Vitamin D Deficiency Before Bariatric Surgery: Should Supplement Intake Be Routinely Prescribed?

Background

Before bariatric surgery, we demonstrate a 96% rate of vitamin D deficiency in morbidly obese French patients: should supplement intake be routinely prescribed? We conducted a prospective observational study to demonstrate the prevalence of vitamin D deficiency in morbidly obese patients awaiting bariatric surgery.

Methods

Clinical and biological data were collected on 50 successive patients.

Results

Data showed vitamin D deficiency in 96% (25-OH vitamin D = 31 ± 13 nmol/l), with a cut-point of 50 nmol/l. Secondary hyperparathyroidism was found in 44% of patients with hypovitaminosis D (parathyroid hormone (PTH), 59?±?24 pg/ml). Impaired PTH level concerned 89% of this group, considering the cut-point at 30 pg/ml. No significant correlation appeared between vitamin D and calcium or phosphate levels.

Conclusions

Before surgery, we demonstrated a higher incidence of vitamin D deficiency in morbidly obese French patients as compared to the general population. The incidence was also higher than previous American studies. Screening for hypovitaminosis D may routinely be considered in morbid obesity. Long-term observation is, however, needed to assess the advantages and potential side effects of systematic vitamin D supplements.

     

Parathyroid Surgery in the Elderly: Should Minimally Invasive Surgery Be Abandoned?

Background

Single adenoma is the cause of 80 % of primary hyperparathyroidism (PHPT) resulting in wide acceptance of minimally invasive parathyroidectomy (MIP). The incidence of PHPT increases with age. Little information is available regarding the prevalence of multiglandular disease (MGD) in older patients.

Methods

The records of 537 patients that underwent parathyroid surgery between January 2005 and October 2012 at two endocrine surgery referral centers were retrospectively reviewed. Comparison was performed between patients younger than 65 and older than 65 years of age. Clinical variables included preoperative laboratories and imaging, extent of neck exploration, number of glands excised, and intraoperative parathyroid hormone levels during surgery.

Results

There were 374 (70 %) patients in the younger age group (YG) and 163 (30 %) patients in the older age group (OG). The mean age was 50 ± 0.5 and 71 ± 0.4 years, respectively. There was no difference between the groups in terms of gender or laboratory results. MGD was significantly more common in the OG (24 % vs. 12 %; p = 0.001) and similarly MIP was less commonly completed in the OG (49 % vs. 68 %; p < 0.001). Cure rates were comparable between the OG and YG (93 % vs. 95 %; p = 0.27). In the OG, patients with MGD had significantly smaller glands as compared to patients with single adenomas in this group (331 ± 67 vs. 920 ± 97 mg; p = 0.006, respectively).

Conclusions

MGD in PHPT was found to be more prevalent in older patients. Planning a bilateral neck exploration should be considered in older patients, especially when a relatively small gland is suggested by imaging or encountered during surgery.     

How Radical Should Surgery Be for Early Esophageal Cancer?

Background  

We have compared the oncologic effectiveness of limited resection (LR) techniques such as transhiatal (TH) or limited resection of the esophagogastric junction with intestinal interposition (LREGJ) in the treatment of early esophageal carcinoma with that of the extended resection such as the classical thoracoabdominal (TA) en bloc esophagectomy.     

Has Laparoscopic Bariatric Surgery been Accepted in Japan? The Experience of a Single Surgeon

Background  Obesity is steadily increasing in Asia due to factors such as a lack of exercise, adoption of a more Western diet, changing lifestyles, environments, or stresses. Even in Japan, this tendency is notable, and metabolic syndrome has become widely recognized. However, bariatric surgery is still uncommon in Japan. There are no adequate data regarding the experience and outcome of bariatric surgery in Asia. Here, we report on the current status of morbid obesity and the outcomes of bariatric surgery by a single surgeon in Japan. Methods  Between February 2002 and January 2008, we have performed laparoscopic bariatric surgery for morbid obesity in 178 cases. They consisted of laparoscopic Roux-en-Y gastric bypass (LRYGBP) in 105 cases, laparoscopic sleeve gastrectomy (LSG) in 26 cases, laparoscopic sleeve gastrectomy with duodenal jejunal bypass (LSG/DJB) in 14 cases, laparoscopic adjustable gastric banding (LAGB) in 13 cases, and laparoscopic biliopancreatic diversion with duodenal switch in one case under the same protocol of follow up. The first author of this paper performed all procedures. Results  One hundred and thirty-eight patients with a follow-up of over 3 months after surgery were enrolled. LRYGBP accounted for 72% of all bariatric procedures. The reduction of weight and body mass index (BMI) in LRYGBP and LSG showed similar results. These outcomes were superior to those of LAGB. Percentage of excess BMI loss (%EBMIL) of LRYGBP showed greater reductions at follow-ups 6, 9, 12, and 18 months after surgery compared to that of LRYGBP and LAGB. All procedures resulted in over 50% of %EBMIL after 18 months of follow-up. There was no postoperative mortality within 30 days after surgery. Preoperative comorbidity including diabetes mellitus, hypertension, and hyperlipidemia were resolved or improved after surgery in most patients. Conclusion  In bariatric surgery, LRYGBP is the most effective treatment for morbid obesity, while LAGB has a low risk of postoperative complications. LSG is also a safe procedure for supermorbidly obese patients. We expect that bariatric surgery will be a common procedure for patients with morbid obesity in Japan.     

DaVinci® Robotic-Assisted Laparoscopic Bariatric Surgery: Is it Justified in a Routine Setting?

Background: Laparoscopic silicone adjustable gastric banding (SAGB) has gained popularity for the surgical treatment of morbid obesity. The implantable gastric stimulator (IGS?) system represents a novel surgical alternative. We aimed to assess the feasibility of robotic-assisted laparoscopic bariatric operations and to critically elucidate the technical and financial advantages and patient outcome. Methods: Robotic-assisted laparoscopic bariatric procedures were performed on 10 consecutive patients using the daVinci? robot system (4 SAGB, 4 IGS?, 2 SAGB revisions). 10 conventional laparoscopic-operated patients (4 SAGB, 4 IGS?, 2 SAGB revisions) during the learning curve served as controls. Equipment, operative technique and procedural time were evaluated. A cost analysis was calculated. Results: The personnel equipment, numbers of trocars and operation technique were comparable in both groups. The mean operative time was 137 min (range 110-175) and 97 min (60-140) in robotic-assisted and conventional laparoscopy, respectively (P =0.04). Establishment of the pneumoperitoneum and placement of trocars and robotic arms took a mean of 30 min (15-45) in the robotic-assisted group, compared with 5 min in the control group (P <0.001). In 1 patient, intraoperative gastric injury was suspected and led to band removal in the robotic-assisted group. There was no postoperative complication. Average procedural costs were significantly higher in the robotic-assisted group. Conclusion: Primary and revisional robotic-assisted bariatric surgery is technically simple, with the benefit of precise instrument handling. However, it is still expensive, the set-up of the system is time-consuming, and a limited variety of instruments are available presently.     

Is Bariatric Surgery Worth Its Costs?

Formal economic evaluations of obesity surgery have not been reported in the medical literature to date. In this article, we briefly review the most important types of health economic evaluations, namely cost-effectiveness analysis, cost-utility analysis, and cost-benefit analysis. Bariatric surgery has the potential to substantially impact quality of life, morbidity, and mortality costs in patients with morbid obesity. Health economic studies that include these effects are needed.     

Does Nonarticlar Tenderness Change after Bariatric Surgery?

Background: A previous study reported an association between obesity and increased tenderness. However, the effect of weight reduction on tenderness is not known. The aim of the study was to assess tenderness thresholds before and after bariatric surgery. Methods: 42 obese women were evaluated for tenderness before and 6 months after bariatric surgery. A count of 18 tender points at 9 symmetrical sites was performed by thumb palpation. 13 point sites (9 tender point sites and 4 control sites) were further studied using a dolorimeter. Results: The obese subjects displayed increased tenderness before surgery and its level did not change 6 months later. The mean tender point count before surgery was 8.8±3.9 and after surgery was 8.3±4.3 (P=0.500). The mean tenderness thresholds at nine tender points were 4.0±1.1 and 3.8±1.1, respectively (P=0.247). Conclusion: Nonarticular tenderness in obese women remained high after weight reduction. These findings are relevant to physicians taking care of obese patients. Further studies are needed to elucidate the relationship between weight reduction and pain thresholds.     

Can Laparoscopic Pancreaticoduodenectomy Be Safely Implemented?

Introduction  

The implementation of laparoscopic pancreaticoduodenectomy (LPD) has been appropriately met with apprehension, and concerns exist regarding outcomes early in a program’s experience. We reviewed our early experience and outcomes of LPD.