Sleeve Gastrectomy as a Stand-alone Bariatric Operation for Severe,Morbid, and Super Obesity

Background:

The laparoscopic sleeve gastrectomy (LSG) is emerging as an effective bariatric operation and is especially attractive in high-risk populations. In this study we examine the efficacy of LSG as a stand-alone operation in the veteran population.

Methods:

This is a retrospective review of consecutive patients who underwent LSG as a stand-alone procedure at the Palo Alto Veterans Affairs medical center with a minimum 12-month follow-up.

Results:

Of 205 patients undergoing bariatric surgery, 71 patients had a sleeve gastrectomy, 40 of whom had the operation performed at least 12 months previously. Thirty-six (90%) were available for 1-year follow-up, with a mean follow-up duration of 22 months (range: 12–42), a mean body mass index of 48.3 kg/m², and an 83% male population. Mean percent excess weight loss was 61% at an average of 22 months, with no significant difference between severely obese, morbidly obese, and super obese cohorts. Diabetes remission was seen in 56% of patients, hypertension remission in 51.6%, and obstructive sleep apnea remission in 46.4%, and gastroesophageal reflux disease improved or did not change in 83%. Medication use significantly decreased after surgery.

Conclusion:

LSG is safe and effective as a stand-alone bariatric operation in the high-risk veteran population. It is effective in severely obese, morbidly obese, and super obese patients. LSG induces remission or improvement in comorbidities of nearly all patients, translating to a decrease in medication use.     

Increased incidence of distal humeral fractures and surgical treatment in 0- to 18-year-old patients treated in Finland from 1987 to 2010

Background

Studies of pediatric and adolescent fractures in general report a significant increase in the incidence of upper-extremity fractures as well as in their surgical treatment. The aim of this study was to determine the trends of the incidence and treatment of distal humeral fractures in hospitalized 0- to 18-year-old patients in Finland.

Method

The study included the entire pediatric and adolescent (<19 years) population in Finland during the 24-year period from 1 January 1987 to 31 December 2010. Data on hospitalized patients were obtained from the nationwide National Hospital Discharge Registry where information is collected from all hospital categories (private, public, and other). Surgical treatment was categorized into three groups; (1) reposition with casting; (2) reposition or reduction and osteosynthesis; (3) reposition or reduction and external-fixation and other fixation methods. Patients were classified into three groups according to age: 0–6 years, 7–13 years, and 14–18 years. Annual incidences were calculated using the annual mid-year population census obtained from the Official Statistics of Finland.

Results

During the 24-year study period, there were a total of 12,590 hospitalizations with a main or secondary diagnosis of distal humeral fracture. In children aged 0–12 years the overall incidence of hospitalization increased 30 % during the 24-year study period, from 4.5 per 10,000 person-years in 1987 to 5.8 per 10,000 person-years in 2010. There were a total of 5,548 operations. During the study period, surgical treatment by repositioning or reduction with osteosynthesis due to a distal humeral fracture increased by fivefold in patients aged <6 years and by twofold in patients aged 7–12 years of age. The incidences of fracture and treatment in children older than 13 years did not change.

Conclusion

The incidence of distal humeral fractures and the incidence of repositioning with osteosynthesis increased remarkably in prepubertal children during the 24-year study period in Finland.     

Paralysis of the first dorsal interosseous muscle after external fixation of a distal radial fracture treated by transfer of the extensor indicis proprius tendon

We describe a patient in whom the motor branch to the first dorsal interosseous muscle was injured by the pins of an fixator used to treat an unstable fracture of the distal radius. She was successfully treated by extensor indicis proprius transfer to the base of the proximal phalanx of the index finger.     

Intraventricular aneurysms: Case reports and review of the literature

Background

Intraventricular aneurysms are rare, with only 49 cases have been reported to date in the literature. Treatment of these aneurysms is difficult because of their deep location, small size, and specific angioarchitecture.

Methods

We report four patients with intraventricular aneurysms. In the third patient, the aneurysm self-occluded during procedure of endovascular embolization, which has previously not been reported in the literature.

Results

The first patient was discharged without definitive treatment of his intraventricular aneurysm and died 1 year later. The third patient's aneurysm self-occluded during the procedure of endovascular embolization procedure. The aneurysms of the second and fourth patients were successfully embolized by coils and Onyx, respectively.

Conclusions

The conclusions drawn from our experience and a comprehensive review of the literature include the following: (1) intraventricular aneurysm should be considered in patients with isolated intraventricular hemorrhage; (2) intraventricular aneurysms are frequently very small (<5 mm diameter), and therefore, cannot always be detected on initial angiography; (3) small intraventricular aneurysms cannot usually be clipped or occluded without sacrificing the parent artery; (4) if an intraventricular aneurysm is identified, it should be treated by endovascular embolization or clipping rather than conservative treatment; (5) endovascular embolization should be the first treatment option, and craniotomy can also be considered.     

A retrospective comparative study of robotic distal pancreatectomy with or without splenic vessel and spleen preservation

BackgroundRobotic distal pancreatectomy has been accepted to be safe and effective for pancreatic tail lesion. Whether spleen preservation by preserving the splenic vessels with robot assistance is feasible and beneficial remains controversial. Here we would like to compare the operative outcomes of robotic distal pancreatectomy and splenectomy (DPS) with robotic spleen preserving distal pancreatectomy by means of splenic vessel preservation (SVP).MethodsBetween March 2011 and September 2019, 56 consecutive patients undergoing robotic distal pancreatectomy were identified, with 28 patients in each group. Patient demographics, histopathology findings and operative outcomes were prospectively collected and compared between the two groups. A subgroup analysis was made after excluding malignant and pancreatic lesions >6 cm in the DPS group.ResultsThe two groups had similar conversion rate, blood loss, morbidity and pancreatic fistula rate. There was no operative mortality. The SVP group had shorter median operative time (245 vs 303.5 min, P = 0.019) and shorter median hospital stay (5 vs 6 days, P = 0.019) than the DPS group. However, all malignant lesions occurred in the DPS group and lesion size in DPS group was significantly larger. After matching, there were 28 SVP and 15 DPS. The histopathology findings and lesion size became comparable. The SVP group still had shorter operative time (245 vs 290 min, P = 0.022) and shorter hospital stay (5 vs 7 days, P = 0.014) than the DPS group.ConclusionApart from avoiding risk of overwhelming postsplenectomy sepsis, robotic SVP had additional advantage of shorter operative time and shorter hospital stay than robotic DPS.     

Major cardiovascular events after metabolic surgery in patients with previous heart disease with or without type 2 diabetes: a nationwide cohort study

BackgroundWhile metabolic surgery is known to improve type 2 diabetes (T2D) as well as established heart disease separately, it is not known whether the outcome is influenced by T2D status in patients with established heart disease.ObjectivesTo evaluate the risks for major cardiovascular events (MACE) or mortality in patients with established heart disease with or without T2D.SettingNationwide and registry-based (Sweden).MethodsPatients with established heart disease operated with sleeve gastrectomy or Roux-en-Y gastric bypass in Sweden from 2007–2019 were matched 1:1 to normal population controls using 2-staged matching (exact matching on T2D, followed by optimal matching on propensity score for age, sex, dyslipidemia, chronic obstructive pulmonary disease, type of heart disease, T2D duration, county of residence, and level of education). The risk for MACE was evaluated separately depending on T2D status.ResultsIn total, 1513 patients who underwent surgery and 1513 matched controls were included. Reduced risk for MACE and mortality were seen after metabolic surgery for patients with heart disease and T2D compared with controls (adjusted hazard ratio [HR] = .59, 95% confidence interval [CI]: .48–.72, P < .001, and adjusted HR = .52, 95% CI: .40–.67, P < .001, respectively), and for patients with heart disease alone compared with controls (adjusted HR = .73, 95% CI: .57–.94, P = .016, and adjusted HR = .63, 95% CI: .45–.89, P = .008, respectively).ConclusionMetabolic surgery was associated with a reduced risk for MACE and mortality in patients with preexisting heart disease and T2D as well as in patients with heart disease without T2D. Patients with heart disease and T2D seem to experience the highest risk reduction.     

Early-phase insulin hypersecretion associated with weight loss outcome after LSG: a prospective cohort study in Asian patients with BMI ≥28 kg/m2

BackgroundObesity has become a global problem that poses a serious threat to human health. Laparoscopic sleeve gastrectomy (LSG) is an effective long-term treatment. However, the weight loss of some patients after LSG is still insufficient. It is necessary to investigate the factors associated with inadequate weight loss after LSG.ObjectiveThe objective of this study was to explore whether preoperative insulin secretion could be associated with weight loss after LSG in patients with obesity.SettingThis is a single-center prospective cohort study conducted in a university hospital.MethodsPatients from a prospective database who underwent LSG were analyzed. All 178 participants underwent a 75-g oral glucose tolerance test (OGTT) to assess preoperative insulin and c-peptide secretion before LSG. The areas under the curve (AUCs) for glucose, insulin, and c-peptide were determined in the OGTT. The percentage of excess weight loss (%EWL) and the percentage of total weight loss (%TWL) were used to estimate the effect of weight loss after LSG. Regression models were used to assess the correlation between preoperative insulin and c-peptide secretion with %EWL ≥75% and TWL ≥35% at 12 months after LSG.ResultsThe AUCs of insulin and c-peptide were significantly lower in the %EWL ≥75% and %TWL ≥35% groups at 0–30 minutes, 0–60 minutes, and 0–120 minutes during the OGTT. At 30, 60, and 120 minutes during the OGTT, c-peptide levels were significantly lower in the %EWL ≥75% group and %TWL ≥35% group. The preoperative c-peptide level at 30 minutes during the OGTT (C₃₀) was significantly negatively correlated with %EWL (β = ?.37, P < .001) and %TWL (β = ?.28, P = .011). Univariate logistic regression analysis showed that preoperative C₃₀ was associated with %EWL ≥75% and %TWL ≥35% after LSG. According to multiple logistic regression analysis, patients with a low preoperative C₃₀ had an 8-fold higher %TWL ≥35% after LSG than those with a high C₃₀ (odds ratio: 8.41 [95% confidence interval: 1.46–48.58], P = .017). Similarly, patients with a low preoperative C₃₀ had a 7-fold higher EWL% ≥75% after LSG than patients with a high C₃₀ (odds ratio: 7.25 [95% confidence interval: 1.11–47.50], P = .039).ConclusionsThe rate of weight loss after LSG is low among patients with preoperative hyperinsulinemia. The preoperative c-peptide level at 30 minutes during the OGTT is associated with weight loss after LSG.     

Simultaneous or sequential gastrectomy in pediatric liver transplant recipients

The association between LT and gastrectomy is not common. Only two studies reported the gastrectomy/LT association in children. Here, we report three children who underwent LT who required a concomitant or sequential gastrectomy for different reasons. Patient 1, a 16‐yr‐old boy, during the LT, underwent a partial gastrectomy due to extensive injury to the duodenum. He had a previous and unusual portoenterostomy performed in the duodenum. Bowel reconstruction was performed using an intestinal loop that was first used for the bilio‐enteric anastomosis and then connected to the gastric stump. Patient 2, a 22‐month‐old female child, underwent a partial gastrectomy with a Roux‐en‐Y reconstruction during a retransplantation. She had a large perforated gastric ulcer blocked by the allograft liver. Patient 3, a 26‐month‐old male child, five yr after living donor LT, was submitted to a partial gastrectomy because of gastric outlet obstruction. The histopathology was compatible with eosinophilic gastritis. The association between LT and gastrectomy in the pediatric population is extremely rare. Appropriate knowledge of the previous transplantation technique is very important. Further studies are required to assess the outcomes of the different types of gastric reconstruction in pediatric recipients.