Evaluation of Gastric Greater Curvature Invagination for Weight Loss in Rats

Background: Many bariatric endocopic or surgical procedures performed today reduce gastric capacity and/or induce an early sensation of satiety, alone or in combination with a distal enteric intervention. A form of prosthetic gastric wrap was used in the past for treating obesity with a high rate of reintervention. Nissen gastric fundoplication used in the treatment of gastroesophageal reflux disease induces a small but significant weight loss. We report the effect of gastric greater curvature invagination on weight in rats. Methods: 30 rats were randomly divided into 3 groups. 10 rats in the first group (sham) were anesthesized and weighed. The rats from the second group (lap) were in addition submitted to a laparotomy plus visceral manipulation. In the third group (inv), invagination of the greater curvature of the stomach was added. All animals were weighed on the 7th and 21st days. They were then autopsied on the 21st day. Results: The mean body weight of the invagination group became statistically less than the laparotomy and sham groups at 7 and 21 days. The mean weight of the peritesticular fat pad from the inv group was also significantly less than from the sham group but not different from the lap group. Conclusion: Gastric greater curvature invagination significantly decreases weight in rats.     

Comparison of Gastric Fundus Invagination and Gastric Greater Curvature Plication for Weight Loss in a Rat Model of Diet-Induced Obesity

Background

Gastric fundus invagination (GFI) is a novel weight loss procedure. The gastric fundus is invaginated inside the gastric lumen and anastomosed to the gastric antrum. In gastric plication (GP), the greater curvature is plicated inside the gastric lumen leaving a narrow gastric channel for food passage. This study compares GFI to GP in a diet-induced obesity rat model.

Methods

Twenty Long-Evans male rats were fed a 60 % high fat diet for 6 weeks. At 14 weeks of age, the rats underwent either GFI (N?=?10) or GP (N?=?10) surgery. Body weight and food intake were measured for 6 weeks. Serum adipokines and ghrelin hormone were assayed. Six weeks after surgery, all rats were euthanized and the stomachs examined. The two-sample t test was used to compare the results between the two groups.

Results

All GFI rats had an intact fundus invagination at 6 weeks following surgery. The greater curvature plication unfurled in three out of ten GP rats. Part of the fundus herniated through the plication suture line in one GP rat. There was no significant difference between the mean percent weight change for the GFI (4.2?±?4.1 %) and GP (8.8?±?6.0 %) groups. There was no difference in food intake between both groups. GFI was associated with a significant lower fasting ghrelin levels (101.1?±?13.1 versus 137.3?±?27.4; p?=?0.044) compared with GP.

Conclusions

GFI offers a more effective and more durable surgical alternative for weight loss than GP.     

Evaluation of Gastric Fundus Invagination for Weight Loss in a Porcine Model

Gastric fundus compliance allows stomach volume increase in response to food intake. Absence of this postprandial relaxation alters hormonal signals and induces early satiety and weight loss. This study demonstrates the effect of gastric fundus invagination on the growth rate of juvenile pigs. After institutional animal care and use committee approval, 15 juvenile pigs were divided into two groups. In the first group, six pigs were anesthetized, weighed, and submitted to laparotomy, stomach manipulation, and short gastric vessel ligation. This is the control group and is referred to as "Sham". In the second group, gastric fundus invagination was added by using a circular stapler. This is the procedure group and is designated as "GFI". Postoperatively, body weight and food intake were measured for 5?weeks. Pigs were euthanized and the stomachs examined. Growth patterns were compared. Three animals were excluded from the analysis. At the end of the 5-week study period, six GFI pigs had intact anastomosis with an invaginated fundus. The mean percent growth rate for the GFI group (54.2?±?2.8?%) was significantly less than the Sham group (77.7?±?4.9?%). Gastric fundus invagination significantly decreases the growth rate in juvenile pigs.     

Effect on Gastric Emptying and Weight Reduction of Botulinum Toxin-A Injection into the Gastric Antral Layer: An Experimental Study in the Obese Rat Model

Background: We investigated the effects of Botox-A on weight loss and gastric emptying in an experimental obese rat model. Although there is evidence of weight loss in normal-weight rats after Botox-A injection, there are no studies indicating the effect of Botox-A injection on weight loss and gastric emptying time in obese rats. Methods: 37 female Wistar Albino rats were given high calorie diet for 90 days. They were separated into 3 groups. The first group (Botox group) consisted of 15 obese rats whose gastric antrum was injected with 20 U of Botulinum Toxin Type A. The second group (Saline group) consisted of 15 obese rats whose gastric antrum was injected with 20 U of saline. The third group (Control group) had no surgical intervention. Gastric scintigraphy was performed in the 3 groups pre- and postoperatively. Results: The saline group had a weight reduction in the early postoperative days but began to gain weight thereafter. The mean weight of the Botox group between the 16th and 28th days postoperatively was significantly lower than the mean weights of the control and the saline groups (P<0.05, P<0.001). The results of gastric emptying scintigraphy in all 3 groups at day 20 revealed significantly higher T1/2 values in the Botox-A group when compared to the results of the control and saline groups (P<0.001). Conclusion: Botox-A application to the gastric antrum in obese rats leads to weight loss by increasing the gastric emptying time.     

Endoscopically Assisted Transumbilical Single-Incision Laparoscopic Gastric Resection for GIST Treatment

Purpose: Complete surgical resection with negative margins without lymphadenectomy is the treatment of choice for nonmetastatic Gastrointestinal Stromal Tumors (GISTs). Laparoscopic resection of gastric GISTs <5 cm is an acceptable and oncologically feasible, safe, and effective treatment. We present our experience of an endoscopically assisted minimally invasive transumbilical single-incision laparoscopic (SILS) technique for gastric GISTs resection. Methods: Four patients with small gastric GISTs ≤5 cm located on the greater curvature or the anterior wall were resected with SILS by using a lesion-lifting technique under the guidance of flexible gastroscopy. Results: The technique was feasible and safe and offered significant advantages in locating the tumor and controlling the resection margins. There were no major intraoperative or postoperative complications, conversions, or tumor ruptures. Pathology showed low-risk GISTs resected with disease-free margins without tumor rupture. No recurrences have been observed. Conclusion: The endoscopically assisted SILS wedge gastrectomy is a feasible, safe, and advantageous technique for the treatment of the greater curvature or anterior wall gastric GISTs.     

网膜囊路径腹腔镜胃后壁间质瘤切除8例报告

目的探讨腹腔镜网膜囊路径切除法治疗胃后壁胃间质瘤（gastric stromal tumor,GST）的可行性。方法2006年9月～2011年9月腹腔镜下网膜囊路径切除胃后壁GST 8例。4例位于胃体后壁胃大弯,2例位于胃体后壁胃小弯,1例位于胃窦后壁,1例位于胃后壁靠近贲门。位于胃体后壁靠近胃大小弯的间质瘤,离断胃相关韧带,显露胃后壁,行局部楔形切除;位于胃窦或贲门的间质瘤,行远端或近端胃大部切除术,然后行消化道重建。结果 6例成功行腹腔镜下网膜囊路径局部楔形切除术,1例行腹腔镜下近端胃大部分切除＋胃-食管吻合,1例行腹腔镜下远端胃大部分切除＋毕Ⅰ式吻合。手术时间30～90 min,平均60 min;术中出血量20～80 ml,平均50 ml。术后2～6 d,平均4 d进食流质。住院时间3～7 d,平均5 d。8例随访3～62个月,平均32.5月,无复发和吻合口狭窄。结论腹腔镜下网膜囊路径治疗胃后壁GST可行。     

Laparoscopic Gastric Greater Curvature Plication: Results and Complications in a Series of 135 Patients

Laparoscopic gastric greater curvature plication (LGGCP) is an emerging restrictive bariatric procedure that successfully reduces the gastric volume by plication of the gastric greater curvature. Its main advantages are the reversibility of the technique as well as the lack of foreign materials or gastrectomy. We present our results, focusing on the effectiveness and complications, and on a new modification of the original technique. One hundred and thirty-five patients underwent LGGCP between April 2008 and December 2009. A five-trocar port technique was used, and following dissection of the greater gastric curvature, single plication of the latter was performed under the guidance of a 36-Fr bougie. Modification of the technique included multiple gastric plications. One hundred and four obese women and 31 obese men (mean age of 36 years) underwent LGGCP for weight reduction. Operative time was 40–50 min, and mean hospital stay was 1.9 days (range 1–6 days). After a follow-up of 8–31 months (mean 22.59), the mean percentage of excess weight loss (%EWL) was 65.29. Subgroup analyses based on BMI values showed that %EWL was significantly higher for patients with BMI < 45 kg/m2 (group I) compared with patients with BMI > 45 kg/m2 (group II) (69.86 vs 55.49, respectively, p = 0.006). Similarly, inadequate weight loss was significantly higher for group II, while the failure of the technique and postoperative complications were comparable. On the other hand, subgroup analysis based on the technique showed that the modification of the technique did not affect the effectiveness or the operative time; however, it reduced early complications dramatically, including prolonged postoperative vomiting and late gastric obstruction, thus affecting the length of hospitalization. Overall complication rate in our series was 8.8% (12/135). Cases of prolonged postoperative vomiting, GI bleeding, and leak were treated conservatively, while one case of portomesenteric thrombosis and three cases of acute gastric obstruction were treated surgically. LGGCP is an emerging technique sparing gastric resection, the use of foreign materials and intestinal bypass. Its effectiveness is satisfactory for patients with BMI < 45 kg/m2, and the complication rate is acceptable.     

Converting Vertical Banded Gastroplasty to a Lesser Curvature Gastric Bypass: Technical Considerations

Background: Vertical banded gastroplasty (VBG) is occasionally followed by poor weight loss or complications requiring reoperation. Several studies have analyzed the morbidity and mortality associated with conversions of VBG to gastric bypass, but few have described the actual technique. The most frequent complications related to this type of reoperation are gastrointestinal leaks. Materials and Methods: The authors analyzed 60 consecutive conversions from VBG to lesser curvature gastric bypass, performed on 60 patients. The cases were analyzed for surgical technique, complications and weight loss. In all the cases the operation was limited to the lesser curvature of the stomach, and certain technical maneuvers were done to facilitate the creation of the pouch and anastomosis. Results: There were three major complications, and two patients required reoperation. There were no gastrointestinal leaks or mortality. Percentage weight loss at 5 years was similar to primary gastric bypasses. Conclusion: Converting failed or complicated VBGs to lesser curvature gastric bypasses are safe and effective weight loss operations. By performing several specific technical maneuvers and limiting the operation to the highly vascular lesser curvature, complications can be reduced to a minimum.     

Single-Incision Versus Conventional Laparoscopic Adjustable Gastric Banding

Background and Objectives:

Laparoscopic adjustable gastric banding is an effective and popular bariatric surgery for weight loss in obese patients that traditionally involves up to 5 incisions. Recently, a more minimally invasive single-incision technique has been developed. In this retrospective study, we compare conventional and single-incision laparoscopic adjustable gastric banding with regard to weight loss and complication rates in a cohort of demographically similar patients.

Methods:

From February 2009 to February 2010, 59 patients underwent laparoscopic adjustable gastric banding by one surgeon at an outpatient surgery center. All patients were compared by age, sex, preoperative body mass index, 30-day complication rates, and excess weight loss. Thirty-seven operations were performed by a conventional, 5-incision technique, whereas 22 patients underwent the single-incision technique. The success of these techniques was determined by comparing complication rates and average percentage excess weight loss at 6-month follow-up intervals.

Results:

Patients who underwent conventional laparoscopic adjustable gastric banding had a mean age of 41.2 years and preoperative body mass index of 48.2 kg/m² compared with 43.9 years and 40.3 kg/m², respectively, for the single-incision patients. The mean operative time in the single-incision group was longer than that in the conventional group: 47.1 minutes versus 37.4 minutes (P = .0027). The overall percentage excess weight loss was not statistically different between the 2 groups for each follow-up period. There were no complications or deaths in either group.

Conclusion:

Although patients undergoing bariatric surgery may choose the single-incision technique for cosmetic purposes, this retrospective review comparing single-incision and conventional laparoscopic adjustable gastric banding shows longer operative times with equivalent weight loss and morbidity.     

Effects and Mechanisms of Implantable Gastric Stimulation on Gastric Distention in Conscious Dogs

Background: While implantable gastric stimulation (IGS) on the lesser curvature has been reported to induce weight loss in obese patients, its mechanisms involving gastric mechanical activity remain largely unknown. The aim of this study was to investigate the effect and mechanism of IGS on gastric tone in canines. Methods: 8 healthy dogs were implanted with a gastric cannula on anterior stomach and a pair of electrodes at lesser curvature. Gastric tone was assessed with an electronic barostat in 2 randomized sessions, a control and a session with L-NNA (nitric oxide synthase inhibitor). The control session included 30 min baseline, followed by 30 min with IGS; the L-NNA session included 30 min baseline, 30 min immediately after a bolus of L-NNA, and 30 min with IGS. Results: 1) In the control session, IGS significantly increased the proximal gastric volume from baseline 91.3±7.1 ml to 186.3±27.1 ml (P<0.05); 2) L-NNA markedly reduced the proximal gastric volume from 110.3±11.9 ml to 56.9±10.8 ml (P<0.01); and subsequent IGS did not significantly increase the proximal gastric volume (P>0.05). Conclusion: IGS significantly inhibits proximal gastric tone or induces gastric distention, and this inhibitory effect is mediated via the nitrergic pathway.     

Effects of Participation in Bariatric Support Group After Roux-en-Y Gastric Bypass

Background: Support group is a service provided by Pacific Bariatric Surgical Medical Group to its gastric bypass patients before and after surgery. It has already been well established that group therapy helps breast cancer patients survive longer. Methods: 102 patients answered self-report questionnaires that were mailed out in the spring 1998 newsletter. The questionnaire was designed to investigate weight loss, mood, postsurgical problems, and the reasons patients chose not to attend the support group meetings. Results: The mean preoperative weight was 303.65 lb (137.73 kg), with a mean weight loss of 95.79 lb (43.45 kg). The mean desired goal weight was 152.47 lb (69.16 kg), and there was a 63.3% loss of excess weight. The mean elapsed time since surgery was 15.2 months. After surgery, 25.5% of patients reported seeing a mental health professional. There was no difference in mood between group meeting attenders and nonattenders. There was a statistical trend for more weight loss (P = .08) in group attenders than in nonattenders. For group attenders, the more often patients attended group meetings, the more weight they lost (P <.05). Patients with reported emotional, psychosocial, dietary, and lifestyle problems were no more likely to attend group than nonattenders. Conclusions: The mean weight loss was as good as or better than reported in the literature. Patients who attended group meetings regularly tended to lose more weight, and increased frequency of attendance was associated with greater weight loss. The implications are discussed.     

Rats Submitted to Gastric Banding are Leaner and Show Distinctive Feeding Patterns

Background: Bariatric surgery is expanding to meet the global epidemic of morbid obesity, because this surgery is successful in achieving sustained weight loss. After having recently established a rat model of gastric banding, our aim now was to investigate the relative fat mass content and the feeding patterns of gastric banded rats. Methods: Two groups of Wistar rats, submitted either to gastric banding or to sham surgery, were followed-up for 26 days regarding weight, daily food intake and feeding patterns both under resting conditions and when refed after fasting. Weight of the epididymal fat pad was used as a measure to evaluate changes in white adipose tissue in the rats. Results: 10 days after surgery and thereafter, rats submitted to gastric banding showed the same daily food intake that was observed in sham-operated rats. Nevertheless, gastric banded rats kept lower body weights and were leaner than controls. These differences were associated with distinctive feeding patterns, both under resting conditions and when refed after fasting, suggesting that gastric banded rats present a significant increase in feeding frequency when compared with controls. Conclusion: This data is the first experimental evidence that an increase in feeding frequency is associated with weight loss after gastric banding, even if there is no decrease in total energy intake. Thus, medical advice on the advantages of fractionating daily caloric intake into multiple meals is further supported by the herein new information obtained in an animal model of gastric banding.     

The continent gastrostomy

In an attempt to facilitate long-term care and patient acceptance of gastrostomy feeding, the technique of permanent Janeway gastrostomy was modified. Using an auto-stapling device, a full-thickness gastric tube (6 cm long and 1.5 cm in diameter at its base) is created from the anterior wall of the stomach, based on the greater curve, with special attention to its vasculature. The base is invaginated into the stomach wall to create a tight valve. After skin closure, the terminal 1 cm is excised and the mucosa is sutured flush with the skin. A #10 French tube is inserted and positioned perpendicularly. A gastrostomy thus created will allow intermittent cannulation without leakage of gastric contents. Results of this procedure in 26 patients show a postoperative wound infection incidence of 3.8 per cent. With a mean follow up of 257 days, the gastrostomy was continent in 87 per cent of patients.     

Primary Gastric Tuberculosis Mimicking Gastric Tumor That Results in Pyloric Stenosis

Summary BACKGROUND: Primary gastric tuberculosis is rarely seen. It usually produces a diagnostic challenge and may mimic peptic ulcer disease and even a neoplasia. We present a case of primary gastric tuberculosis initially thought to be a neoplasia. METHODS: A 46-year-old female was admitted with one-month history of nausea, vomiting and weight loss. A barium swallow showed a constant filling defect in the antral and prepyloric region. On upper endoscopy, an 8 cm mass was noted in antral and prepyloric regions. The biopsy specimens taken during endoscopy were insufficient for precise diagnosis. An operative diagnosis of gastric carcinoma leading to pyloric stenosis without any distant metastasis was made; a subtotal distal gastrectomy and roux-en-Y gastroenterostomy procedure was therefore applied. RESULTS: Pathologic evaluation revealed necrotic granulomatous inflammation throughout the wall of corpus, necrotizing granulomatous lymphadenitis in the lesser and greater curvature lymph nodes, and also in omentum. There were no findings of carcinoma. Ehrlich-Ziehl-Nielsen staining method revealed numerous acid-fast bacilli. Despite extensive studies, no evidence of extragastric tuberculous involvement was discovered, and she was prescribed an antituberculosis therapy for a period of one year. The patient remains asymptomatic. CONCLUSIONS: Primary gastric tuberculosis usually produces a diagnostic challenge and may mimic peptic ulcer disease and even a neoplasia.     

Gastric Banding for Morbid Obesity: Initial Experience with a New Adjustable Band

A new adjustable gastric band was developed, consisting of a silicone balloon connected to a subcutaneous port in a closed system. The stoma diameter can be regulated within an extensive range (0-40 mm). The diameter is adjusted individually for each patient and weight loss can therefore be controlled and optimized. We evaluated the application of this new gastric banding procedure in terms of technical feasibility, complication rate and weight loss, and also the relationship between weight loss and pouch volume. Between January 1987 and April 1990 two preliminary studies of 18 and 24 patients respectively were carried out. In the first group there were technical problems resulting in insufficient weight loss. We therefore changed the procedure. In the second group the system thereafter worked as expected. In the second group mean preoperative weight was 132 kg, mean excess weight 60 kg, and mean BMI 45. The mean follow-up was in 21 months. At follow-up mean weight was 91 kg, mean weight loss 41 kg, and mean BMI 31. The mean postoperative stay was 6.0 days.     

Weight Loss and Caloric Intake after Regular and Extended Gastric Bypass

The morbidly obese and especially the super-morbidly obese (>225% ideal body weight) often require gastric bypass surgery as treatment for long-term remission of their obesity. The extended gastric bypass Roux-en-Y (X-GBP) procedure evolved as a result of a perceived need to increase weight loss in morbidly obese subjects beyond the limitations of the regular gastric bypass Roux-en-Y (R-GBP). We compared weight loss, caloric intake, and percentage of total caloric intake from carbohydrate, protein, and fat in eight R-GBP and eight X-GBP patients at 3, 6, 9, and 12 months following surgery. We found that R-GBP and X-GBP groups were similar in age and height, adjusting for baseline weight differences (p = 0.122). Both groups demonstrated significant weight loss over time (p<0.0001), with similar patterns of weight loss at each interval of nonsignificant interaction (p = 0.585). Weight loss for the two groups did not differ statistically. The X-GBP group lost 5% more weight than the R-GBP group by 12 months following surgery. The adjusted average weight loss over 12 months was 56.82 kg for X-GBP and 46.82 kg for R-GBP patients. Furthermore, the X-GBP group ingested fewer calories than the R-GBP group at 3, 6, 9, and 12 months following surgery. The X-GBP group ingested a lower percentage of calories from fat than the R-GBP group at 3, 9, and 12 months following surgery. This study depicts clinical trends in weight loss following X-GBP and R-GBP surgeries. The greater weight loss of the X-GBP group may be due to differences in total caloric intake or the lower perventage of calories ingested from fat. Other possibilities for the greater weight loss shown by the X-GBP group may include changes in malabsorption or resting energy expenditure over time following surgery.     

Weight Reduction after an Early Version of the Open Gastric Bypass for Morbid Obesity: Results after 23 Years

Background: While numerous promising short-term results of open gastric bypass for morbid obesity were published, the long-term outcome of earlier versions was somewhat disappointing. Thus, it was not until 1993 that this procedure was reintroduced with current modifications and now performed laparoscopically. Published long-term results of gastric bypass are still lacking. Methods: Out of an original population of 195 patients, we retrospectively analyzed the outcome of 98 patients (82 women, 16 men, mean age 32 years [range 17-54], mean weight 132 kg [range 65-200], mean BMI 46.6 kg/m²) operated on in Erlangen with mean follow-up 22.9 years (range 16.5-25.4). 3 different bariatric operations were performed: horizontal gastroplasty (HGP, n=18), stapled Roux-en-Y gastric bypass (S-RYGBP, n=14) and transected Roux-en-Y gastric bypass (T-RYGBP, n=66). BMI and percentage of excess weight loss (%EWL) were calculated at time 0, and after 1, 2, 3, 10, 15, 20 and 25 years. Results: Statistically significant weight loss was found for the whole patient population at every postoperative time-point compared to preoperative values. Maximal weight loss was achieved mainly during the first 3 years. However, initial and long-term outcome after HGP was significantly worse than after S-RYGBP or T-RYGBP. Gender did not significantly influence the results. Conclusion: Traditional open gastric bypass resulted in acceptable and safe long-term weight reduction. It may be assumed that laparoscopic gastric bypass with modern tiny pouch volumes based on the lesser curvature achieves even better and life-long weight reduction.     

Single-incision laparoscopic gastric resection for submucosal tumors: report of three cases

Between March and April 2009, three consecutive patients underwent single-incision laparoscopic gastric wedge resection for a submucosal tumor located in the anterior wall or greater curvature of the stomach. First, we placed two or three trocars through the same infra-umbilical skin incision. Then, we either elevated the tumor with a mini-loop retractor or retracted the gastric wall near the tumor with a laparoscopic grasper. Finally, we resected the tumor using an endoscopic linear stapler. Single-incision laparoscopic gastric resection was successfully completed in all three patients without the need for any extraumbilical skin incisions or conversion to conventional laparoscopic procedures. There was no morbidity. The mean operating time and blood loss were 86 min and 4 ml, respectively, and the mean tumor size and surgical margin were 34 mm and 8 mm, respectively. Histopathologically, two tumors were diagnosed as gastrointestinal stromal tumors and one as a carcinoid tumor. Thus, single-incision laparoscopic gastric resection for submucosal tumors is safe and feasible when performed by experienced laparoscopic surgeons using conventional laparoscopic instruments.     

Neonatal Gastric Perforation: Review of 23 Years’ Experience

Purpose To review our experience of treating 13 neonates with gastric perforation (GP) over the past 23 years.Methods The records of all 13 patients were reviewed, noting gender, weight, gestational age, age at admission, associated anomalies, site of perforation, type of operation, and clinical outcome.Results There were 11 boys and 2 girls, with a mean body weight of 2375g, including 4 (45%) preterm infants. The mean age at admission was 3.2 days. Three (23%) infants had associated anomalies. Perforation occurred in the lesser curvature and anterior wall in 3 (23%) infants, at the greater curvature and anterior wall in 2 (15.4%), in necrosis of anterior wall in 1 (7.7%), at the esophageal junction and posterior wall in 2 (15.4%), at the lesser curvature and posterior wall in 1 (7.7%), at the lesser curvature and esophageal junction in 1 (7.7%), and the site was not specified in 3 (23%). Twelve patients were treated with gastrorrhaphy and drainage, and 1 was treated with gastrorrhaphy alone. Three patients required additional gastrostomy. Mortality was 53.8% (n = 7). Early diagnosis and management before clinical deterioration of the metabolic status improved the prognosis.Conclusion The pattern of presentation and surgical findings should be investigated comparatively in premature and full-term neonates, as the etiology of this condition is likely to differ in these two gestational groups.