 years) and the mean preoperative body mass index (BMI) was 37.42?±?4.75 kg/m² (range, 32.08–65.69 kg/m²). Mean operative time was 60.63?±?27.37 min. The mean BMI decreased to 26.15?±?3.71 kg/m² at 3 years (p?<?0.001) and to 27.94?±?4.08 kg/m² at 5 years (p?<?0.001). Mean percentage excess weight loss was 71.96?±?21.30 % at 3 years and 63.71?±?20.08 % at 5 years. The 30-day readmission rate was 3.07 %.Overall complication rate was 4.3 %, including strictures, leaks, peritonitis, gastrocutaneous fistula, and one (0.43 %) mortality. One patient with weight regain and another with stricture underwent conversion to Roux-en-Y gastric bypass. Complication rates significantly decreased after the first 50 cases (p?=?0.022), suggesting an initial learning curve. Resolution of diabetes, hypertension, and hyperlipidemia was 66.67, 100, and 50 %, respectively, at 5 years.

Conclusions

LSG as a single-stage bariatric procedure is safe and durable, achieving weight loss and resolution of comorbidities up to 5 years. Adherence to technical details is pivotal in reducing complications associated with the initial learning phase.     

Efficacy of Laparoscopic Sleeve Gastrectomy and Intensive Medical Management in Obese Patients with Type 2 Diabetes Mellitus

Background

There are a dearth of studies comparing laparoscopic sleeve gastrectomy (LSG) and intensive medical treatment (IMT) in obese type 2 diabetes mellitus (T2DM) patients. This study compares these modalities in terms of weight loss, metabolic parameters and quality of life (QOL) score.

Methods

We evaluated the efficacy of LSG (n?=?14) vs. IMT (n?=?17) comprising of low calorie diet, exenatide, metformin and if required insulin detemir in 31 obese T2DM patients with BMI of 37.9?±?5.3kg/m² and target HbA1c?<?7 %. The mean (±SD) age of the patients was 49.6?±?11.9 years and 74 % were women. The mean duration of diabetes was 8.5?±?6.1 years and mean HbA1c was 8.6?±?1.3 %. Primary end point was excess body weight loss (EBWL) at the final follow-up.

Results

The mean duration of follow-up was 12.5?±?5.0 (median 12) months. EBWL was 61.2?±?17.6 % and 27.4?±?23.6 % in LSG and IMT group respectively (p?<?0.001). Glycemic outcomes improved in both with mean HbA1c of 6.6?±?1.5 % in LSG and 7.1?±?1.2 % in IMT group. In LSG group, there was resolution of diabetes and hypertension in 36 and 29 % of patients respectively while none in the IMT group. HOMA-IR, hsCRP, ghrelin and leptin decreased while adiponectin increased significantly in LSG compared to IMT group. QOL score improved in LSG as compared to IMT.

Conclusions

In obese T2DM patients, LSG is superior to IMT in terms of weight loss, resolution of comorbidities and QOL score.