Laparoscopic Gastric Bypass Surgery Research Articles

Construction and validation of a nomogram for predicting diabetes remission at 3 months after bariatric surgery in patients with obesity combined with type 2 diabetes mellitus.

Bariatric metabolic surgery (BMS) is a proven treatment option for patients with both obesity and type 2 diabetes mellitus (T2DM). However, there is a lack of comprehensive reporting on the short-term remission rates of diabetes, and the existing data are inadequate. Hence, this study aimed to investigate the factors that may contribute to diabetes remission (DR) in patients with obesity and T2DM, 3 months after undergoing BMS. Furthermore, our objective was to develop a risk-predicting model using a nomogram. In total, 389 patients with obesity and T2DM, who had complete preoperative information and underwent either laparoscopic sleeve gastrectomy or laparoscopic gastric bypass surgery between January 2014 and May 2023, were screened in the Chinese Obesity and Metabolic Surgery Database. The patients were randomly divided into a training set (n = 272) and a validation set (n = 117) in a 7:3 ratio. Potential factors for DR were analysed through univariate and multivariate logistic regression analyses and then modelled using a nomogram. The model's performance was evaluated using receiver operating characteristic curves and the area under the curve (AUC). Calibration plots were used to assess prediction accuracy and decision curve analyses were conducted to evaluate the clinical usefulness of the model. Glycated haemoglobin, triglycerides, duration of diabetes, insulin requirement and hypercholesterolaemia were identified as independent factors influencing DR. We have incorporated these five indicators into a nomogram, which has shown good efficacy in both the training cohort (AUC = 0.930) and validation cohort (AUC = 0.838). The calibration plots indicated that the model fits well in both the training and the validation cohorts, and decision curve analyses showed that the model had good clinical applicability. The prediction model developed in this study holds predictive value for short-term DR following BMS in patients with obesity and T2DM.

THU400 Parameters Of Vitamin D Metabolism, Calcium And Phosphate Homeostasis In Patients Undergoing Bariatric Surgery

Abstract Disclosure: A. Zhukov: Grant Recipient; Self; Russian Science Foundation (project 19-15-00243-P). A. Povaliaeva: Grant Recipient; Self; Russian Science Foundation (project 19-15-00243-P). Z. Abilov: Grant Recipient; Self; Russian Science Foundation (project 19-15-00243-P). L. Usoltseva: None. D. Trukhina: None. E. Pigarova: Grant Recipient; Self; Russian Science Foundation (project 19-15-00243-P). L. Rozhinskaya: Grant Recipient; Self; Russian Science Foundation (project 19-15-00243-P). Objective: to evaluate the parameters of vitamin D metabolism and calcium and phosphate homeostasis in patients undergoing bariatric surgery. Materials and Methods: The study included 10 patients without chronic kidney disease and mineral metabolism disorders who underwent laparoscopic gastric bypass surgery for obesity. After surgery, all patients were recommended to take cholecalciferol depending on the initial level of 25-OH D in blood in accordance with the Endocrine Society Clinical Practice Guideline. Ninety nine [96; 130] days after the surgery, the levels of vitamin D metabolites: D3, 25-OH D3, 24,25-OH2 D3, 1,25-OH2 D3 were determined by ultra-high performance liquid chromatography in combination with tandem mass spectrometry (certified by DEQAS) as well as the PTH, total calcium, albumin, creatinine, phosphorus, magnesium levels in serum. Results: Median age of the patients was 39 [34; 50] years, 80% women, 90% initially had type 2 diabetes mellitus (BMI before surgery 49.1 [39.7; 51.0] kg/m2, median decrease in BMI by the time of inclusion in the study 8.3 [8.0; 9.2] kg/m2). The median level of 25-OH D3 was 28.5 [24.6; 32.0] ng/ml (1 patient had a level less than 20 ng/ml, 6 patients from 20 to 30 ng/ml), D3 levels were below the laboratory sensitivity threshold (12.5 ng/ml) in all participants. The median 24,25-OH2 D3 level was 1.49 [1.04; 1.95] ng/ml (reference interval (RI) 0.5-5.6 ng/ml), the median 25-OH D3/24,25-OH2 D3 ratio was 21.87 [15.57; 22.55] (RI 7-23). All patients had normal levels of 1,25-OH2 D3 (median 45.95 [35.18; 53.65] pg/ml, RI 25-66). One patient had secondary hyperparathyroidism (albumin-adjusted calcium 2.14 mmol/l, RI 2.15-2.55; PTH 73.8 pg/ml, RI 15-65; 25-OH D3 24.8 ng/ml) while other biochemical parameters were normal. The remaining patients had normal levels of PTH, calcium, phosphorus and magnesium. Conclusions: The revealed changes in the levels of D3 and 25-OH D3 in patients undergoing bariatric surgery may be due to malabsorption, increased deposition in adipose tissue, an insufficient dosage of cholecalciferol or low patient compliance. At the subsequent stages of vitamin D metabolism, no abnormalities were identified. It is likely that this cohort of patients requires higher doses of cholecalciferol. Presentation: Thursday, June 15, 2023

Monitoring performance in laparoscopic gastric bypass surgery using risk-adjusted cumulative sum at 2 high-volume centers.

Traditional surgical outcomes are measured retrospectively and intermittently, limiting opportunities for early intervention. The objective of this study was to use risk-adjusted cumulative sum (RA-CUSUM) to track perioperative surgical outcomes for laparoscopic gastric bypass. We hypothesized that RA-CUSUM could identify performance variations between surgeons. Two mid-Atlantic quaternary care academic centers. Patient-level data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) were abstracted for laparoscopic gastric bypasses performed by 3 surgeons at 2 high-volume centers from 2014 to 2021. Estimated probabilities of serious complications, reoperation, and readmission were derived from the MBSAQIP risk calculator. RA-CUSUM curves were generated to signal observed-to-expected odds ratios (ORs) of 1.5 (poor performance) and .5 (superior performance). Control limits were set based on a false positive rate of 5% (α = .05). We included 1192 patients: Surgeon A = 767, Surgeon B = 188, and Surgeon C = 237. Overall rates of serious complications, 30-day reoperations, and 30-day readmissions were 3.9%, 2.5%, and 5.2% respectively, with expected rates of 4.7%, 2.2%, and 5.8%. RA-CUSUM signaled lower-than-expected (OR < .5) rates of readmission and serious complication in Surgeon A, and higher-than-expected (OR > 1.5) readmission rate in Surgeon C. Surgeon A further demonstrated an early period of higher-than-expected (OR > 1.5) reoperation rate before April 2015, followed by superior performance thereafter (OR < .5). Surgeon B's performance generally reflected expected standards throughout the study period. RA-CUSUM adjusts for clinical risk factors and identifies performance outliers in real-time. This approach to analyzing surgical outcomes is applicable to quality improvement, root-cause analysis, and surgeon incentivization.

Robotic versus laparoscopic gastric bypass in bariatric surgery: a systematic review and meta-analysis on perioperative outcomes

BackgroundRobotic-assisted surgery has emerged as a compelling approach to bariatric surgery. However, current literature has not consistently demonstrated superior outcomes to laparoscopic bariatric surgery to justify its higher cost. With its mechanical advantages, the potential gains from the robotic surgical platform are likely to be apparent in more complex cases such as gastric bypass, especially revisional cases. ObjectiveThis systematic review and meta-analysis aimed to summarize the literature and evaluate the peri-operative outcomes of patients with obesity undergoing robotic gastric bypass versus laparoscopic gastric bypass surgery. SettingSystematic review. MethodsA literature search of Embase, Medline, Pubmed, Cochrane library, and Google Scholar was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies comparing outcomes of robotic and laparoscopic gastric bypass for obesity were included. ResultsTwenty-eight eligible studies comprised a total of 82,155 patients; 9051 robotic bypass surgery (RBS) versus 73,104 laparoscopic bypass surgery (LBS) were included. All included studies compared Roux-en-Y gastric bypass. RBS was noted to have higher reoperation rate within 30 days (4.4% versus 3.4%; odds ratio 1.31 [95% CI, 1.04–1.66]; P = .027; I2 = 43.5%) than LBS. All other endpoints measured (complication rate, anastomotic leak, anastomotic stricture, surgical site infections, hospital readmission, length of stay, operative time, conversion rate and mortality) did not show any difference between RBS and LBS. ConclusionThis systematic review and meta-analysis showed that there was no significant difference in key outcome measures in robotic versus laparoscopic gastric bypass. RBS was associated with a slightly higher reoperation rate and there was no reduction in overall complication rate with the use of robotic platform.

Is one anastomosis better than two in laparoscopic primary gastric bypass surgery?

Is one anastomosis better than two in laparoscopic primary gastric bypass surgery?

Redo Laparoscopic Gastric Bypass in a Patient with Intestinal Malrotation: Report of a Case and Video Vignette.

Unknown intestinal rotation anomaly poses a challenge in laparoscopic gastric bypass surgery. We present a case of a patient with intestinal non-rotation that stayed undetected throughout performing a laparoscopic Roux-en-Y gastric bypass. As a result, the alimentary limb was constructed in an anti-peristaltic way, and the whole gastric bypass was located far more distally than usual. Postoperatively, the patient presented with recurring nausea and vomiting. After several diagnostic steps, a computed tomography finally revealed the inadvertently reverse directed gastric bypass and the pre-existing condition of intestinal non-rotation. This was followed by a diagnostic laparoscopy and the reconstruction of the gastric bypass in "mirrored" technique.

Preserving privacy in surgical video analysis using a deep learning classifier to identify out-of-body scenes in endoscopic videos

Surgical video analysis facilitates education and research. However, video recordings of endoscopic surgeries can contain privacy-sensitive information, especially if the endoscopic camera is moved out of the body of patients and out-of-body scenes are recorded. Therefore, identification of out-of-body scenes in endoscopic videos is of major importance to preserve the privacy of patients and operating room staff. This study developed and validated a deep learning model for the identification of out-of-body images in endoscopic videos. The model was trained and evaluated on an internal dataset of 12 different types of laparoscopic and robotic surgeries and was externally validated on two independent multicentric test datasets of laparoscopic gastric bypass and cholecystectomy surgeries. Model performance was evaluated compared to human ground truth annotations measuring the receiver operating characteristic area under the curve (ROC AUC). The internal dataset consisting of 356,267 images from 48 videos and the two multicentric test datasets consisting of 54,385 and 58,349 images from 10 and 20 videos, respectively, were annotated. The model identified out-of-body images with 99.97% ROC AUC on the internal test dataset. Mean ± standard deviation ROC AUC on the multicentric gastric bypass dataset was 99.94 ± 0.07% and 99.71 ± 0.40% on the multicentric cholecystectomy dataset, respectively. The model can reliably identify out-of-body images in endoscopic videos and is publicly shared. This facilitates privacy preservation in surgical video analysis.

Long-term Safety and Efficacy of Closure of Mesenteric Defects in Laparoscopic Gastric Bypass Surgery

Short-term and midterm data suggest that mesenteric defects closure during laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery reduces the risk of internal herniation with small bowel obstruction (SBO) but may increase risk of kinking of the jejunojejunostomy in the early postoperative period. However, to our knowledge, there are no clinical trials reporting long-term results from this intervention in terms of risk for SBO or opioid use. To evaluate long-term safety and efficacy outcomes of closure of mesenteric defects during LRYGB. This randomized clinical trial with a 2-arm, parallel, open-label design included patients with severe obesity scheduled for LRYGB bariatric surgery at 12 centers in Sweden from May 1, 2010, through November 14, 2011, with 10 years of follow-up after the intervention. During the operation, patients were randomly assigned 1:1 to closure of mesenteric defects beneath the jejunojejunostomy and at the Petersen space using nonabsorbable running sutures during LRYGB or to nonclosure. The primary outcome was reoperation for SBO. New incident, chronic opioid use was a secondary end point as a measure of harm. A total of 2507 patients (mean [SD] age, 41.7 [10.7] years; 1863 female [74.3%]) were randomly assigned to closure of mesenteric defects (n = 1259) or nonclosure (n = 1248). After censoring for death and emigration, 1193 patients in the closure group (94.8%) and 1198 in the nonclosure group (96.0%) were followed up until the study closed. Over a median follow-up of 10 years (IQR, 10.0-10.0 years), a reoperation for SBO from day 31 to 10 years after surgery was performed in 185 patients with nonclosure (10-year cumulative incidence, 14.9%; 95% CI, 13.0%-16.9%) and in 98 patients with closure (10-year cumulative incidence, 7.8%; 95% CI, 6.4%-9.4%) (subhazard ratio [SHR], 0.42; 95% CI, 0.32-0.55). New incident chronic opioid use was seen among 175 of 863 opioid-naive patients with nonclosure (10-year cumulative incidence, 20.4%; 95% CI, 17.7%-23.0%) and 166 of 895 opioid-naive patients with closure (10-year cumulative incidence, 18.7%; 95% CI, 16.2%-21.3%) (SHR, 0.90; 95% CI, 0.73-1.11). This randomized clinical trial found long-term reduced risk of SBO after mesenteric defects closure in LRYGB. The findings suggest that routine use of this procedure during LRYGB should be considered. ClinicalTrials.gov Identifier: NCT01137201.

The outcome of concomitant cholecystectomy with bariatric surgery: a retrospective cohort study.

The records of 396 patients who underwent BS at Samsun VM Medicalpark Hospital between September 2017 and October 2021 were retrospectively reviewed. The length of hospital stay, operation time, complications, and safety of patients who underwent simultaneous cholecystectomy and BS only were examined. Of 396 patients, 262 (66.1%) underwent laparoscopic sleeve gastrectomy and 134 (33.8%) underwent laparoscopic gastric bypass surgery. Gallstones were detected during the preoperative examination in 72 (18.1%) of the 396 patients who underwent BS. It was observed that 11 of them had symptoms. No major complications occurred during or after surgery in patients who underwent simultaneous cholecystectomy and only in those who underwent BS. Simultaneous cholecystectomy with BS does not burden the patient, and complication rates are very low. The procedure is also cost-effective, as patients do not require a second surgery.

Aberrant QRS morphologies during atrial tachycardia: What is the mechanism?

A 12-lead electrocardiogram was obtained in a 73-year-old woman after laparoscopic gastric bypass surgery (Figure 1). The electrocardiogram reveals an ectopic atrial tachycardia with a cycle length of 360 ms. There is 2nd degree AV block in a 3:2 pattern. The second PR interval of each 3:2 period is longer than the first, so the block is of the Wenckebach (Mobitz 1) type. In every other Wenckebach cycle, the second QRS is conducted with right bundle branch block aberrancy. What is the mechanism of this pattern of aberrancy?

Gastro-pleural fistula complicated by left-sided pleural empyema after laparoscopic gastric bypass surgery

Gastro-pleural fistula complicated by left-sided pleural empyema after laparoscopic gastric bypass surgery

Intraoperative lidocaine infusion as a sole analgesic agent versus morphine in laparoscopic gastric bypass surgery

BackgroundThe aim of this study was to assess the effect of intra-operative intra-venous (IV) lidocaine infusion compared to IV morphine, on the post-operative pain at rest, the intra-operative and post-operative morphine requirements, the sedation and the Modified Aldrete scores in the post-anesthesia care unit (PACU), the hemodynamic parameters; mean values of the mean blood pressure (MBP) and the heart rate (HR), the peri-operative changes in the SpO2, and the respiratory rate (RR) in laparoscopic Roux-en-y gastric bypass. Sixty patients ˃ 18 years old, with body mass index (BMI) ˃ 35 kg/m2, American Society of Anesthesiologists (ASA) physical status II or III, were randomly divided into 2 groups: the lidocaine (L) group patients received intra-operative IV lidocaine infusion, and the morphine (M) group patients received intra-operative IV morphine.ResultsThe post-operative numeric pain rating scale (NPRS) at rest was statistically significant less in group L than in group M patients, in the post-operative 90 min in the PACU. This was reflected on the post-operative morphine requirements in the PACU, as 26.6% of patients in group M required morphine with a mean total dose of 10.8 mg. The mean values of the MBP and HR recorded after intubation were comparable between patients of both groups, indicating attenuation of the stress response to endotracheal intubation by both lidocaine and morphine. However, the mean values of the MBP and HR recorded after extubation were statistically significant lower in patients of group L, indicating the attenuation of the stress response to extubation by lidocaine. Patients in group M showed statistically significant lower mean values of the MBP; before pneumoperitoneum and after 15 min from the pneumoperitoneum, this was reflected on statistically significant higher mean values of the HR. Patients in group L showed statistically significant lower mean values of the MBP and the HR; at 30 and 45 min from the pneumoperitoneum. Patients in group L showed statistically significant lower mean values of the MBP; 60 min from the pneumoperitoneum, after release of pneumoperitoneum and in the PACU. Patients of both groups showed comparable mean values of the HR after 60 min from the pneumoperitoneum, after release of the pneumoperitoneum and in the PACU. No patient in either groups developed post-operative respiratory depression in the PACU. Patients in group L showed statistically significant higher median sedation score, which was reflected on statistically but not clinically significant less Modified Aldrete score in patients of group L.ConclusionsIn morbid obese patients, the intra-operative IV lidocaine infusion offered post-operative analgesia in the PACU, on the expense of a higher sedation score, which didn’t affect the Modified Aldrete score clinically, with attenuation of the stress response to endotracheal intubation and extubation.Trial registrationsFMASU R16/2021. Registered 1st February 2021, with Clinical Trials Registry (NCT05150756) on 10/08/2021.

Factors Affecting Muscle Mass Loss Following Laparoscopic Sleeve Gastrectomy and Laparoscopic Mini Gastric Bypass Surgeries

Excessive muscle mass loss is common following bariatric surgery due to decreased protein intake. Therefore, this study aimed to examine factors associated with muscle mass loss after three months in patients who underwent Laparoscopic Sleeve Gastrectomy (LSG) and Mini-gastric bypass (MGB) in a bariatric surgery centre in Alexandria, Egypt. An observational study was performed on 50 patients, 25 of whom underwent LSG, whereas 25 underwent MGB. At baseline and after three months, physical activity level, energy and protein intake were assessed. Bioelectric impedance analysis assessed the body composition preoperatively and after three months. The current study's demonstrated that LSG and MGB three months postoperatively lost -17.3 ± 2.8 % and -18.5 ± 3.1 %, respectively, of their weight. Nevertheless, in MGB, patients lost more muscle mass (-17.2±12.4 %) compared to LSG (-11.5 ± 5.6 %) (p=0.063). In MGB, females lost -23.5 ± 11.6 % of their muscle mass compared to -7.9 ± 6.6 % in males (p&lt;0.05). Muscle mass loss in &lt; 60 g protein eaters was higher in MGB than LSG (M ± SD= 20.3 ± 12.5 % vs -13.0 ± 5.3 %, p=0.033). While muscle mass loss in ≥ 60 g protein eaters was -5.6± 1.5 % in LSG and 7.4± 5.9 % in MGB. In conclusion, females in MGB lost more muscle mass than males after three months. Protein intake ≥ 60 g/day during the first three months postoperative is associated with low muscle mass loss. High preoperative HbA1c correlates with muscle mass loss in MGB especially in females . High preoperative Hba1c and protein intake of &lt; 60 g/d are associated with muscle mass loss in LSG.

Liver assessment post laparoscopic mini gastric bypass versus sleeve gastrectomy operation in obese and morbidly obese patients

Background: Morbid obesity is a severe disorder associated with major co‐morbidities reduced quality of life (QoL) and reduced life expectancy. Aim and objectives: The purpose of the study was to compare the effect of laparoscopic mini gastric bypass versus sleeve operation on liver function in a prospective randomized study. Subjects and methods: This study was a prospective study conducted on 80 patients who visit the general surgery clinic at Damietta university hospital (Al Azhar University) and National hepatology and tropical medicine research institute (NHTMRI); patients were being divided into 2 groups: Group A (40 patients): Undergoing laparoscopic sleeve gastrectomy surgery. Group B (40 patients): undergoing laparoscopic mini gastric bypass surgery. Results: There a gradual significant decrease from preoperative to 12 months postoperative regarding ALT and AST in Group A, while there a gradual significant decrease from preoperative to 12 months postoperative regarding AST in Group B, Conclusion: This study demonstrated a low prevalence of abnormal LFT in our morbidly obese patients who underwent bariatric surgery. This may serve as an indirect indication of a lower prevalence of significant liver damage in these subjects.

Assessment of 2D and 3D imaging for patients undergoing laparoscopic bariatric surgery.

&lt;b&gt;Aim:&lt;/b&gt; The aim of this study is to compare the association of 2D and 3D imagery with technical performance and operative time during laparoscopic surgery. &lt;/br&gt;&lt;/br&gt; &lt;b&gt; Material and methods:&lt;/b&gt; A systematic review of the literature was conducted through an online search in databases such as PubMed, Cochrane, Embase and CNKI in order to identify articles published in English and Chinese from 2010 to 2020 that compared the clinical results of 2D and 3D laparoscopic gastric bypass surgery. &lt;/br&gt;&lt;/br&gt; &lt;b&gt; Results:&lt;/b&gt; A total of 50 articles were included in the qualitative analysis. Out of these, 5 articles that met the inclusion criteria were selected for analysis, according to which 3D laparoscopic surgery had a shorter surgery time than 2D laparoscopic surgery. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Conclusions:&lt;/b&gt; Compared with a 2D laparoscopic system, a 3D laparoscopic system can significantly reduce the operative time and errors and can increase the comfort of the surgeons performing laparoscopic gastric bypass surgery.

Weight loss before bariatric surgery and its impact on poor versus excellent outcomes at 2years.

To identify preoperative factors that influence the outcomes of gastric bypass surgery, in terms of excess weight loss at 24months. This retrospective study included two groups of patients who underwent laparoscopic gastric bypass surgery. Group A (poor outcomes) had ≤ 50%EWL or BMI ≥ 30kg/m2; group B (excellent outcomes) had ≥ 80%EWL at 24months. A comparative analysis of demography, anthropometry, comorbidities, and metabolic status was performed. A linear regression model was used to evaluate %EWL association; the number of preoperative and postoperative consultations were also compared. A total of 202 patients completed follow-up; 71 (35.1%) and 78 (38%) had poor and excellent outcomes (%EWL 44.1 ± 9.4% vs. 92 ± 10.9%), respectively. Mean age was 40.4 ± 8.9years. Patients with poor outcomes had higher weight and BMI, lesser preoperative %EWL, higher dyslipidemia and diabetes rates with longer periods of evolution, and increased HbA1c% levels. In the linear regression analysis, preoperative %EWL and initial and preoperative BMI were statistically significant determinants of %EWL at 24months Diabetes remission was 46.2% (group A) vs. 66.6% (group B). Group A had higher non-attendance rates after surgery. The factors independently associated with greater %EWL at 24months between groups were higher preoperative %EWL, and lower initial and preoperative BMI.

Biliary reflux after laparoscopic modified antireflux monoanastomotic gastric bypass surgery

Aim. Determination of biliary reflux in patients with morbid obesity after a single-anastomotic gastric bypass operation performed in the clinic's modification and according to the classical Roux-en-Y gastric bypass technique. Development of diagnostic criteria for biliary reflux Materials and methods. The results of treatment of 36 patients with morbid obesity who underwent bypass surgery were studied. The patients are divided into two groups. Clinically modified laparoscopic monoanastomotic gastric bypass surgery was performed in 25 patients (main group). The control group included 11 patients after the standard technique of Roux-en-Y laparoscopic gastric bypass. Inclusion criteria were: persons of both sexes aged 18-60 years with morbid obesity and a body mass index of 40 or more, as well as 35 or more in the presence of comorbid diseases (type 2 diabetes mellitus, arterial hypertension, dyslipidemia, sleep apnea syndrome). In both groups, impedance pH measurements were performed in the postoperative period. Statistical processing was performed using the Statistica 13.0 software package using parametric and nonparametric statistical methods. Results: Clinical manifestations of the enterogastric biliary reflex were found in both groups; in addition, clinical manifestations of the corresponding symptoms were noted by patients of both groups. The analysis of daily pH-metry in the studied groups showed that in the esophagus the time with pH &lt;4 in the main group 2.83 (1.55; 3.95)% 3.00 (2.30; 3.50)% in the control group, time with pH 4-6.9 (physiological for the esophagus) 92.40 (90.65; 94.20)% and 94.10 (89.80; 95.50)%, respectively, time with pH&gt; 7 (weak alkaline) was 4.80 (3.45; 5.85)% and in the control group 2.90 (1.20; 7.20)%. There was no statistically significant difference in these indicators (p&gt; 0.05). Conclusions. Monoanastomotic gastric bypass surgery in the modification of the clinic has the same positive properties as the Rouen-Wye technique, allowing you to avoid the risks associated with possible pathological reflux of bile into the esophagus. Patients who have undergone mini-gastric bypass surgery require a thorough examination with fibrogastroscopy in combination with pH impedance measurement at least 1 time per year in order to determine biliary reflux and morphological changes both in the lumen of the esophagus and in the stomach stump. The level of quality of life of patients after surgery in the control group and the main group does not significantly differ, as evidenced by the results of the questionnaire survey using the GERG Q questionnaire, which indicates the effectiveness of the methodology of laparoscopic monoanastomotic gastric bypass surgery modified in the clinic. Key words: morbid obesity, gastric bypass surgery, surgical treatment, mini-gastric bypass, biliary reflux.

Low-Dose Ketamine Infusion for Perioperative Pain Management in Patients Undergoing Laparoscopic Gastric Bypass: A Prospective Randomized Controlled Trial.

Introduction Obesity is a common comorbidity seen in the perioperative setting and is associated with many diseases including cardiovascular disease and obstructive sleep apnea. Laparoscopic Roux-en-Y gastric bypass is the gold standard surgical treatment for patients whose weight is refractory to diet and exercise. Caring for these patients perioperatively presents unique challenges to anesthesiologists and is associated with an increased risk of adverse respiratory events. In our study, we hypothesize that a low-dose perioperative ketamine infusion will reduce opioid consumption and improve analgesia when compared to standard therapy. Methods This is a single-center, prospective randomized controlled study enrolling 35 patients in total. Patients were randomized equally into the ketamine and control group. Preop, intraop, and postop management regimens were standardized. The ketamine group received a 0.3 mg/kg ideal body weight ketamine bolus after induction followed by a 0.2 mg/kg/hr ketamine infusion continued into the postop setting for up to 24 hours. Data collected included total perioperative opioids used converted to oral morphine equivalents (ME), pain scores, side effects, hospital length of stay, and patient satisfaction captured via postoperative questionnaires. Results The use of perioperative opioid consumption was significantly lower in the ketamine group when compared with the control group (179.9 ME versus 248.7 ME, P=0.03). There was no statistically significant difference in pain scores or hospital length of stay postoperatively between the two groups. There were also no reported adverse respiratory events, prolonged sedation, agitation, or other side effects reported in either group. The patient satisfaction questionnaires showed a significant difference with the ketamine group reporting lower maximum pain scores, a decrease in how pain limited activities of daily living once discharged, and increased hospital pain management satisfaction scores. Conclusions Perioperative low-dose ketamine infusions significantly reduced opioid consumption in morbidly obese patients undergoing laparoscopic gastric bypass surgery.

The Effect of Laparoscopic Sleeve Gastrectomy and Gastric Bypass Surgery on Non-Alcoholic Steatohepatitis in Iranian Patients with Obesity.

BACKGROUND Non-alcoholic steatohepatitis (NASH) is a serious comorbidity in patients with obesity and because of the high risk of cirrhosis and the extreme mortality rate of NASH, approaching effective treatment methods, and improvements are crucial. Following few studies comparing the impact of laparoscopic gastric bypass (LGB) and laparoscopic sleeve gastrectomy (LSG) surgery on NASH, our study was conducted to assess the effect of these two surgical methods separately in patients with NASH through ultrasonography, and concurrently, on other factors such as lipid profiles and blood pressure to reduce the complications of complex obesity surgeries on patients and also provide a solution to prevent NASH-related cirrhosis. METHODS This study was performed at Imam Khomeini Hospital Complex; Vali-e-Asr Hospital affiliated to Tehran University of Medical Sciences.All patients with obesity who had undergone bariatric surgery at Vali-e-Asr Hospital during 2017 and 2018 were included in this prospective cohort study. Weight, body mass index (BMI), blood pressure, Alanine transaminase(ALT), Aspartate transaminase(AST),lipid profile and Fasting blood sugar(FBS)were evaluated before and one year after surgery. The patients underwent an ultrasound examination before surgery to determine the fatty liver grade. The type of operation (sleeve or bypass) was governed by the patient him/herself after receiving thorough clarifications about the available methods, their complications, and expected outcomes. In addition, by the separation of fatty liver grading with ultrasound modality, the correlation between ultrasound grading, laboratory results, and the rate of weight loss in patients who undergone both sleeve and bypass surgeries were evaluated and compared during a one-year follow-up. RESULTS In this study, 44 patients were included. 22 patients underwent laparoscopic sleeve gastrectomy (LSG), and 22 patients underwent laparoscopic gastric bypass (LGB) surgery. The mean age of the patients was 40.45 ± 12.01 years. 35 patients (79.5%) were women, and 9 patients (20.5%) were men. Most patients (81.8%) had grade I and II in terms of preoperative liver ultrasonography results. Bariatric surgery (LSG and LGB) greatly enhanced NASH's hepatic status in liver ultrasonography. Since the liver status of patients with preoperative ultrasonography was not significantly different between the two groups, there was no substantial distinction among the two groups in this regard, postoperatively. Weight and BMI, lipid profile, liver enzymes, FBS, and mean arterial blood pressure (MAP) were significantly reduced individually in both groups and all patients one year after surgery. None of the postoperative variables and their modifications had a prominent difference between the two groups except for High-density lipoprotein(HDL)level after surgery. The postoperative HDL was considerably higher in the LGB group (p = 0.014). However, the changes in HDL were not statistically different between both groups. The levels of AST, ALT, total cholesterol, LDL, and FBS were associated with the NASH grade. CONCLUSION Both types of LSG and LGB bariatric surgeries have been shown to significantly reduce BMI and improve lipid profiles, liver enzymes, and blood glucose levels in patients one year after surgery. The NASH status was also ameliorated considerably. The two types of surgery were not remarkably different in these modifications. Besides, there was a significant correlation between AST, ALT, total cholesterol, LDL, and FBS levels with the NASH grade.

Comment on: Randomized clinical trial on closure versus non-closure of mesenteric defects during laparoscopic gastric bypass surgery.

Comment on: Randomized clinical trial on closure versus non-closure of mesenteric defects during laparoscopic gastric bypass surgery.