Post Roux-en-Y Gastric Bypass Research Articles

Perforated duodenal ulcer after Roux-en-Y gastric bypass: an unusual complication.

Bariatric surgery is increasingly being accepted as a viable treatment for managing the growing obesity epidemic. Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed procedures. Perforated duodenal ulcer following RYGB is a rare condition with a low incidence. We report a case of a patient with a perforated duodenal ulcer post RYGB, and the surgical approach. A 66-year-old man with hypertension and a history of laparoscopic RYGB for class III obesity was admitted to the emergency department with severe epigastric pain radiating to the right side of his abdomen and right shoulder, associated with nausea and vomiting. Computed tomography (CT) showed intraperitoneal free fluid, a thickened wall of the duodenum and free air, duodenal perforation was suspected. The patient underwent exploratory laparoscopy that revealed a perforated duodenal ulcer that was closed with an absorbable barbed suture and omental patch. Perforated ulcers in excluded segments after RYGB are a rare entity with a challenging diagnosis, and clinicians should be aware of and have a low threshold for diagnostic laparoscopy. Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed procedures in bariatric surgery. Perforated ulcers in excluded segments after RYGB are a rare entity with a challenging diagnosis. The pathophysiology of this perforation is not clear, but several mechanisms have been proposed. Helicobacter pylori has been implicated. Clinicians should be aware and have a low threshold for diagnostic laparoscopy for a patient who has acute abdominal pain after RYGB, despite negative diagnostic measures.

FRI080 Post Bariatric Hypoglycemia And Pregnancy: Successful Utilization Of Remnant Stomach Gastrostomy Tube Placement In Severe Refractory Hypoglycemia After Roux-en-Y Gastric Bypass Surgery

Abstract Disclosure: S.S. Habbsa: None. A. Port: None. Introduction: Post bariatric hypoglycemia (PBH) can occur following Roux-En-Y Gastric Bypass (RYGB). Due to an exaggerated glucagon-like-peptide-1 (GLP-1) response from rapid nutrient transit to the distal bowel, patients with PBH exhibit endogenous hyperinsulinemic hypoglycemia following a carbohydrate load. Severe cases can result in significantly impaired quality of life (QoL), including syncope, seizures, and nutritional deficits from restricted intake. Recently, remnant stomach percutaneous endoscopy gastrostomy (PEG) tube placement has been reported in a handful of cases as a successful long-term strategy for RYGB-PBH refractory to nutritional and medical therapy. However, there are no known outcomes in pregnancy. Case: A 25-year-old female with a history of RYGB presented with increasingly severe and frequent PBH beginning 12 months after surgery. Mixed meal testing was consistent with prandial hypoglycemia (down to 20 mg/dL) with hyperinsulinemia (C-peptide 11 [0.80 - 3.10 ng/mL], Insulin 50 [<23 uIU/mL]). Ultrasound was negative for pancreatic anomalies. Dietary modification and medical therapy with acarbose, diazoxide, and liraglutide were unsuccessful. 3 years after RYGB, she required hospitalization for hypoglycemic seizures, and she underwent remnant stomach PEG tube placement. Oral intake was discontinued (except for protein for comfort) and substituted with 12-hour nocturnal feeds. Her PBH diminished, and she reported significant improvement in QoL. 6 years after PEG placement, the patient became pregnant. Working closely with a dietician, she increased caloric intake by 200-250 kcal/day in the second and third trimesters. Screening for gestational diabetes with oral glucose tolerance testing was deferred given risk of PBH exacerbation, and CGM was used instead for glycemic monitoring. Intolerance to overnight feeds was remedied using concentrated enteral formulas and incorporation of short daytime tube feed boluses. She delivered a healthy baby via elective C-section. During lactation, due to concern for food protein allergy, she was transitioned to a non-dairy non-soy-based feeding regimen. She returned to her pre-pregnancy weight and her sugars remained stable. Conclusion: This is the first case report documenting safe and effective use of remnant stomach enteral feeds for management of severe refractory PBH post RYGB during pregnancy and lactation. Pregnancy presents a unique situation in which increased carbohydrate intake is necessary to support fetal development; however, this can be life-threatening for patients with severe PBH. Remnant stomach PEG feeds utilize the original gut without need for surgical RYGB reversal, preventing rapid nutrient transit. Long-term reversal of PBH, sustained weight loss and customizable feeding regimens support the use of remnant PEG placement for severe RYGB-PBH in the appropriate patient. Presentation: Friday, June 16, 2023

CHANGES IN NUTRITIONAL PROFILE AFTER 6 MONTHS OF BARIATRIC SURGERY

The aim of this study was to verify, through a densitometric laboratory database, the changes in the nutritional profile of women after 6 months of bariatric surgery. Methods. A total of 23 Brazilian women aged 40.8±10.4 yrs were included in this study. The sample was recruited at densitometric laboratory database. The analysis was made between 2018 to 2019. Body composition assessments were performed through dual-energy X-ray absorptiometry immediately before and after 6-months Roux-en-Y gastric bypass (RYGB). Data collected pre and post RYGB were included. Food consumption occurred by method of food record, which used data on total caloric intake, macronutrient and micronutrient intake. The collected data was evaluated using the nutritional software WebDiet. Results. Nutritional variables decreased with the exception of the protein and calcium which showed a small increase after surgery following lower calorie intake. Total mass and BMI presented a significant difference, but for the nutritional analysis, despite the important differences between the two stages, they did not present a statistically significant difference. We verified that the Kcal had an important influence in the others nutritional variables in both stages, pre and post surgery, mainly in carbohydrate. Conclusions. We conclude that for this sample there was an important change in eating habits after six months of bariatric surgery and these changes together with bariatric surgery may be the cause of changes and maintenance of weight loss in the patients involved.

BP Limb Length as a Factor for T2DM Remission

Background: There has been increased interest in identifying the associated factors to Type 2 Diabetes Mellitus (T2DM) remission after bariatric surgery. One of these factors is the BP limb length. The objective of our study was to evaluate the T2DM remission rate in patients subjected to Roux -en- Y gastric bypass (RYGB) who had different Biliopancreatic (BP) limbs length. Methods: 48 patients with obesity grade II, and T2DM diagnosis, were subjected to RYGB and completed a one year of surgical follow up. All patients were grouped according to the BP limb length: In group A (n= 24) patients with BP limbs of 100 cm or less; in group B (n= 24) patients with BP limb from 150 to 170 cm in length. Results: Both groups presented an elevated remission rate of T2DM (83% full remission in the population studied). In group A 18 patients (75%) presented a full remission, while 2 patients (8.3%) showed a partial remission and only 4 patients (16.7%) were considered without remission at the one year follow up. In group B all patients had some remission: 22 patients (91.7%) presented a full remission (91.7%) and the rest of the patients showed a partial remission (8.3%), no significant difference was found between the two groups. Conclusions: Bariatric surgery remains as the best long term treatment for obesity and its comorbidities, despite some differences in the RYGB technique, BP limb length from 50 to 170 cm did not affect post RYGB glycemic control.

Usual dietary intake, physical activity, weight loss, and body composition after five years of Roux-en-Y gastric bypass.

To estimate usual dietary intake (UDI), physical activity (PA), and their association with weight loss and body composition in patients who underwent Roux-en-Y gastric bypass (RYGB) after five years in the Federal District, Brazil. We assessed anthropometry and body composition using bioimpedance, and dietary intake and PA with three nonconsecutive 24-h recalls. PC-Side was used to estimate UDI. Dietary patterns (DPs) were identified through principal component analysis, and association between UDI and PA with percentage of total weight loss (%TWL) and fat-free mass (FFM) through multinomial logistic regression. Sample (n = 124) presented mean (SD) age of 48.9 (9.4) years, median (IQR) of 9 years (7-10) post RYGB, current BMI = 32.3 kg/m² (28.8-35.7), %TWL = 24.7% (10.9), and FFM = 45.1 kg (41.1-51.9). Mean usual energy intake of 1556 kcal/d, with adequate protein intake, poor fiber intake, and excessive carbohydrate, total fat, and added sugar intake, compared to dietary guidelines. Calcium, vitamins C, D, and E presented the greatest inadequacy (15%, 24%, 32%, and 49% of individuals, respectively, reported usual intake below EAR); 83 participants were considered active/very active, according PA. DP with high energy, protein, total fat, saturated fat, and sodium intake, was negatively associated with %TWL (OR = 0.545, p = 0.037). Protein intake was positively associated with FFM (OR = 1.091, p = 0.004). PA was not associated with %TWL or FFM. Participants demonstrated intake of carbohydrate, fat, fiber, added sugar not in accordance with guidelines. A DP rich in energy, protein, total fat, saturated fat, and sodium appears to decrease TWL. However, protein intake appears to increase FFM.

BS P05 Laparoscopic repair of internal hernia post Roux-en-Y Gastric Bypass: Our tricks and technique

Abstract Background The incidence of internal herniation (IH) post Roux-en-Y gastric bypass (RYGB) is variable across literature (0.5–11%). This may be partially related to the difference in the operative techniques of RYGB. Routine closure of mesenteric and Petersen's defects has shown noticeable decline in the incidence of IH over last few years. Nevertheless, it didn't prevent the development of IH at long-term follow up. Methods We describe a video of a case with a large non-obstructing mesenteric internal hernia post RYGB. A 33 years old female patient presented to our bariatric clinic with recurrent attacks of post-prandial abdominal pain over 6 months. She had RYGB 2.5 years before this presentation, with EWL of 65%. Of note, the mesenteric and Petersen's defects were closed in the original RYGB operation. CT scan showed suspicious findings of internal herniation without obstructing signs. Patient had a laparoscopic exploration which showed a large internal herniation through mesenteric defect containing more than two thirds of bowel length. Closure of the defect was done by a purse string technique using non-absorbable prolene 2/0 stitch after reduction of the bowel. Patient had an uneventful postoperative recovery. She denied any further attacks of abdominal pain at her follow up till 6 months postoperatively. Conclusions Diagnosis of non-obstructing internal herniation post RYGB is very challenging. Low threshold for laparoscopic exploration in suspicious cases of remittent abdominal pain is highly recommended. CT scan can't rule out IH completely due to its intermittent nature. Laparoscopic repair remains the optimal approach, even in the large IH, with favourable outcomes. Appropriate identification of the bowel configuration is the key step in such procedure.

S2875 The Utility of Endoscopic Ultrasound and Fine Needle Biopsy in Diagnosing Remnant Gastric Cancer After Roux-en-Y Gastric Bypass Procedure

Introduction: Roux-en-Y gastric bypass (RYGB) procedure is commonly performed for severe obesity. These patients are at risk of developing remnant gastric cancer. Double-balloon endoscopy (DBE) is typically used to obtain a biopsy. We present two cases of remnant gastric cancer diagnosed using endoscopic ultrasound (EUS). Case Description/Methods: Case 1 is a 76-year-old female status post RYGB who presented with 40-pound weight loss, anorexia and constipation. Labs showed hemoglobin of 6.1 g/dL. Computed tomography (CT) of the chest, abdomen and pelvis revealed hepatic masses and gastric remnant thickening. CA 19-9 was 200,000 U/ml and CEA was 683 ng/dL. Esophagogastroduodenoscopy (EGD) revealed Roux-en-Y gastrojejunostomy with healthy appearing mucosa and a normal jejunum. Colonoscopy showed internal hemorrhoids. Liver biopsy was inconclusive. Concern for remnant gastric cancer, in light of no obvious primary, prompted transgastric EUS guided fine needle biopsy (FNB) of the remnant pouch which confirmed gastric adenocarcinoma.Case 2 is a 49-year-old female status post RYGB who presented with left flank pain,12-pound weight loss and fevers. Labs showed hemoglobin 9 g/dL. CT of the abdomen showed wall thickening involving the gastric pouch and gastric remnant. CEA was 96.6 ng/dL and CA-125 was 348.7 U/ml. EGD revealed a small gastric pouch, gastrojejunal anastomosis characterized by polypoid appearing lesions which were biopsied and found to be benign, and a normal jejunum. Colonoscopy showed inflammation in the cecum and transverse colon and biopsies revealed adenocarcinoma consistent with metastatic signet ring cell carcinoma. Transjejunal EUS guided FNB of the gastric remnant confirmed signet ring cell adenocarcinoma. (Figure) Discussion: EUS is a valuable tool for tissue acquisition especially because DBE has challenges of high operator dependence and long procedure times. Case reports have described EUS guided placement of lumen-apposing metal stents (LAMS) to create a conduit into the gastric remnant to obtain biopsies. However, LAMS are highly operator dependent and carry complications of stent migration, bleeding, infection and perforation. The EUS guided FNB technique is shown in image 1. There were no complications intra or post operatively. Our cases show that EUS with a trans-gastric or trans-jejunal approach provides a less invasive approach that is more operator-friendly, time saving and yields adequate tissue acquisition.Figure 1.: EUS images. A, Case 1: Transgastric view of thickened gastric remnant. B, Case 1: Fine needle biopsy of gastric remnant wall. C, Case 2: Transjejunal view of thickened gastric remnant. D, Fine needle biopsy of gastric remnant wall.

Endoscopic surveillance after bariatric surgery: Results from a large, single-institution cohort

Abstract Objective Sleeve gastrectomy (SG) and Roux-en-Y-gastric bypass (RYGB) are associated with long- term abnormalities, including erosive esophagitis (EE), hiatal hernia (HH), gastritis, Barrett`s esophagus and ulcers. The aim of this study is to assess the prevalence of abnormal endoscopic and histologic findings after SG and RYGB in a large cohort. Methods This is a retrospective analysis of 720 consecutive patients who underwent esophagogastroduodenoscopy (EGD) after primary SG or RYGB. Patients were invited for a control EGD after two years of follow-up. EGD was also performed in order to evaluate postoperative symptoms, such as nausea, vomiting or reflux. If revisional surgery was planned, an EGD was included in the prerevisional work up. Results 304 post-SG patients (64.1% female) and 416 post-RYGB patients (85% female) were included. The mean age at the time of operation was 43.9 years (95% confidence intervals (CI) 42.5–43.3 years) for the post-SG group and 40.5 years (95% CI 39.4–41.6 years) for the post-RYGB group (p<0.001). The mean preoperative body mass index (BMI) was 44.2 kg/m2 (95%CI 43.4–44.9) and 41.1 kg/m2 (95%CI 40.7–41.5) for the post-SG and the post-RYGB group respectively (p<0.001). EE, gastritis and HH were more prevalent after SG than RYGB (38.8% vs 8.9%, 62.5% vs 27.6% and 28% vs 2.6% respectively, p<0.001). RYGB was associated with more postoperative ulcers than SG (14.4% vs 0.7%, p<0.001). The incidence of anastomotic strictures requiring anastomotic dilatation after RYGB was 4.6%. No significant difference was found in the prevalence of Barrett`s esophagus (4.3% post SG vs. 4.1 post RYGB, p=1.000) and Helicobacter pylori (3.3% post SG vs. 1.2% post RYGB, p=0.065) between the two groups. Conclusion SG is associated with higher rates of EE, gastritis and HH, while the prevalence of ulcers is higher post RYGB. There is a low risk of anastomotic stricture post RYGB. The incidence of Barrett`s oesophagus is low after both procedures. Routine use of EGD after bariatric surgery should be evaluated.

S2345 A Rare Case of Bleeding Ulceration From the Excluded Stomach After Roux-en-Y Gastric Bypass Surgery

Introduction: Roux-en-Y gastric bypass (RYGB) is among the most common bariatric surgeries for treatment of morbid obesity, with >450,000 RYGB performed in the United States since 2011. Formation of an excluded stomach and duodenum that are difficult to access via conventional endoscopy can pose a unique challenge for diagnosis and treatment of gastrointestinal (GI) bleeding in post-RYGB patients. Case Description/Methods: A 60-year-old man with a history of morbid obesity and status post RYGB in 2017 presented in January 2021 with black tarry stools and a hemoglobin of 7.4 from a baseline of 13 g/dL without recent NSAID or tobacco use. He underwent upper endoscopy, colonoscopy, push enteroscopy and video capsule endoscopy without identification of a bleeding source. He was ultimately discharged home after stabilization and no further bleeding. Due to concern for an unidentified source of bleeding, further outpatient workup was pursued. CT enterography was unrevealing. Attempted endoscopic ultrasound (EUS)-guided gastrotomy to access the excluded stomach was unsuccessful due to inability to pass an Axios stent into the excluded stomach. Antegrade balloon enteroscopy failed to reach the jejuno-jejunal anastomosis. The patient was re-admitted in April 2021 for recurrent melena and a hemoglobin of 8.3 g/dL. Laparoscopic gastrotomy was performed with intraoperative transgastric endoscopy which revealed blood in the excluded stomach and duodenum. An ulcer in the excluded stomach was discovered and excised via subtotal gastrectomy. Pathology revealed focal transmural ulceration without dysplasia; H. pylori testing was negative. The patient was discharged home without recurrence of bleeding. Discussion: Alteration in GI anatomy after RYGB impedes access to excluded segments of the upper GI tract. Access to the excluded segments may be achieved by balloon enteroscopy depending on the length of the alimentary limb, EUS-assisted gastrotomy or laparoscopic formation of a temporary gastrotomy with transgastric endoscopy. A review of post-RYGB cases of excluded segment ulceration found that 93% of patients required surgery for definitive treatment. The most common interventions were remnant gastrectomy and oversewing of perforated ulcers with a 94% cure rate at short-term follow-up. Our case demonstrates that a high degree of suspicion for bleeding from the excluded gastric or small bowel segments should be maintained in patients with RYGB presenting with upper GI bleeding and initial negative GI tract evaluation.Figure 1.: Transmural ulceration in the remnant stomach status post subtotal gastrectomy

S20 Common Bile Duct Dilation After Roux-en-Y Gastric Bypass Surgery

Introduction: As the obesity epidemic continues, surgical interventions to address this issue have become more prevalent. One of the most widely used methods for bariatric surgery is Roux-en-Y gastric bypass (RYGB). A unique problem that has been identified in the post-bariatric surgery population is biliary duct dilation without specific pancreatobiliary pathology. This study aims to evaluate the change in common bile duct (CBD) diameter following RGYB. Methods: This was a single center retrospective study that evaluated patients who had undergone RYGB between 1/1/2010 and 12/31/2020. Adults (>18 years of age) who had CT imaging for non-pancreatobiliary reasons before and after their RYGB were included. Patients with known pancreatobiliary pathology were excluded from analysis. An abdominal radiologist measured the diameters of the CBD in all images at the porta hepatis. Linear regression modeling and t-tests in SPSS were used to analyze data. Results: 46 patients met the inclusion criteria. The average age and BMI at time of RYGB was 48.4 years and 46.4. The average age and BMI at time of post-operative CBD measurement was 49 years and 38.1. The mean CBD diameter of all included patients pre-RYGB was 5.93 mm (SD 1.5) and the mean diameter post-RYGB was 7.0 mm (SD 3.3). Mean diameter change between pre and post RYGB was 1.31 mm (SD 2.8, P < 0.05). Controlling for prior cholecystectomy as well as narcotic use at the time of post-operative imaging, the change in CBD diameter was 1.15 mm (SD 0.6, P value 0.06). Prior cholecystectomy and narcotic usage did not affect in person change of CBD diameter (P 0.9, P 0.6). Conclusion: There are many known causes of non-pathological biliary duct dilation, including age, history of cholecystectomy and narcotic use. Our data shows that biliary dilation can occur after bariatric surgery. This finding is important because endoscopic biliary evaluation with EUS and ERCP in RYGB anatomy is challenging and associated with high failure rates. Other biliary interventions like laparoscopic assisted, percutaneous and trans-gastric procedures are associated with higher risk of complications. Given these issues, it is crucial for patients to have a strong indication for biliary intervention. As physicians treat an increasing number of patients with RYGB anatomy, they must consider that incidentally found biliary dilation might not necessarily indicate the presence of biliary pathology in order to prevent avoidable imaging and interventions.

Use of lumen-apposing metal stents (LAMS) in the management of gastro jejunostomy stricture following Roux-en-Y Gastric Bypass for obesity: a prospective series

BackgroundChronic strictures following Roux-en-Y Gastric Bypass (RYGB) are a troublesome complication that can lead to significant morbidity. The use of stents has been described but the need for X-ray and risk of migration have meant limited use in the management of these strictures. Lumen apposing metal stents (LAMS) have traditionally been used for management of pancreatic pseudocysts. They don’t require X-ray and are easy to deploy with a short learning curve. This paper explores the use of LAMS to treat post RYGB strictures and explores their safety and efficacy.MethodsA prospective study over a 4-year period looking at 14 patients with post RYGB strictures. These patients were privately insured patients operated within a tertiary Private facility. The patients were followed up for between 1 and 3 years. We have prospectively collected data on the efficacy and safety of LAMS in these patients. Patients were followed up until stent removal or definitive surgery to correct a stricture.Results421 patients underwent RYGB in the study period. 14 (3.3%) of these patients developed a stricture that resulted in insertion of LAMS. There was no immediate complications and 12 patients had complete resolution of their stricture. There were no reoperations due to migration related issues although a migration rate of 19% was noted. 2 patients required surgery to correct refractory strictures not relieved by a LAMS stent, both of these were strictures associated with marginal ulceration of the gastro jejunostomy.ConclusionLAMS are a safe and effective method to manage post RYGB strictures. They have a high rate of resolution of strictures and can be safely deployed across strictures with no immediate complication. Migration does still appear to be a problem, however, does not appear to affect patient outcome or increase morbidity. Insertion is straightforward and doesn’t appear to be associated with a long learning curve.

Laparoscopy-Assisted Transgastric ERCP: A Challenging Technique for Biliary Clearance Post Roux-en-Y Gastric Bypass

AbstractBiliary complications after Roux-en-Y gastric bypass (RYGB) are not uncommon. Managing choledocholithiasis in this subset of patients is challenging as conventional endoscopic retrograde cholangiopancreatography (ERCP) is not possible due to lack of peroral access to the second part of duodenum. Enteroscopic approach, however, theoretically feasible is difficult and cumbersome, often resulting in failed procedure. Small series has reported higher success with a novel technique of laparoscopic transgastric access for ERCP. Laparoscopy-assisted ERCP (LA-ERCP) is now increasingly being recognized as a safe and reliable technique for biliary clearance with a low complication rate, making it a preferred approach for managing biliopancreatic disease in these groups of patients. Here we report a case of a young patient with gallstone disease and choledocholithiasis presenting with obstructive jaundice post RYGB who was successfully managed by LA-ERCP followed by laparoscopic cholecystectomy in the same session.

Efficacy of transoral outlet reduction in Roux-en-Y gastric bypass patients to promote weight loss: a systematic review and meta-analysis.

Background and study aims Transoral outlet reduction (TORe) is an endoscopic procedure used in patients with weight gain post Roux-en-Y gastric bypass (RYGB). We performed a systematic review and meta-analysis to evaluate the efficacy and safety of TORe with a full-thickness suturing device for treating patients with weight regain after RYGB. Patients and methods We conducted a comprehensive search of several databases and conference proceedings including PubMed, EMBASE, Google-Scholar, MEDLINE, SCOPUS, and Web of Science databases (earliest inception to March 2020). The primary outcomes assessed were technical success, absolute weight loss (AWL) and percent of total weight loss (% TWL) at 3, 6, and 12 months after the procedure. The secondary outcomes assessed were pooled rate of adverse events (AEs), adverse event subtypes and association of size of gastrojejunal anastomosis (GJA) and percent TWL. Results Thirteen studies on 850 patients were included. The pooled rate of technical success was 99.89 %. The absolute weight loss (kg) at 3, 6, and 12 months was 6.14, 10.15, and 7.14, respectively. The percent TWL at 3, 6, and 12 months was 6.69, 11.34, and 8.55, respectively. The pooled rate of AE was 11.4 % with abdominal pain being the most common adverse event. The correlation coefficient (r) was –0.11 between post TORe GJA size and weight loss at 12 months. Conclusion TORe is an endoscopic procedure that is safe and technically feasible for post RYGB with weight gain.

Hyposalivation is prevalent in bariatric patients but improvesaftersurgery.

Obesity and type 2 diabetes can be associated with poor oral health. This can be because of hyposalivation leading to chronic oral inflammation (OI) and periodontal disease. To assess the prevalence of hyposalivation and OI in individuals undergoing Roux-en-Y gastric bypass (RYGB) and determine the relationship with metabolic and anthropometric parameters before and after RYGB. University hospital in Canada. This was a cross-sectional and prospective cohort study of 59 patients undergoing RYGB from September 2015 to December 2019. Anthropometric, biochemical, and oral measurements were taken before surgery and 1 and 6 months post RYGB. Oral parameters included salivary flow rate and neutrophil count as marker of OI. Fifty-nine patients were enrolled with 29 completing this study. At baseline, the median age was 47 years and body mass index was 46.5 kg/m2, 52 (88.1%) were female and 14 individuals (23.7%) had type 2 diabetes; 54.2% (n = 32) of patients had hyposalivation and 13.6% (n = 8) had high neutrophil count. Patients with hyposalivation had significantly higher fasting glucose (5.7 mmol/L) compared with those without hyposalivation (5.2 mmol/L) but no difference was found between high versus low neutrophil count. At 6 months post RYGB, all variables except oral neutrophil count significantly improved. Hyposalivation persisted in 7 (24%) individuals. In our bariatric patients, more than half the patients had hyposalivation before RYGB and this was associated with higher fasting glucose. Hyposalivation improved post RYGB in parallel with improvements in metabolic parameters but there was no change in OI. Increased salivation may reduce the risk of periodontal disease.

Sustained Improvements in Glucose Metabolism Late After Roux-En-Y Gastric Bypass Surgery in Patients with and Without Preoperative Diabetes

To describe glucose metabolism in the late, weight stable phase after Roux-en-Y Gastric Bypass (RYGB) in patients with and without preoperative type 2 diabetes we invited 55 RYGB-operated persons from two existing cohorts to participate in a late follow-up study. 44 (24 with normal glucose tolerance (NGT)/20 with type 2 diabetes (T2D) before surgery) accepted the invitation (median follow-up 2.7 [Range 2.2–5.0 years]). Subjects were examined during an oral glucose stimulus and results compared to preoperative and 1-year (1 y) post RYGB results. Glucose tolerance, insulin resistance, beta-cell function and incretin hormone secretion were evaluated. 1 y weight loss was maintained late after surgery. Glycemic control, insulin resistance, beta-cell function and GLP-1 remained improved late after surgery in both groups. In NGT subjects, nadir glucose decreased 1 y after RYGB, but did not change further. In T2D patients, relative change in weight from 1 y to late after RYGB correlated with relative change in fasting glucose and HbA1c, whereas relative changes in glucose-stimulated insulin release correlated inversely with relative changes in postprandial glucose excursions. In NGT subjects, relative changes in postprandial nadir glucose correlated with changes in beta-cell glucose sensitivity. Thus, effects of RYGB on weight and glucose metabolism are maintained late after surgery in patients with and without preoperative T2D. Weight loss and improved beta-cell function both contribute to maintenance of long-term glycemic control in patients with type 2 diabetes, and increased glucose stimulated insulin secretion may contribute to postprandial hypoglycemia in NGT subjects.

OR01-6 LncRNA GAS5 Directed Therapeutic Increases Insulin Receptor Expression in Adipocytes

Obesity continues to escalate as a significant public health problem and as the leading preventable cause of death. Obesity is a major risk factor for cardiovascular disease and type 2 diabetes. Obese patients with high morbidities are directed towards bariatric surgeries such as Roux-En-Y gastric bypass (RYGB). These procedures not only result in successful weight loss, but also reduce insulin resistance and lead to resolution of type 2 diabetes mellitus independently of BMI reduction. Type 2 Diabetes Mellitus (T2DM) is polygenic in nature and is frequently associated with insulin resistance and impaired insulin signal transduction. Using the oral glucose tolerance tests (IVGTT), the glycosylated hemoglobin (HbA1c) and the homeostasis model assessment of insulin resistance (HOMA-IR), large cohort studies revealed diabetes resolution in 74-83% of patients who underwent Roux-en-Y procedure. While the underlying genetics of T2DM has been extensively studied, the emphasis has been on genes encoding transcripts that are translated to proteins. However, it is becoming increasingly clear that regulatory noncoding transcripts play an important role in disease manifestation. Long noncoding RNAs (lncRNA) are regulatory RNAs >200nt. We previously showed that lncRNA GAS5 decreased significantly in serum of type 2 diabetes mellitus (T2DM) patients. The data here shows that GAS5 levels are low in obese and diabetic patients and are increased post- RYGB in adipose tissue. Adipose tissue is an important endocrine regulator of energy homeostasis and glucose metabolism. Hence, we sought to decipher the molecular mechanisms underlying the role of GAS5 in T2DM in adipose tissue (AT). We used an unbiased diabetes array to determine the genes affected by knockdown of GAS5 in human AT. Our results show a sharp reduction of insulin receptors A and B with depletion of GAS5. Using CHIP-RIP, we demonstrate that GAS5 binds to promoter of insulin receptor to regulate its expression, and its depletion inhibits glucose uptake and insulin signaling. Towards stabilizing GAS5 levels in adipocytes, a small molecule was identified using OBTC screening strategy. NP-C86 binds to GAS5 with high affinity, increases GAS5 levels and glucose uptake in diabetic patient adipocytes. These results demonstrate that GAS5 plays a pivotal role in resolution of T2DM post RYGB.

New microbe genomic variants in patients fecal community following surgical disruption of the upper human gastrointestinal tract

Recent studies have shown that microbe strains in normal individuals fecal microbe community are relatively stable over time. Given the role the gut microbe community plays in human health, it is important to understand if disruption of the gastrointestinal tract environment results in emergence of new genomic variants. To address this, we have used a new technique called Window-based single nucleotide similarity (WSS) to analyze the impact of several surgical procedures of the human gastrointestinal tract on the stability of the fecal microbes. Previously, we established a WSS boundary score cutoff to determine if microbe genomic variants were similar. Based on analysis of normal individuals from the Human Microbiome Project, 93% of microbes in paired fecal samples up to 1 year apart were above the cutoff, indicating similar (stable) microbes. For the current study, we analyzed fecal samples from 18 patients undergoing Roux-en-Y gastric bypass (RYGB) or 6 patients undergoing gastric sleeve for extreme obesity. From comparison of the pre-RYGB versus 1–2 year post RYGB samples from the same patients, 65% of the WSS were above the boundary cutoff, while for pre versus 1–2 year samples post surgery for patients undergoing sleeve gastrectomy, 75% of the WSS were above the cutoff. In contrast, analysis of fecal samples from 5 patients pre and post removal of segments of the sigmoid colon revealed that 97% of WSS scores were above the cutoff. Our study establishes emergence of new microbe genomic variants in the fecal community following alteration of the upper gastrointestinal environment.

Post-Prandial Acid Pocket as a Cause of GERD, Nausea and Vomiting Post Sleeve Gastrectomy

Introduction: Patients with complaints of gastro-esophageal reflux disease (GERD), nausea and vomiting post bariatric surgery are frequently referred to gastroenterology service for evaluation. These symptoms are worse in patients status post sleeve gastrectomy compared to Roux-en-Y gastric bypass (RYGB) as the former involves mechanical or functional narrowing of the incisura and removal of the angle of His. We found no reports of gastric emptying in the extant literature regarding GERD post bariatric surgery especially sleeve gastrectomy. Methods: We analyzed and summarized the gastric emptying studies of 10 patients referred to us status post bariatric surgery, both sleeve gastrectomy and RYGB, with complaints of nausea, vomiting, and heartburn. Results: In patient’s status post sleeve gastrectomy, 5 of 7 patients demonstrated normal or accelerated gastric emptying times with an average t1/2 of 44 minutes (normal 45 - 110 minutes). One of the three RYGB patients had delayed gastric emptying. None of the RYGB patients exhibited reflux on nuclear medicine gastric emptying study. However, sleeve gastrectomy patients exhibited fundic retention of tracer (2/7, Figure A), delayed esophageal emptying (4/7, Figure B), esophageal reflux (5/7) and to and fro motion in the esophagus and/or fundus (3/6). Of note is that 2 sleeve gastrectomy patients could not remain supine to complete all aspects of the nuclear medicine gastric emptying study without vomiting. Patients had partial response to proton pump inhibitors alone. One patient had revision of her sleeve gastrectomy; repeat nuclear medicine gastric emptying study showed improved gastric emptying, less retention of tracer in the fundus, and less reflux in the esophagus. She also had the most symptomatic improvement. Conclusion: In our experience, sleeve gastrectomy patients were more likely to complain of GERD, nausea, or vomiting than RYGB patients. Their nuclear medicine gastric emptying studies were also more abnormal. We hypothesize that the physiologic changes observed in the sleeve gastrectomy patients more than the RYGB patients represent an exacerbation of the acid pocket which is the unbuffered pool of acid that floats on top of ingested food after meals. It is known that proximal displacement of the acid pocket worsens GERD. The anatomical changes associated with sleeve gastrectomy and not RYGB are more likely to displace the acid pocket proximally.356 Figure 1 No Caption available.

Impact of bariatric surgery on neural food processing and cognition: an fMRI study

IntroductionThe Roux-en-Y gastric bypass (RYGB) is one of the most widely used techniques for bariatric surgery. After RYGB, weight loss up to 50%–70% of excess body weight, improvement of insulin-resistance,...

The effects of bariatric surgery on pharmacokinetics of antidepressants: A systematic review

IntroductionMorbid obesity (BMI ≥ 35) has been associated with mood and anxiety disorders. Regular use of antidepressants is common among patients who are candidate for bariatric surgery. The Roux-en-Y gastric bypass (RYGB) is one of the most common techniques used in bariatric surgery for reducing nutrient absorption. This type of surgery may however result in major changes in drug absorption.Objectives and aimsTo report and discuss the consequences of bariatric surgery on changes in antidepressant drug absorption.MethodsWe present all published in vitro and in vivo studies on antidepressant drug absorption after bariatric surgery.ResultsIn vitro studies showed that only bupropion had a significantly increased dissolution in a post-RYGB environment; venlafaxine and citalopram showed no alteration of dissolution; fluoxetine, paroxetine, sertraline, and amitryptiline had an significantly decreased dissolution in a post RYGB environment. Some in-vivo studies reported that only citalopram and escitalopram had an increased dissolution.ConclusionAfter bariatric surgery, special caution is required in patients using antidepressant medication because of the expected changes in drug absorption, nutritional status, and electrolyte balance.Disclosure of interestThe authors have not supplied their declaration of competing interest.