Small Gastric Pouch Research Articles

Transumbilical Stapling Technic of OAGB.

Single-port or single-incision laparoscopic surgery (SILS) is esteemed for its efficacy in achieving superior postoperative cosmetic outcomes compared to the conventional laparoscopic approach (Behnia-Willison et al. in Aust N Z J Obstet Gynaecol 52:366-370, 2012; Rogula et al. in Obes Surg 24:1102-1108, 2014; Pitot et al. in Surg Endosc 28:3007-3011, 2014). The introduction of SILS for bariatric procedures can be attributed to the pioneering work of Saber in 2008, who initially applied this technique to laparoscopic sleeve gastrectomy (SG), followed by its utilization in laparoscopic adjustable gastric banding (AGB) (Saber et al. in Obes Surg 18:1338-1342, 2008;Nguyen et al. in Obes Surg 18:1628-1631, 2008). The inaugural application of SILS in Roux-en-Y gastric bypass (RYGB) was documented in 2009, employing a plastic reconstruction methodology. Acknowledging the intricate nature of complex bariatric interventions, we previously detailed a modified SILS approach termed the transumbilical two-site (TUTS) technique for RYGB, which was established as a standard procedure in 2010 (Lee et al. in Surg Obes Relat Dis. 8:208-13, 2012). At that juncture, a solitary article surfaced in 2010 elucidating the dimensions of the small gastric pouch as a mere 8-9cm, falling short of contemporary surgical requisites for optimal outcomes in one anastomosis gastric bypass (OAGB) (Tacchino et al. in Obes Surg 20:1154-1160, 2010). Notably, the TUTS technique, which was successfully implemented for RYGB, had hitherto not been extended to OAGB due to the complexities associated with creating a slender gastric tube spanning 25cm. In a pioneering development this year, we have devised a novel strategy to surmount this challenge. The present study is designed to expound upon the transumbilical stapling technique tailored to the unique demands of OAGB.

Comparison of 1-year outcomes between Roux-en-Y gastric bypass and sleeve gastrectomy with Roux-en-Y duodenojejunal bypass in the patients of obesity with type 2 diabetes mellitus

Objective: To compare the 1-year effects of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy with Roux-en-Y duodenal bypass (SG+RYDJB) on weight loss, remission of diabetes, and postoperative complications in patients with obesity and type 2 diabetes. Methods: A single-center retrospective cohort study was conducted at the First Affiliated Hospital of Nanjing Medical University from January 2020 to December 2020. Sixty-four patients with type 2 diabetes and body mass index (BMI) of 27.5-40.0 kg/m2 were included in this study and divided into the RYGB group (n=34) and the SG+RYDJB group (n=30). In both procedures, the biliopancreatic branch was measured 100 cm distal to the Treitz ligament, and the food branch was measured 100 cm distal to the gastric or duodenojejunal anastomosis. Patients were followed up by telephone or WeChat, a free messaging and calling app at 1, 3, 6, and 12 months postoperatively to determine their weight loss and remission of diabetes. The primary outcomes were the weight loss and reduction in blood glucose concentrations at 1 year after surgery and postoperative complications. Other postoperative changes, including body weight, BMI, percentage of total weight loss (%TWL), percentage of excess weight loss (%EWL), glycated hemoglobin A1c (HbA1c), and fasting blood glucose at 1 year after surgery were also assessed. Results: There were no significant differences in baseline data between the two groups (all P>0.05). No conversion to open surgery or death occurred in either group. Operation time was longer in the SG+RYDJB than the RYGB group (137.8±22.1 minutes vs. 80.0±24.9 minutes, t=9.779, P<0.001) and the incidence of perioperative complications was higher in the SG+RYDJB than the RYGB group (20% [6/30] vs. 2.9% [1/34], χ2=4.761, P=0.029). However, the postoperative hospital stay was similar between the two groups [3.0 (3.0, 4.3) days vs. 3.0 (4.0, 6.0) days, U=641.500, P=0.071]. Perioperative complications comprised small gastric pouch anastomotic leakage in one patient in the RYGB group and leakage (three patients) and bleeding (two patients with gastrointestinal bleeding and one with trocar site bleeding) in the SG+RYDJB group. Long-term complications were as follows. The incidence of anemia was significantly higher in the RYGB than the SG+RYDJB group (26.5% [9/34] vs. 3.3% [1/30], χ2=6.472, P=0.011). However, there were no significant differences in incidences of postoperative reflux, dumping syndrome, alopecia, diarrhea, constipation or foul-smelling flatus between the two groups (all P>0.05). Compared with 1 year before surgery, the body weights and fasting plasma glucose concentrations of patients in the SG+RYDJB and RYGB group (72.4±10.6 kg vs. 98.5±14.2 kg, respectively; 68.2±10.0 kg vs. 91.9±14.8 kg, respectively), BMI (25.2±2.9 kg/m2 vs. 34.3±4.2 kg/m2, respectively; 24.3±2.4 kg/m2 vs. 32.7±3.7 kg/m2, respectively) (5.5±1.6 vs. 10.6±3.3, respectively; 5.8±2.1 vs. 9.0±3.4, respectively); HbA1c (5.7±0.8 vs. 9.7±1.2, respectively; 9.1±1.9 vs. 5.9±0.9, respectively) were significantly lower at 1 year after surgery (all P<0.05). However, the % TWL (26.5%±6.0% vs. 25.6%±4.4%, t=0.663, P=0.510) and % EWL (109.1%±38.2% vs. 109.4%±40.3%, t=-0.026, P=0.026), rate of complete remission of diabetes at 1 year (80.0% [24/30] vs. 82.4% [28/34], χ2=0.058, P=0.810] did not differ significantly between the two groups (all P>0.05). Conclusions: Although SG+RYDJB surgery compared with RYGB is more difficult to perform, it can achieve similar weight loss and remission of diabetes and is associated with a lower incidence of anemia because of the preservation of the pylorus.

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.

Large Versus Small Gastric Pouch for Roux-en-Y Gastric Bypass in Individuals With Type 2 Diabetes and a Body Mass Index < 35 kg/m2: Six-Year Outcomes.

BackgroundRoux-en-Y gastric bypass (RYGB) results in extraordinary weight loss and glycemic control outcomes for patients with obesity; however, the effect of gastric pouch size is still unclear, and the reported results are contradictory. Additionally, long-term data on type 2 diabetes (T2D) patients with low body mass index (BMI) are sparse. This study was to assess the effect of 6-year outcomes in Chinese patients with T2D and a BMI < 35 kg/m2 who underwent RYGB with gastric pouches of different sizes.MethodsA retrospective cohort study was performed. There were 42 patients in the large gastric pouch group (L) and 53 patients in the small gastric pouch group (S). Baseline demographic history, pre- and postoperative BMI, waist circumference, and glucose- and lipid metabolism-related indicators were compared.ResultsAssessments were completed in 100%, 100%, 93.6%, and 89.4% of patients at baseline, 1 year, 3 years, and 6 years, respectively. At 6 years, the changes in BMI and fasting plasma glucose were greater in the S group (-4.25 ± 0.51 kg/m2 and -4.58 ± 0.73 mmol/l) than in the L group (-2.06 ± 0.48 kg/m2 and -2.64 ± 0.61 mmol/l). The independent predictors of complete remission of T2D were preoperative BMI and the size of the gastric pouch. A large gastric pouch was associated with a higher risk for marginal ulcers.ConclusionsA small gastric pouch results in better weight loss and glycemic control. High preoperative BMI and a small gastric pouch are associated with better T2D remission rates. A large gastric pouch leads to a higher incidence of marginal ulcers.

Skeletal muscle mitochondrial network dynamics in metabolic disorders and aging

With global demographics trending towards an aging population, the numbers of individuals with an age-associated loss of independence is increasing. A key contributing factor is loss of skeletal muscle mitochondrial, metabolic, and contractile function. Recent advances in imaging technologies have demonstrated the importance of mitochondrial morphology and dynamics in the pathogenesis of disease. In this review, we examine the evidence for altered mitochondrial dynamics as a mechanism in age and obesity-associated loss of skeletal muscle function, with a particular focus on the available human data. We highlight some of the areas where more data are needed to identify the specific mechanisms connecting mitochondrial morphology and skeletal muscle dysfunction.

A Protocol for Roux-en-Y Gastric Bypass in Rats using Linear Staplers.

Roux-en-Y gastric bypass (RYGB) is commonly performed for the treatment of severe obesity and type 2 diabetes. However, the mechanism of weight loss and metabolic changes are not well understood. Multiple factors are thought to play a role, including reduced caloric intake, decreased nutrient absorption, increased satiety, the release of satiety-promoting hormones, shifts in bile acid metabolism, and alterations in the gut microbiota. The rat RYGB model presents an ideal framework to study these mechanisms. Prior work on mouse models have had high mortality rates, ranging from 17 to 52%, limiting their adoption. Rat models demonstrate more physiologic reserve to surgical stimulus and are technically easier to adopt as they allow for the use of surgical staplers. One challenge with surgical staplers, however, is that they often leave a large gastric pouch which is not representative of RYGB in humans. In this protocol, we present a RYGB protocol in rats that result in a small gastric pouch using surgical staplers. Utilizing two stapler fires which remove the forestomach of the rat, we obtain a smaller gastric pouch similar to that following a typical human RYGB. Surgical stapling also results in better hemostasis than sharp division. Additionally, the forestomach of the rat does not contain any glands and its removal should not alter the physiology of RYGB. Weight loss and metabolic changes in the RYGB cohort were significant compared to the sham cohort, with significantly lower glucose tolerance at 14 weeks. Furthermore, this protocol has an excellent survival of 88.9% after RYGB. The skills described in this protocol can be acquired without previous microsurgical experience. Once mastered, this procedure will provide a reproducible tool for studying the mechanisms and effects of RYGB.

Per Oral Endoscopic Myotomy for the Management of Achalasia in a Patient with Prior Lap Band, Sleeve Gastrectomy, and Roux-en-Y Gastric Bypass.

Achalasia after bariatric surgery is a rare pathological entity. Nonetheless, several cases have been described in literature. Per oral endoscopic myotomy has recently emerged as the preferred approach for the management of esophageal motility disorders. We report a video case of POEM performed in a female patient with prior multiple bariatric surgical procedures. In her past medical history, she underwent to laparoscopic lap band, sleeve gastrectomy, and Roux-Y-gastric bypass. POEM was carried out without complication. Myotomy was performed only for 1 cm below the cardias due to the presence of the gastro-jejunal anastomosis. Post-operative course was uneventful and oral diet was restarted after one day. At 2 months follow-up, the patient is asymptomatic with no weight regain. We report the first case of POEM after three different bariatric surgical procedure. Fibrosis due to prior interventions did not hampered POEM procedure, and the shorter myotomy due to the presence of small gastric pouch did not reduced its efficacy.

Weight Loss Surgery Increases Risk of Unhealthy Drinking

Weight Loss Surgery Increases Risk of Unhealthy Drinking

S3028 Swept Under the Adipose Rug: Is Bariatric Surgery a Risk Factor in the Development of Cancer?

INTRODUCTION: According to the WHO, gastric cancer (95% of the cases are adenocarcinomas) is the third most common cause of cancer-related death and the fifth most common malignancy in the world today and can arise from any viable gastric mucosa. The Roux-en-Y gastric bypass is a commonly performed weight loss surgery that involves the creation of a small gastric pouch which is connected to the small intestine. We submit a case of gastric adenocarcinoma in the excluded gastric pouch of a prior Roux-en-Y bypass presenting with non-specific symptoms. CASE DESCRIPTION/METHODS: A 70 year old female with a past medical history of Roux-en-Y 15 years prior and subsequent gastroesophageal reflux disease presented to ER with greater than 2 months of intermittent epigastric pain. She had emesis and an inability to tolerate oral intake. Endoscopy was largely unremarkable and surgical pathology was negative. An esophagram showed nutcracker esophagus so the patient was started on Diltiazem. Continued symptoms prompted a CT abdomen showing relatively pronounced dilatation of the excluded stomach pouch with oral contrast material, likely entering via a fistula. Failure of conservative management prompted an exploratory laparotomy that revealed a severely distended stomach pouch, with intraoperative drainage of 800 cc of fluid. A tight duodenal stenosis with complete obstruction of the gastric outlet was also noted. Surgical pathology showed high grade adenocarcinoma involving the resected stomach and proximal duodenum with clear proximal and distal margins. H. pylori was not found. The tumor itself was positive for CK7 and CA 19-9 and negative for CK20. The tumor cells were ER/PR negative and cdx-2 negative. Repeat CT showed postsurgical changes without evidence of fluid collections or bowel obstruction. DISCUSSION: Up to 36% of patients who undergo gastric bypass are found to have duodenal reflux. Exposure to bile salts from the duodenal reflux can cause gastritis, intestinal metaplasia, and adenocarcinoma in the gastric mucosa. Literature review reveals multiple cases of gastric cancer in the excluded portion of the stomach after bariatric surgery, but long-term studies do not demonstrate a statistical or causal link between bariatric surgery and the development of gastric adenocarcinoma. Our case demonstrates that the excluded pouch of a Roux-en-Y bypass should be evaluated in at risk patients, even with non-specific symptoms, to allow early diagnosis of possible gastric adenocarcinomas.

Laparoscopic sleeve gastrectomy and esophageal motility

Laparoscopic sleeve gastrectomy (LSG) is becoming popular between the bariatric procedures. There are few studies available in the literature about LSG impact on esophageal motility, with debatable results. Technically, it modifies the anatomy of the esophago-gastric junction; it can damage the phreno-esophageal ligament and decrease the lower esophageal sphincter pressure that will predispose to reflux. Gastroesophageal reflux disease (GERD) is already common in obese patients due to frequent hiatal hernia, high intraabdominal pressure, increased transient lower esophageal sphincter relaxations (TLESR), altered esophageal motility and poor esophageal clearance. LSG can worsen gastroesophageal reflux disease, but also the weight loss achieved after it and the decrease of acid production in the small gastric pouch will probably reduce the GERD symptoms. Dysphagia and odynophagia were reported after sleeve gastrectomy, but usually associated with anatomical narrowing of the gastric sleeve, caused by esophageal dismotility or secondary to diabetes mellitus, low tiamine level, the use of opioids and non-steroidal anti-inflammatory drugs, even hypothyroidism. In addition to upper GI tract endoscopy, high-resolution esophageal manometry (HRM) should be required for all patients planning to undergo a LSG, and in the follow-up period according to the contractility pattern.

Gastric Bypass Improves Obesity and Glucose Tolerance Independent of Gastric Pouch Size.

We investigated whether metabolic phenotype improvements following gastric bypass are associated with gastric resection strategy in high-fat diet-induced obese (DIO) mice. We developed the mouse Roux-en-Y gastric bypass (RYGB) model with different gastric pouch sizes: (i) RYGB with a large gastric pouch (RYGB-LP), where the stomach was transected, and the jejunum was anastomosed to the residual forestomach, in which 30% of the stomach is retained. (ii) RYGB with a small remnant gastric pouch (RYGB-SP), where the stomach was transected 0.8cm distal to the esophagogastric junction, and the jejunum is attached to a small remnant of the forestomach (~ 10% of the stomach). (iii) RYGB without gastric pouch (RYGB-NP), where the jejunum is anastomosed to the lower portion of the esophagus. Surgical success rate (or 4-week mouse survival rate) of the RYGB-LP, RYGB-SP, and RYGB-NP procedures was 50, 75, and 85%, respectively. Our data demonstrate that all RYGB procedures improved body weight, glucose tolerance, and liver steatosis, compared with untreated DIO mice at 8-week post-surgery. Major surgical complication, such as obstruction at the forestomach, occurred predominantly in RYGB-LP mice, resulting in a higher mortality. Pre- and post-prandial plasma ghrelin levels did not correlate with improved metabolic phenotype after gastric bypass. We conclude that RYGB with different gastric pouch equally improves obesity and glucose tolerance independent of gastric pouch size and total plasma ghrelin levels in the mouse model of RYGB surgery.

A Case Report Identifying the Clinical Significance of Spontaneous Gastrojejunal Fistulization Related to Roux-en-Y Bypass

Within the United States the rise in obesity and related metabolic complications, has led to an increase in the number of bariatric surgeries over the last decade. Roux-en-Y gastric bypass( RYGB) procedure is one of the most common weight-loss procedures performed in the United States. Notwithstanding the improvement in the bariatric surgical procedures, complications do occur. In the early postoperative phase, complications can occur including; obstruction of bypassed bowel, anastomotic leak and nutritional deficiencies to list a few. In rare cases, a gastro-jejunal leakage and fistula can occur. We present a rare complication of RYGB leading to formation of a gastro-jejunal fistula formation. A 51 year old woman with history of gastric bypass in 2007 presented to clinic with worsening epigastric abdominal pain associated with nausea, and unintentional weight loss of ˜8lbs over a 2 week period. She denied vomiting, hematemesis, melena or hematochezia. Physical examination was unremarkable. Laboratory investigation revealed a normal complete blood count and basic metabolic profile. An Esophagogastroduodenoscopy( EGD) showed a small gastric pouch consistent with prior gastric bypass, erythematous mucosa at the gastro-enteric anastomosis and a fistulous opening in distal gastric pouch near the anastomosis (image). The opening into the jejunal loop was narrowed precluding intubation with an upper endoscope. Biopsies of the anastomotic site exhibited mild chronic inactive gastritis, negative for Helicobacter pylori. The patient was managed with a proton pump inhibitor(PPI) daily for 8 weeks. On follow up, she reported complete resolution of her symptoms. A follow up EGD showed healing of the fistilous tract. As reviewed in literature, spontaneous fistulization formation secondary to gastritis (peptic ulcer disease particularly) is a rare complication. Fistulaization typically affects middle aged to elderly females with risk factors; NSAID use, H. Pylori infection, postoperative stress and minimal mesenteric adipose tissue. It is our responsibility as gastroenterologists to be familiar with potential complications after bariatric surgery and management strategies. This case further validates that surgical intervention is not always required in gastroenteric fistulas and that medical therapy with appropriate follow up can be used to manage such complications.1888 Figure 1. Small gastric pouch, erythematous mucosa with a gastro-jejunal fistulous opening (left) near gastro-enteric anastomosis (right).

Is Bypassing the Stomach a Means to Optimize Sodium Bicarbonate Supplementation? A Case Study With a Postbariatric Surgery Individual.

Sodium bicarbonate (SB) is an ergogenic supplement shown to improve high-intensity exercise via increased blood bicarbonate buffering. Substantial amounts of the ingested bicarbonate are neutralized in the stomach. Bariatric surgery results in a small gastric pouch which dramatically reduces exposure time of any ingested food in the stomach. The aim of this study was to examine the pharmacokinetics of orally ingested SB in a postgastric bypass individual to determine the magnitude of changes in blood bicarbonate and associated side effects. We hypothesized that SB supplementation in a gastric bypass model would result in greater blood bicarbonate increases and fewer side effects than in healthy individuals due to minimal bicarbonate losses in the stomach. One postbariatric male ingested 0.3g/kg·body mass of SB on three occasions (SB1, SB2, and SB3) and 0.3g/kg·body mass of placebo on a further occasion. Blood bicarbonate was determined before and every 10min following supplement ingestion for 3hr and then every 20min for a further 1hr. Side effects were reported using an adapted questionnaire at identical time points. Maximal increases in blood bicarbonate with SB were +20.0, +15.2, and +12.6mM, resulting in maximal bicarbonate concentrations of 42.8, 39.3, and 36.2mM. Area under the curve was SB1: 8,328mM/min; SB2: 7,747mM/min; SB3: 7,627mM/min, and 6,436mM/min for placebo. Side effects with SB were scarce. Maximal bicarbonate increases were well above those shown previously, with minimal side effects, indicative of minimal neutralization of bicarbonate in the stomach. The large increases in circulating bicarbonate and minimal side effects experienced by our postgastric surgery bypass patient are indicative that minimizing neutralization of bicarbonate in the stomach, as would occur with enteric coated capsules, may optimize SB supplementation and thus warrants investigation.

Opened Proton Pump Inhibitor Capsules Reduce Time to Healing Compared With Intact Capsules for Marginal Ulceration Following Roux-en-Y Gastric Bypass

Marginal ulceration, or ulceration at the gastrojejunal anastomosis, is a common complication of Roux-en-Y gastric bypass (RYGB). Acidity likely contributes to the pathophysiology, and proton pump inhibitors (PPIs) frequently are prescribed for treatment. However, patients with gastric bypass only have a small gastric pouch and rapid small-bowel transit, which limits the opportunity for capsule breakdown and PPI absorption. Soluble PPIs (open capsules [OCs]) might be absorbed more easily than intact capsules (ICs). We compared time to ulcer healing, number of endoscopic procedures, and use of health care for patients with marginal ulceration who received PPIs in OC vs IC form. We performed a retrospective study of 164 patients diagnosed with marginal ulceration who underwent RYGB at the Brigham and Women's Hospital from 2000 through 2015. Patients received high-dose PPIs and underwent repeat endoscopy every 3 months until ulcer healing was confirmed. We used time-to-event analysis with a Cox proportional hazards model to evaluate the association between mode of PPI administration and time to ulcer healing, in addition to Cox multivariate regression analysis. Total charge (procedural and maintenance) was determined by comparison of categorized charges incurred from time of ulcer diagnosis to resolution. The primary outcome was time to healing of marginal ulceration in RYGB patients receiving high-dose PPIs in OC vs IC form. A total of 162 patients were included (115 received OC and 49 received IC). All patients were followed up until ulcer healing was confirmed. The median time to ulcer healing was 91.0 days for the OC group vs 342.0 days for the IC group (P < .001). OC was the only independent predictor of time to ulcer healing (P < .001) when we controlled for known risk factors. The number of endoscopic procedures (P= .02) and overall health care utilization (P= .05) were lower in the OC than the IC group. Patients with marginal ulceration after RYGB who receive OC PPIs have shorter ulcer healing times, fewer endoscopic procedures, and use less health care resources compared with patients who receive IC PPIs. Given these results and the high prevalence of marginal ulceration in this patient population, the use of OC PPIs is a low-risk, low-cost alternative that should be considered.

Body Composition, Food Intake, and Energy Expenditure in a Murine Model of Roux-en-Y Gastric Bypass Surgery.

The mechanisms by which Roux-en-Y gastric bypass surgery (RYGB) so effectively lowers body weight and improves glycemic control are not well understood, and murine models are essential for identifying the crucial signaling pathways involved. The aim of this study is to characterize the time course of RYGB on body weight, body composition, food intake, and energy expenditure in diet-induced obese mice and establish a tissue bank for global "omics" or targeted biochemical and structural analyses. High-fat diet-induced obese mice were subjected to RYGB using an improved surgical technique with a small gastric pouch. The effects on body weight, body composition, food intake, and energy expenditure were compared to sham surgery, high-fat diet-restricted weight-matched controls, and never-obese chow-fed controls. Without mortality or complications, RYGB surgery in high-fat diet-induced obese mice gradually decreased body weight to a plateau that was more or less sustained for up to 12weeks (33g, -18%, p < 0.01) and significantly lower compared with sham-operated mice (51g, +25%, p < 0.01), but higher (+18%, p < 0.01) than age-matched, chow-fed control mice (27g). Energy intake after RYGB was significantly suppressed compared to sham only for the first 10days, but significantly higher compared to weight-matched mice. Energy expenditure after RYGB was higher throughout the study compared with weight-matched, but not sham animals. RYGB surgery in diet-induced obese mice results in similar body weight and body composition changes as observed in humans, but in contrast with humans, this is achieved mainly through increased energy expenditure rather than decreased food intake.

SIMPLIFIED LAPAROSCOPIC GASTRIC BYPASS WITH GASTROJEJUNAL LINEAR MECHANICAL ANASTOMOSIS: TECHNICAL ASPECTS.

ABSTRACTBackground:Gastric bypass is a restrictive and malabsorptive surgery. The restrictive part consists in the creation of a small gastric pouch. The gastrointestinal bypass serves as the malabsorptive element.Aim: To describe a simplified gastric bypass approach for morbid obese patients, showing our results, and also remarking the importance of this technique for reducing the learning curve.Method:The patient is positioned in a split legs position and carefully strapped to the operating room table, with the surgeon between the patient's legs. Five trocars are inserted after pneumoperitoneum at the umbilicus. Dissection of the esophagogastric angle and lesser curvature is mandatory before the gastric pouch manufacturing. This pouch is done with two blue load staplers. Using a blue load linear stapler inserted only half way into the hole in the pouch is used to perform the gastrojejunal anastomosis and in order to create an anastomosis that is about 2 cm in length. A side-to-side jejunojejunostomy is done with a white load linear stapler. The last step of the gastric bypass consists in the cut of the jejunum between the two anastomosis with a white load linear stapler. Blue test is performed in order to detect leaks.Results: From January 2012 to December 2015, 415 simplified RYGB were performed. Gender: 67% female and 33 % males. Average of BMI 44.7. Mean age was 42 years old. Mean operative time 79 min. 39 % of this sample had T2 diabetes. Regarding complications were observed, one fistula, one gastrojejunal stenosis and one obstruction due to a bezoar.Conclusion: The described technique is a simplified approach in which all the anastomosis are performed in the upper part of the abdomen, allowing the surgeons to be more systematized and avoiding them to make mistakes in the confection of the Roux-en-Y anastomosis. This simplified gastric bypass is a safe and reproducible technique.

Preoperative Predictive Factors of Successful Weight Loss and Glycaemic Control 1 Year After Gastric Bypass for Morbid Obesity

Gastric bypass (GBP) is one of the most effective surgical procedures to treat morbid obesity and the related comorbidities. This study aimed at identifying preoperative predictors of successful weight loss and type 2 diabetes mellitus (T2DM) remission 1 year after GBP. Prospective longitudinal study of 771 patients who underwent GBP was performed at four Italian centres between November 2011 and May 2013 with 1-year follow-up. Preoperative anthropometric, metabolic and social parameters, the surgical technique and the previous failed bariatric procedures were analyzed. Weight, the body mass index (BMI), the percentage of excess weight lost (% EWL), the percentage of excess BMI lost (% BMIL) and glycated haemoglobin (HbA1c) were recorded at follow-up. Univariate and multivariate analysis showed that BMI <50 kg/m(2) (p = 0.006) and dyslipidaemia (p = 0.05) were predictive factors of successful weight loss. Multivariate analysis of surgical technique showed significant weight loss in patients with a small gastric pouch (p < 0.001); the lengths of alimentary and biliary loops showed no statistical significance. All diabetic patients had a significant reduction of HbA1c (p < 0.001) after surgery. BMI ≥ 50 kg/m(2) (p = 0.02) and low level of preoperative HbA1c (p < 0.01) were independent risk factors of T2DM remission after surgery. This study provides a useful tool for making more accurate predictions of best results in terms of weight loss and metabolic improvement.

Comparison of the effects of Roux-en-Y gastrojejunostomy and LRYGB with small stomach pouch on type 2 diabetes mellitus in patients with BMI

BackgroundObjective: Based on distinct epidemiologic features of Chinese type 2 diabetes mellitus (T2DM) patients, who tend to have abdominal fat deposition, but with normal or mildly overweight epidemiologic features, our center initially had treated T2DM with body mass index (BMI)<35 kg/m² by performing laparoscopic Roux-en-Y gastrojejunostomy since 2008. This procedure is successful in treating abnormal glucose metabolism but not in improving abdominal visceral obesity. However, since 2011, laparoscopic Roux-Y gastric bypass (LRYGB) with a small stomach pouch has been performed at our center, with prominent resolution of abdominal visceral obesity and lower incidences of postoperative complications. The purpose of the present study was to formally compare these different procedures. MethodsFrom 2011 to 2013, 60 patients who met the NIH criteria were recruited and randomly assigned to undergo either laparoscopic Roux-en-Y gastrojejunostomy (n = 30) or LRYGB with a small stomach pouch (n = 30). All of the patients were followed for 12 months, and pre- and postoperative changes in BMI, waist circumference, fasting plasma glucose (FPG), postprandial plasma glucose (PBG), glycated hemoglobin (HbA1c), homoeostatic model assessment (HOMA-IR), the body fat rate and major complications were recorded. ResultsBoth procedures were successful in reducing HbA1c, FPG, and PBG levels and HOMA-IR scores. However, LRYGB with a small stomach pouch resulted in a greater reduction in FPG, PBG, and HbA1c levels, and HOMA-IR scores compared with Roux-en-Y gastrojejunostomy. In addition, the reductions in BMI, body fat content, waist circumference, and the incidence of postoperative marginal ulcers in the small-stomach-pouch LRYGB were significant. ConclusionsBoth procedures are effective treatments for T2DM patients with BMI<35 kg/m². However, the advantages of resolved abnormal glucose metabolism and abdominal visceral obesity and decreased incidences of surgical complications are more obvious for LRYGB with a small gastric pouch. Potentially, LRYGB with a small gastric pouch is more suitable for Chinese diabetic patients with BMI <35 kg/m².

Iron Deficiency Anemia after Bariatric Surgery

As obesity and bariatric surgery rates continue to increase, anemia will become noticeable problems for this patient population. Preoperative assessment of patients should include a complete hematological work-up, including measurement of iron stores, vitamin B12, and folate. Iron deficiency after bariatric surgery results from both malabsorption and maldigestion of dietary iron. Bariatric bypass surgeries, namely Roux-en-Y gastric bypass (RYGB) and Biliopancreatic diversion-duodenal switch (BPD-DS), exacerbate this problem. Iron deficiency is identified in preoperative and postoperative bariatric patients, particularly in premenstrual women. Decreased acid production in the small gastric pouch impedes the solubilization of ferric iron and ultimately absorption of the reduced form, ferrous iron, in the duodenum. Postoperative changes in eating habits and food preferences may also contribute to development of iron deficiency after RYGB. Menstruating women are at high risk for iron deficiency and anemia after bypass surgery. Postoperatively, oral iron supplementation in addition to a multivitamin should be prescribed for RYGB patients. Pregnant women who have undergone bariatric surgery may also be at high risk of developing iron deficiency, and these patients may require aggressive oral iron supplementation. Once iron deficiency has developed, however, it may show refractory to treatment. In some cases, intravenous iron, blood transfusions, and surgical interventions to stop sources of bleeding may be required. Bariatric surgery patients call for lifelong follow-up of hematological and iron parameters, since iron deficiency and anemia may develop years after surgery.

Management of complications after laparoscopic adjustable gastric banding

Objective To investigate the management of complications after laparoscopic adjustable gastric banding (LAGB).Methods The clinical data of 83 obese patients who were treated by LAGB at the Nankai Hospital from September 2005 to June 2011 were retrospectively analyzed.The complications after LAGB were analyzed.The adjustable gastric band was installed under laparoscope so as to form a small gastric pouch with a volume ranged between 20-30 ml.The water pump was fixed in the rectus abdominis anterior sheath under the appendix ensiformis.The gastric band was adjusted according to the changes of the body weight,symptoms after diet and results of imaging examination of upper gastrointestinal tract.Patients were followed up via out-patient examination and phone call till July 2013.Results The incidence of complications of the 83 patients was 44.6％ (37/83).Six patients had short-term complications and 31 patients had long-term complications.The short-term complication mainly presented as post-prandial vomiting.The symptoms of 5 patients were relieved by changing of eating habit.The condition of 1 patient was severe,and the symptom was relieved 5 days later after fasting and nutritional support.For the 31 patients with long-term complications,25 were complicated with band erosion into gastric lumen via gastric wall (6 patients were complicated with infection of the water pump site),and they were cured by removal of band laparoscopicly.Ten patients were complicated with water pump-related complications,including 6 with infection of the water pump site and 4 with pump migration.The water pumps of the 4 patients with pump migration were surgically removed.Two patients had band slipping to the stomach.The band was restored to the original place after removing the liquid from the band and reducing the food intake,and then the position of the band in 1 patient was restored to normal,and no change was observed in another patient,and the band was removed laparoscopicly.Conclusions The incidence of complications after LAGB is high,and it increases as the time passes by.Most of the long-term complications after LAGB need to be treated by reoperation. Key words: Obesity; Laparoscopy ; Adjustable gastric banding; Complications ; Treatment