Hemochromatosis,<Emphasis Type="Italic"> HFE</Emphasis> C282Y Homozygosity,and Bariatric Surgery: Report of Three Cases

Background: Iron absorption is decreased in some individuals who have undergone bariatric surgery. Methods: We evaluated measures of iron metabolism and therapeutic phlebotomy in 3 adults with hemochromatosis and HFE C282Y homozygosity who underwent bariatric surgery. Results: 1 male and 1 female had surgery before diagnosis of hemochromatosis (jejuno-ileal bypass and Roux-en-Y gastric bypass, respectively); neither had iron overload. Another man was treated with serial phlebotomy to induce iron depletion; later, he underwent Roux-en-Y gastric bypass. His maintenance phlebotomy requirement for hemochromatosis decreased substantially (on average ~1 unit each 71 days before surgery, and ~1 unit each 173 days after surgery). None of these patients developed iron deficiency, and none took supplemental iron. Conclusions: Iron absorption is decreased in some patients with hemochromatosis and HFE C282Y homozygosity after bariatric surgery, but their risk of developing iron deficiency may be diminished.     

Severe Intra-abdominal Infection due to Streptococcus <Emphasis Type="Italic">Milleri</Emphasis> Following Adjustable Gastric Banding

Background: Laparoscopic adjustable gastric banding represents a safe and effective bariatric surgical method. Nevertheless, complications such as intraabdominal infections are associated with high morbidity and mortality. Case Report: A 50-year old morbidly obese female patient underwent adjustable gastric banding with the Swedish band (SAGB). After an uneventful postoperative follow-up of 2 years, she developed band infection due to colon microperforation during endoscopic polypectomy. As the causative microorgansim, Streptococcus Milleri was revealed. Band removal was required, and recovery was quite prolonged. Conclusion: Intra-abdominal infection with Streptococcus Milleri can cause severe and life-threatening disease. Therefore, early diagnosis and surgical intervention combined with body weight adapted antibiotic therapy for a sufficiently long period of time seems necessary. In patients with intra-abdominal implanted devices such as the SAGB who undergo endoscopic polypectomy, antibiotic prophylaxis should therefore be considered.     

<Emphasis Type="Italic">In Vivo</Emphasis> Band Manometry: a New Access to Band Adjustment

Background: By application of a newly developed device for invasive pressure measurements, we have investigated band adjustments monitored by in vivo intraband pressures. With access to the port of the gastric banding device, pressures can be recorded inside the band system at rest and during bolus application with different adjustments of the band. Methods: 25 patients (mean age 38.7, mean BMI 45.1, 80% women) had intraband pressure measurements at the first band adjustment 8.2 weeks (range 6 to 17) postoperatively. For this purpose, we adapted a pressure monitoring system with the TruWave disposable pressure transducer of Edwards^?. All patients underwent gastric banding using the Swedish adjustable gastric band (SAGB) by the pars flaccida technique. Results: In vivo intraband pressures differ from ex vivo intraband pressures. With increasing fill volume in vivo measurements show increasingly higher pressures than ex vivo measurements. This difference can mainly be attributed to the influence of the enclosed tissue. The in vivo intraband pressures correlate with the amount of outflow obstruction. Conclusion: Intraband pressure measurement is an encouraging new access to gastric banding. It appears to be a feasible method to control band adjustment without need for x-ray studies in low pressure bands. We expect physiologically exact adjustments to achieve good weight loss and to prevent esophageal problems in the long term.     

<Emphasis Type="Italic">ESR1</Emphasis>, <Emphasis Type="Italic">FTO</Emphasis>, and <Emphasis Type="BoldItalic">UCP2</Emphasis> Genes Interact with Bariatric Surgery Affecting Weight Loss and Glycemic Control in Severely Obese Patients

Background  

Significant variability in weight loss and glycemic control has been observed in obese patients receiving bariatric surgery. Genetic factors may play a role in the different outcomes.     

Purpura Fulminans due to <Emphasis Type="Italic">Streptococcus pneumoniae</Emphasis> Sepsis following Gastric Bypass

An older female underwent bariatric surgery which was followed by a significant weight loss and diarrhea, from which C. difficile was isolated just before her hospitalization. Less than 48 hours after admission, she became febrile, developed deep venous thrombosis of the leg and a pulmonary embolus. Blood cultures grew out Streptococcus pneumoniae and the patient developed purpura fulminans. There was convincing laboratory evidence for disseminated intravascular coagulation and a marked depletion of proteins C and S as well as antithrombin. Treatment with ceftriaxone and drotrecogin alfa together with parenteral nutrition led to disappearance of the pathogen and ultimate normalization of the anticoagulant factors. We believe that malabsorption of vitamin K dependent proteins C, S and antithrombin due to bariatric surgery predisposed the patient to purpura fulminans and disseminated intravascular coagulation.     

Devastating Methicillin Resistant <Emphasis Type="Italic">Staphylococcus Aureus</Emphasis> Wound Infection following Abdominoplasty in a Prior Bariatric Surgery Patient

A 46-year-old female smoker presented 12 months after laparoscopic adjustable gastric banding, with massive weight loss and skin excess of the abdomen and flanks. She underwent abdominoplasty with muscle plication and flanks liposuction, but on the 14th postoperative day this was complicated by a methicillin-resistant Staph. aureus wound infection. Multiple surgical debridements and high doses of intravenous antibiotics were necessary for cure and to avoid further septic complications. Complete wound closure was achieved after 3 months of therapy. Concomitant risk factors for wound infection (obesity, smoking, flap construction) contributed to a rare but potentially fatal wound complication following abdominoplasty.We alert the surgeon to such postoperative infections and the necessity for a non-conservative approach.     

The Effect of Intraoperative <Emphasis Type="Italic">N</Emphasis>-Acetylcysteine on Hepatocellular Injury During Laparoscopic Bariatric Surgery. A Randomised Controlled Trial

Background

The combination of pneumoperitoneum and intraoperative retraction of the left lobe of the liver leads to hepatocellular injury during laparoscopic gastric surgery. Fatty livers are more susceptible to ischaemic insults. This trial investigated whether the antioxidant N-acetylcysteine (NAC) reduced liver injury during laparoscopic sleeve gastrectomy (LSG).

Methods

Patients undergoing LSG were randomised (single blinded) to receive intraoperative NAC infusion or standard anaesthetic treatment. Blood samples were taken before and after surgery (days 0 to 4). Primary endpoints included serum aminotransferases. Secondary measures were C-reactive protein, weight cell count (WCC), cytokines (interleukin 6 and 10) and cytokeratin-18 as markers of apoptosis. Intraoperative liver biopsy samples were assessed using a locally developed injury score.

Results

Twenty patients (14 females, mean age 44.5 (SEM?±?2.9)?years, mean BMI 60.8 (SEM?±?2.4)?kg/m²) were recruited (NAC n?=?10, control n?=?10). The trial was stopped early after a planned interim analysis. Baseline liver function was similar. The peak rise in liver enzymes was on day 1, but levels were not significantly different between the groups. Rates of complications and length of stay were not significantly different. Secondary outcome measures, including white cell count (WCC), cytokines and cytokeratin (CK)-18 fragments, were not different between groups. Liver injury scores did not differ significantly.

Conclusions

NAC did not reduce intraoperative liver injury in this small number of patients. The heterogenous nature of the study population, with differences in co-morbidities, body mass index and intraabdominal anatomy, leads to a varied post-operative inflammatory response. Significant hepatocyte injury occurs through both necrosis and apoptosis.