Glycemic Control Predicts Severity of Hepatocyte Ballooning and Hepatic Fibrosis in Nonalcoholic Fatty Liver Disease.

BACKGROUND AND AIMS: Whether glycemic control, as opposed to diabetes status, is associated with the severity of NAFLD is open for study. We aimed to evaluate whether degree of glycemic control in the years preceding liver biopsy predicts the histological severity of NASH. APPROACH AND RESULTS: Using the Duke NAFLD Clinical Database, we examined patients with biopsy-proven NAFLD/NASH (n = 713) and the association of liver injury with glycemic control as measured by hemoglobin A1c (HbA1c). The study cohort was predominantly female (59%) and White (84%) with median (interquartile range) age of 50 (42, 58) years; 49% had diabetes (n = 348). Generalized linear regression models adjusted for age, sex, race, diabetes, body mass index, and hyperlipidemia were used to assess the association between mean HbA1c over the year preceding liver biopsy and severity of histological features of NAFLD/NASH. Histological features were graded and staged according to the NASH Clinical Research Network system. Group-based trajectory analysis was used to examine patients with at least three HbA1c (n = 298) measures over 5 years preceding clinically indicated liver biopsy. Higher mean HbA1c was associated with higher grade of steatosis and ballooned hepatocytes, but not lobular inflammation. Every 1% increase in mean HbA1c was associated with 15% higher odds of increased fibrosis stage (OR, 1.15; 95% CI, 1.01, 1.31). As compared with good glycemic control, moderate control was significantly associated with increased severity of ballooned hepatocytes (OR, 1.74; 95% CI, 1.01, 3.01; P = 0.048) and hepatic fibrosis (HF; OR, 4.59; 95% CI, 2.33, 9.06; P < 0.01). CONCLUSIONS: Glycemic control predicts severity of ballooned hepatocytes and HF in NAFLD/NASH, and thus optimizing glycemic control may be a means of modifying risk of NASH-related fibrosis progression.

Racial Disparities in Bariatric Surgery Complications and Mortality Using the MBSAQIP Data Registry.

BACKGROUND: Racial disparities in postoperative complications have been demonstrated in bariatric surgery, yet the relationship of race to complication severity is unknown. STUDY DESIGN: Adult laparoscopic primary bariatric procedures were queried from the 2015 and 2016 MBSAQIP registry. Adjusted logistic and multinomial regressions were used to examine the relationships between race and 30-day complications categorized by the Clavien-Dindo grading system. RESULTS: A total of 212,970 patients were included in the regression analyses. For Black patients, readmissions were higher (OR = 1.39, p < 0.0001) and the odds of a Grade 1, 3, 4, or 5 complication were increased compared with White patients (OR = 1.21, p < 0.0001; OR = 1.21, p < 0.0001; OR = 1.22, p = 0.01; and OR = 1.43, p = 0.04) respectively. The odds of a Grade 3 complication for Hispanic patients were higher compared with White patients (OR = 1.59, p < 0.0001). CONCLUSION: Black patients have higher odds of readmission and multiple grades of complications (including death) compared with White patients. Hispanic patients have higher odds of a Grade 3 complication compared with White patients. No significant differences were found with other races. Specific causes of these disparities are beyond the limitations of the dataset and stand as a topic for future inquiry.

Remission of type 2 diabetes after Roux-en-Y gastric bypass is associated with greater weight loss.

BACKGROUND: Physiologic studies in rodents and preliminary human studies have suggested that Roux-en-Y gastric bypass (RYGB) improves type 2 diabetes mellitus (T2DM) by way of metabolic changes, long before the bariatric or weight loss effects occur, leading to the concept of "metabolic surgery." To test this hypothesis, we studied patients with insulin-dependent T2DM who underwent RYGB to determine whether T2DM remission in this treatment-resistant subgroup occurred independent of weight loss. METHODS: Of all the patients undergoing RYGB from 2000 to 2006 (n = 1546) with >/=12 months of follow-up, 318 had T2DM (21%), and 75 (24%) of these were insulin dependent. Of the 75 patients, 4 were found to have T1DM (5.3%) and were excluded, leaving a study population of 71 patients. The patients who achieved remission, defined as a cessation of diabetic medications with a hemoglobin A1c level of <7%, were compared with those who did not achieve remission. Statistical significance was set at P < .05, using the Student t test, chi-square test, and logistic regression analysis, as appropriate. RESULTS: After RYGB, all 71 patients with insulin-dependent T2DM had achieved a reduction in the dose and/or number of medications at 29.6 +/- 17.0 months. Of these 71 patients, 35 (49%) demonstrated a remission of T2DM. The preoperative body mass index, age, number of medications, and hemoglobin A1c level did not differentiate between those who attained remission and those who still required diabetic medication. From the multivariate analysis, the significant factors associated with remission were the preoperative insulin dose and the percentage of excess weight loss. The percentage of excess weight loss was greater in the remission patients as early as 3 months postoperatively (P = .04) and also at 6, 12, 18, and 24 months. CONCLUSION: RYGB uniformly improved the medication requirements of patients with insulin-dependent T2DM. Although physiologic mechanisms likely contributed, early rapid weight loss was associated with the remission of T2DM.

Preoperative weight gain does not predict failure of weight loss or co-morbidity resolution of laparoscopic Roux-en-Y gastric bypass for morbid obesity.

BACKGROUND: Success with preoperative weight loss (PWL) is often mandated by the bariatric team to assess patient compliance and has been suggested to correlate with improved postoperative weight loss outcomes. METHODS: We performed a retrospective analysis of 1629 consecutive patients undergoing laparoscopic Roux-en-Y gastric bypass at Duke University Medical Center. Patients with a preoperative weight gain (PWG) or loss of > or =10 lb were compared. Patients with <12 months of follow-up were excluded. RESULTS: We found no difference between the 2 groups (PWG, n = 115, PWL, n = 88) with regard to age, gender, race, preoperative body mass index, presence of co-morbidities, or interval between the initial program-entry weight and surgery (149 versus 141 d). No difference was found in the percentage of excess weight loss (EWL) at 12 months, when calculated using the patient's immediate preoperative weight (PWG group, 63.5% EWL versus PWL group, 63.9% EWL, P = NS). If the %EWL was calculated using the initial program-entry weight, the PWL did confer a transient postoperative weight loss advantage; however, this did not persist past 24 months postoperatively. At both 12 and 24 months, the resolution rates of diabetes (82% versus 83% at 2 yr; P = NS), hypertension (48% versus 42% at 2 yr, P = NS), and continuous positive airway pressure discontinuation (87% versus 87% at 1 yr, P = NS) were equivalent. No differences in perioperative complications or conversion rates were detected. The operative time was slightly longer for the PWG group (119.7 versus 104.9 min, P = .02). CONCLUSION: The results of our study have shown that weight loss before laparoscopic Roux-en-Y gastric bypass is not mandatory and might deter patients from considering weight loss surgery. Laparoscopic Roux-en-Y gastric bypass can be performed safely with equivalent co-morbidity resolution and %EWL regardless of PWG or PWL.

New developments in surgery: Natural Orifice Transluminal Endoscopic Surgery (NOTES).

Natural orifice transluminal endoscopic surgery refers to the method of accessing the abdominal cavity through a natural orifice under endoscopic visualization. Since its introduction in 2004, numerous reports have been published describing different surgical interventions. Recently, a group of expert laparoscopic surgeons and endoscopists outlined the limitations of this approach and issued recommendations for progress toward human trials. Herein we review the published data and propose a series of questions to be considered for future investigations. We also address the controversy involved in the incorporation of this new technology into surgical practice.

Expectant management of the asymptomatic gallbladder at Roux-en-Y gastric bypass.

BACKGROUND: Because of the claim that about one third of patients develop gallstones within 6 months of Roux-en-Y gastric bypass (RYGB), many have recommended preoperative ultrasonography for all patients and/or prophylactic cholecystectomy (CCY), or ursodiol to prevent stone formation. METHODS: Prospective data were collected from 1391 consecutive patients followed up for > or = 6 months after RYGB (2000-2005) to assess our practice of not routinely removing the gallbladder and not administering ursodiol. RESULTS: Of the 1391 patients, 334 (24%) had undergone CCY before RYGB. Of the remaining 1057 asymptomatic patients, 516 had undergone preoperative ultrasonography. Stones were identified in 99 (19%), sludge in 5 (0.97%), and polyps in 6 (1.1%). Of the 984 patients with gallbladders left in situ after RYGB, only 80 (8.1%) became symptomatic and required delayed CCY. The average excess weight loss at the delayed CCY was 65%. The risk of undergoing delayed CCY seemed to be restricted to the first 29 months after RYGB, because none of 165 patients followed up for 30-144 months required CCY. CONCLUSION: Although CCY should be performed whenever symptoms mandate, the value of routine preoperative ultrasonography and CCY was not apparent from the results of our study. Waiting until symptoms develop might simplify the operative procedure because of the significant weight loss that should have occurred after RYGB. Using an expectant approach, most patients undergoing RYGB will not require CCY.

Patient Selection and Surgical Management of High-Risk Patients with Morbid Obesity.

Bariatric surgery is the most effective way to improve comorbidities related to obesity. Since the introduction of minimally invasive laparoscopic surgery in the bariatric surgery techniques, the number of procedures has increased substantially; advances in techniques and the transition from open to minimally invasive procedures have decreased morbidity and mortality. Multidisciplinary teams in charge of the operative planning, surgical act, and postoperative recovery are determinant in the success of the management of high-risk bariatric patients; careful identification and preoperative management of these higher-risk patients is crucial in decreasing complications after weight loss surgery.

Effectiveness of laparoscopic Roux-en-Y gastric bypass on obese class I type 2 diabetes mellitus patients.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) can dramatically improve type 2 diabetes mellitus (T2D) in obese class II and III patients. There is increasing evidence that shows bariatric surgery can also ameliorate T2D in patients with BMI between 30 kg/m(2) and 35 kg/m(2) (obese class I). OBJECTIVE: To compare the effectiveness of LRYGB on T2D in obese class I patients with that of obese class II and III T2D patients. SETTING: University Hospital, China METHODS: A prospective study was performed in the authors' center from March 2010 to July 2011. Forty-two consecutive obese patients were included in the study. Anthropometric and metabolism parameters were compared between obese class II and III patients and obese class I patients before and after LRYGB. RESULTS: No patients were lost to follow up. After 36 months, metabolic parameters significantly improved in both groups. Partial remission rates between the 2 groups at each time point (12 months, 24 months, and 36 months) were comparable. Obese class II and III patients had higher complete remission rates at 12 months and 24 months, but no difference was observed at 36 months. CONCLUSION: Both obese class II and III patients and obese class I T2D patients showed significant improvement in multiple parameters after LRYGB. Obese class II and III patients had a higher complete remission rate than obese class I patients. Standardized remission criteria are needed to make outcomes form different centers comparable. Large prospective studies are needed and long-term outcomes have to be observed to better evaluate effectiveness of LRYGB on obese class I T2D patients.

Patient predictors of follow-up care attendance in Roux-en-Y gastric bypass patients.

BACKGROUND: Multidisciplinary care after bariatric surgery is important for long-term safety and optimal weight loss, yet many patients do not attend follow-up appointments. We sought to identify demographic, psychosocial, and weight-related variables that were associated with medical and behavioral health appointment attendance after bariatric surgery. METHODS: A retrospective chart review was conducted with consecutive patients (n=538) obtaining first-time Roux-en-Y gastric bypass surgery between August 2009 and August 2010. Demographic and psychosocial data were compared between high (>50%) and low (≤50%) medical appointment attendees and high (>50%) and low (≤50%) behavioral health group attendees in their first postoperative year. Percentage excess weight loss at 6 months after surgery was evaluated as a predictor of 12-month appointment attendance. RESULTS: High medical appointment attendees were more likely to be older, be Caucasian, and have lower phobic anxiety than low medical appointment attendees. High behavioral health attendees had shorter travel distance to the clinic and lower levels of hostility, anxiety, and phobic anxiety compared with low attendees. In multivariate analyses, race/ethnicity and phobic anxiety remained significant predictors of medical attendance, while travel distance to clinic predicted behavioral health attendance. Six-month percent excess weight loss predicted medical appointment attendance at 12 months. CONCLUSION: The identified predictors of poor attendance at medical and behavioral bariatric surgery follow-up appointments should inform efforts to increase follow-up and improve surgical outcomes.

Evidence for a metabolic mechanism in the improvement of type 2 diabetes after sleeve gastrectomy in a rodent model.

BACKGROUND: Sleeve gastrectomy (SG) is at least as effective at producing weight loss as gastric banding but may be superior in producing remission of type 2 diabetes mellitus (T2DM). The objective of this study was to elucidate mechanisms of diabetes improvement in SG beyond caloric restriction. We studied SG in Zucker Diabetic Fatty (ZDF) rats. METHODS: Twenty-eight ZDF rats were randomly assigned to 1 of 3 groups: SG, sham-operated ad lib fed (AL), or sham-operated pair fed (PF). SG and AL rats had free access to food. PF rats were fed the average daily intake of the SG group. Comparisons of caloric intake, weight loss, intraperitoneal glucose tolerance testing (IPGTT), insulin, and total ghrelin were performed preoperatively and at postoperative days 10, 20, and 30. Differences between means were evaluated using one-way ANOVA and the paired t test as appropriate. RESULTS: Postoperatively, SG rats had lower daily caloric intake than the AL controls (78.3±10.5 kcal versus 104.7±4.6 kcal). Both SG and PF groups had sustained weight loss (-5.3±3.8 g and -27.5±2.6 g, respectively); however, SG rats had significantly lower AUC for glucose after IPGTT than both controls. This is in contrast to AL controls that experienced weight gain (34.1±4.7 g) and increases in AUC for glucose after IPGTT. CONCLUSION: Although SG is considered a restrictive procedure, there is evidence for a metabolic effect by virtue of decreased insulin resistance, which may not be reproduced by PF controls.

Single-incision laparoscopic right colectomy: an efficient technique.

PURPOSE: Laparoscopic right colectomy has an established patient benefit. We sought to demonstrate that a single-incision approach to laparoscopic right colectomy is safe, reproducible, and efficient. METHODS: Photographs were acquired from cases to depict a step-by-step approach. We collected operative, pathologic, and postoperative outcomes from 8 patients who underwent a single-incision laparoscopic right colectomy. RESULTS: There were no intraoperative complications nor deaths and 3 complications postoperatively. The average return of bowel function and length of stay was 3 and 5 days, respectively. Pathologic assessment revealed negative margins and an average of 17 lymph nodes harvested from the specimens. CONCLUSIONS: Single-incision laparoscopic right colectomy is an evolving technique and likely to supplant conventional laparoscopic colectomy because of its equivalent and reproducible outcomes and the ease of the procedure. We depict our preferred method and review the current literature of single-incision right colectomy.

Algorithm to diagnose etiology of hypoglycemia after Roux-en-Y gastric bypass for morbid obesity: case series and review of the literature.

BACKGROUND: Gastric bypass is a proven treatment option for weight loss and the reduction of medical co-morbid conditions in the obese population. Severe refractory and/or recurrent hypoglycemia can occur, especially in postoperative patients who do not comply with the guidelines for oral glucose consumption. In a very small number of patients, the cause is not dietary indiscretions but, instead, factitious insulin administration or nesidioblastosis. The optimal evaluation and management for these diagnoses is not completely lucid yet important for bariatric surgeons and physicians alike to be familiar. Our objectives were to review the appropriate evaluation and treatment options for etiologies of hypoglycemia after gastric bypass and to create an algorithm that biochemically assesses the etiology of hypoglycemia. The setting was a university hospital in the United States. METHODS: We present the cases of 3 patients who developed symptomatic hypoglycemia from distinct etiologies after laparoscopic Roux-en-Y gastric bypass. We also reviewed the current data regarding diagnosis and treatment. RESULTS: Each patient's evaluation and management is elaborated in detail. We propose a novel algorithm for the biochemical evaluation of hypoglycemia after gastric bypass according to our experience and the review of the literature. CONCLUSION: Most cases of symptomatic hypoglycemia that develop in gastric bypass patients are associated with dietary indiscretions. However, a small subset of patients can develop refractory, recurrent, hyperinsulinemic hypoglycemia from factitious insulin administration or nesidioblastosis.

In vivo assessment of an absorbable and nonabsorbable knotless barbed suture for laparoscopic single-layer enterotomy closure: a clinical and biomechanical comparison against nonbarbed suture.

BACKGROUND: Laparoscopic intracorporeal suturing and knot tying is a complex skill that requires repeated deliberate practice to master. A novel self-anchoring barbed suture material that does not require knot tying can eliminate knot failure and reduce operating time. The goal of this study was to compare the in vivo efficacy of two novel knotless barbed sutures (absorbable and nonabsorbable) for use with the Endo Stitch™ device (Covidien), against conventional suture (Endo Stitch device with Polysorb™ suture; Covidien) for laparoscopic closure of viscerotomies in canine stomach, jejunum, and colon. METHODS: Following Institutional Animal Care and Use Committee approval, 24 dogs underwent laparoscopic creation of 25-mm viscerotomies, three each in the stomach, jejunum, and colon. All viscerotomies were closed with the Endo Stitch device using the absorbable or nonabsorbable barbed suture or conventional suture. Closure time for each viscerotomy was recorded. Animals were survived for 3, 10, or 21 days, at which point the viscerotomies were burst-pressure tested. RESULTS: The closure leak rate in this study with 216 total viscerotomy closures was 0%. There was no statistically significant difference in mean burst pressure between viscerotomies closed with barbed suture versus control suture at any of the survival intervals. Barbed suture with the Endo Stitch device was associated with statistically significantly faster closure times than the control suture with the Endo Stitch device (P<.05), resulting in a reduction in closure time between 35% and 42%. CONCLUSION: This study reports the first use of barbed suture for the Endo Stitch device in laparoscopic gastrointestinal closure. The barbed suture for the Endo Stitch device is effective for laparoscopic single-layer gastrointestinal closure and is associated with a significantly reduced closure time.