Short-Term Outcomes of Self-Expandable Metallic Stent versus Decompression Tube for Malignant Colorectal Obstruction: A Meta-Analysis of Clinical Data.

Purpose: To compare the short-term outcomes between self-expandable metallic stent (SEMS) and decompression tubes (DT) for malignant colorectal obstruction. Methods: A comprehensive literature search was performed from inception to 2018/12/6 covering Pubmed, Embase, and Cochrane library. Methodological assessments of eligible studies were performed by using Newcastle-Ottawa Scale (NOS). The Revman software (version 5.3) was used in our statistical analysis. Results: Totally 7 cohort studies were enrolled in our meta-analysis. All the 7 eligible studies proved to be high quality according to the NOS scale. Patients receiving SEMS had higher clinical success rates, higher laparoscopic surgery rates, and higher primary anastomosis rates compared with patients receiving DT. Conclusions: Based on evidence from eastern countries, SEMS placement is an effective procedure that treats malignant colorectal obstruction. Compared with DT placement, patients receiving SEMS may benefit from higher clinical success rates, higher laparoscopic surgery rates, and higher primary anastomosis rates.

Is There Necessity for Oversewing the Staple Line During Laparoscopic Sleeve Gastrectomy? An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Background: Laparoscopic sleeve gastrectomy (LSG) has become the current mainstream surgical treatment for obesity. With the development of clinical practice, surgeons realized the associated severity and danger of postoperative bleeding and leakage. Surgeons constantly explore different strategies to reduce the incidence of these complications. By reviewing previous clinical articles on the staple line reinforcement (SLR) in LSG, the conclusions were inconsistent regarding effectiveness. This article aims to discuss effectiveness of oversewing the staple line in LSG. Methods: From the start date of each database to September 27, 2018, a comprehensive search of published articles in English was conducted in PubMed, Embase, Central (Cochrane) databases and Scopus databases. We extracted and analyzed the main results on postoperative bleeding, staple line leakage, hospital stay and operative time of the final included articles. This review was compliant with PRISMA guidelines. Results: Finally, we extracted and analyzed 11 randomized controlled trials (RCTs) which contain 2411 patients (1219 patients as part of the oversewing (OS) group and 1192 patients in the no-oversewing (NOS) group). In the OS group, there were 15 cases (1.23%) of postoperative bleeding, and 8 cases (0.66%) of postoperative leakage. While in the NOS group, 35 patients (2.94%) had postoperative bleeding and 21 patients (1.76%) had postoperative leakage. By comparing and analyzing the OS group and the NOS group, the risk ratio (RR) for postoperative bleeding was 0.48 (95% confidence interval [CI], 0.27-0.83 p = 0.447). In addition, the RR for postoperative leakage was 0.44 (95% CI, 0.21-0.89 p = 0.835). The standardized mean difference (SMD) for hospital stay was -0.10 (95% CI, -0.25 to 0.04 p = 0.061) and 2.26 for operative time (95%CI, 0.82-3.69 p = 0.000). Conclusion: This study suggested that oversewing the staple line during LSG has a significant clinical value: it decreased the incidence of postoperative bleeding, postoperative leakage; moreover, it also significantly prolonged the operative time and but did not change hospital stay. More high-quality and large sample RCTs are expected to get more accurate results.

Clinical Outcomes of Sleeve Gastrectomy Versus Roux-En-Y Gastric Bypass After Failed Adjustable Gastric Banding.

BACKGROUND: Over recent decades, laparoscopic adjustable gastric banding (LAGB) has been among the most common bariatric surgeries. Nowadays, many patients require revision surgery due to insufficient weight loss and band-related complications. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the two most common revision surgeries for failed LAGB, but the conclusions about their efficacy and safety have been inconsistent. This meta-analysis aimed to review the clinical outcomes of SG and RYGB after failed LAGB. METHODS: In accordance with the PRISMA guidelines, the PubMed, Embase, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were systematically searched for articles that had studied the efficacy and safety of SG and RYGB. The most appropriate effects model was chosen based on the heterogeneity of the articles included in this meta-analysis. Statistical analysis was conducted using Stata 14.0. RESULTS: Of 586 articles that were retrieved, 16 articles which examined 2141 SG and 2990 RYGB patients met the inclusion criteria. The patients in RYGB groups showed increased percent excess weight loss (%EWL) at 12 and 24 months after revision surgery but no statistically significant change was found about %EWL after 3, 6, or 36 months. In addition, RYGB was associated with a higher rate of complications, interventions, and readmission in addition to being of more operative time. CONCLUSIONS: This review suggested that RYGB was more effective at demonstrating weight loss after 12 and 24 months, but comparisons of the long-term efficacy of RYGB with that of SG remain inconclusive. In addition, RYGB was accompanied by a greater number of post-operative complications, interventions, and readmissions. Thus, surgeons should consider the overall status of the patients and their comorbidities as crucial factors when selecting a form of revision surgery. Additional high-quality randomized controlled studies are required to further compare the efficacy and safety of these treatments with longer follow-up times.

Differential composition of gut microbiota among healthy volunteers, morbidly obese patients and post-bariatric surgery patients.

The modulation of the gut microbiota was recently deemed one of the mechanisms responsible for the excellent outcomes of bariatric surgery. However, to date, only few studies have assessed this, and they have high heterogeneity. In the present study, next-generation 16S ribosomal DNA amplicon sequencing was used to characterize the gut microbiota of healthy volunteers, as well as patients prior to and after sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). Significant differences in α diversity, ß diversity and species were identified between the different groups/time-points. The results demonstrated excellent outcomes of SG and RYGB. The ß diversity was lower in healthy volunteers compared with that in morbidly obese patients with or without type 2 diabetes mellitus. At 3 months after SG, the α diversity was increased and the ß diversity was decreased. The abundance of certain species changed significantly after SG and RYGB. It was also revealed that the abundance of certain microbes was significantly correlated with the body mass index, fasting blood glucose and glycosylated haemoglobin. It may be concluded that bariatric surgery may cause obvious alterations in the gut microbiota and compared with healthy volunteers and obese patients without bariatric surgery, the microbiota composition of post-bariatric surgery has unique characteristics. However, studies with a larger cohort and longer follow-up may be required to confirm these results.

Comparison of anastomotic leakage rate and reoperation rate between transanal tube placement and defunctioning stoma after anterior resection: A network meta-analysis of clinical data.

OBJECTIVE: Defunctioning stoma (DS) and transanal tube (TT) placement have all been reported to be effective procedures to prevent anastomotic leakage after anterior resection. However, there are few studies that directly compare the 2 procedures, and those that do are unclear. METHODS: We performed a systematic literature search from the databases of Pubmed, Embase and Cochrane library. We limited the publication date from 2008/01/01 to 2018/07/29. The bias risk of eligible randomized controlled trials and cohort studies were assessed by Cochrane Collaboration's tool and Newcastle-Ottawa Scale, respectively. The direct meta-analysis was performed by RevMan 5.3 software. The network graph, inconsistency test and comparison-adjusted funnel plot were performed by the Stata 14.0 software. The indirect meta-analysis and rank probabilities were performed by GeMTC R package. RESULTS: 6 randomized controlled trials and 26 cohort studies were included in our meta-analysis. All eligible studies were assessed as low risk of bias. The anastomotic leakage rate and reoperation rate was lower in the patients receiving DS or TT placement than patients with non-protection. DS shared similar anastomotic leakage rate with TT. However, the reoperation rate was significantly lower in patients receiving DS than patients receiving TT. CONCLUSION: Both TT and DS were protective factors for anastomotic leakage after anterior resection for rectal cancer. DS reduced severity of anastomotic leakage in a more effective way than TT placement. However, we still suggested the routing use of TT for decreasing the risk of anastomotic leakage in anterior resection because it was cheaper and technically simpler.

Outcomes of transanal tube placement in anterior resection: A meta-analysis and systematic review.

BACKGROUND: In recent years, transanal tube placement was reported to be an effective procedure preventing anastomotic leakage after anterior resection of rectal cancer. However, this procedure is still controversial owing to inconsistent results found in previous studies. METHODS: A comprehensive literature search was performed using Pubmed, Embase, Cochrane library from the databases inception up until June 21, 2018. The methodological quality of randomized controlled trials and cohort studies were evaluated by Cochrane Collaboration's tool for assessing risk of bias and Newcastle-Ottawa Scale, respectively. Statistical analysis was performed using the RevMan 5.3 software. RESULTS: 1 randomized controlled trial and 9 cohort studies were included in our meta-analysis. The randomized controlled trial was proven to be low risk according to the Cochrane Collaboration's tool for assessing risk of bias. All of the cohort studies proved a high quality according to the Newcastle-Ottawa Scale. Patients in transanal tube group had more disadvantageous preoperative demographic characteristics than patients in non-transanal tube group. The anastomotic leak rate was lower in the transanal tube group. Patients in the transanal tube group tended to have lower reoperation rates and shorter hospital stays compared with patients in the non-transanal tube group. CONCLUSION: Despite various unfavorable preoperative characteristics, anastomotic leakage after anterior resection was lower in patients who received transanal tube placement compared with the control group. Transanal tube placement may be an alternative procedure of defunctioning stoma. A large sample size, multicenter RCT was needed to prove our results.

Outcomes of Mini vs Roux-en-Y gastric bypass: A meta-analysis and systematic review.

BACKGROUND: Mini gastric bypass has been proved to be capable of achieving excellent metabolic results by numerous published studies. Compared to Roux-en-Y gastric bypass, mini gastric bypass is a technically simpler and reversible procedure. However, comparative outcomes of the effectiveness between Mini gastric bypass and Roux-en-Y gastric bypass remain unclear. METHODS: A systematic literature search was performed in Pubmed, Embase, Cochrane library from inception to February 9, 2018. For assessment of method quality, NOS (Newcastle-Ottawa Scale) and Cochrane Collaboration's tool for assessing risk of bias were used for cohort study and randomized controlled trials, respectively. The meta-analysis was performed by RevMan 5.3 software. RESULTS: 10 cohort studies and 1 randomized controlled trial was included in our meta-analysis. The method quality of the 10 cohort studies was proved as high quality according to the Newcastle-Ottawa Scale. The randomized controlled trial was proved to have a low risk of bias according to Cochrane Collaboration's assessment. Patients receiving mini-gastric bypass had multiple advantageous indexes as compared with patients receiving Roux-en-Y gastric bypass. Examples include: a higher 1-year EWL% (P < 0.05), higher 2-year EWL% (P < 0.05), higher type 2 diabetes mellitus remission rate, as well as a shorter operation time (P < 0.05). No significant statistical difference was observed in hypertension remission rate, mortality, leakage rate, GERD rate, or hospital stay between mini gastric bypass and Roux-en-Y gastric bypass. CONCLUSION: Mini gastric bypass seems to be a simpler procedure with a better weight reduction effect. This seems to also be the case regarding remission rates of type 2 diabetes mellitus when using Mini gastric bypass in comparison to Roux-en-Y gastric bypass. A small sample size and biased data may have influenced the stability of our results. In light of this, surgeons should treat our results in a conservative way. Larger sample size and multi-center randomized control trials are needed to compare the effectiveness and safety between mini-gastric bypass and Roux-en-Y gastric bypass.

Comparison of safety and effectiveness between laparoscopic mini-gastric bypass and laparoscopic sleeve gastrectomy: A meta-analysis and systematic review.

BACKGROUND: The laparoscopic mini-gastric bypass is a newly emerged surgical procedure in recent years. Owe to safe and simple process and effective outcomes, laparoscopic mini-gastric bypass has quickly become one of the most popular procedures in some countries. The safety and effectiveness of laparoscopic mini-gastric bypass versus laparoscopic sleeve gastrectomy remain unclear. METHODS: A systematic literature search was performed in PubMed, Embase, Cochrane library from inception to May 20, 2017. The methodological quality of Randomized Controlled Trials and non-Randomized Controlled Trials were, respectively, assessed by Cochrane Collaboration's tool for assessing risk of bias and Newcastle-Ottawa scale. The meta-analysis was performed by RevMan 5.3 software. RESULTS: Patients receiving mini-gastric bypass had a lot of advantageous indexes than patients receiving sleeve gastrectomy, such as higher 1-year EWL% (excess weight loss), higher 5-year EWL%, higher T2DM remission rate, higher hypertension remission rate, higher obstructive sleep apnea (OSA) remission rate, lower osteoarthritis remission rate, lower leakage rate, lower overall late complications rate, higher ulcer rate, lower gastroesophageal reflux disease (GERD) rate, shorter hospital stay and lower revision rate. No significant statistical difference was observed on overall early complications rate, bleed rate, vomiting rate, anemia rate, and operation time between mini-gastric bypass and sleeve gastrectomy. CONCLUSION: Mini-gastric bypass is a simpler, safer, and more effective bariatric procedure than laparoscopic sleeve gastrectomy. Due to the biased data, small sample size and short follow-up time, our results may be unreliable. Large sample and multicenter RCT is needed to compare the effectiveness and safety between mini-gastric bypass and sleeve gastrectomy. Future study should also focus on bile reflux, remnant gastric cancer, and long term effectiveness of mini-gastric bypass.

Application of side-to-side anastomosis of the lesser curvature of stomach and jejunum in gastric bypass.

AIM: To evaluate the feasibility of side-to-side anastomosis of the lesser curvature of stomach and jejunum in laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: Seventy-seven patients received side-to-side anastomosis of the lesser curvature of stomach and jejunum by utilization of linear stapler in LRYGB from April 2012 to July 2015 were retrospectively analyzed. RESULTS: All patients were successfully completed laparoscopic gastric bypass with the side-to-side anastomosis of the lesser curvature of stomach and jejunum. No patient was switched to laparotomy during operation. No early complications including gastrointestinal anastomotic bleeding, fistula, obstruction, deep vein thrombosis, incision infections, intra-abdominal hernia complications were found. One patient complicated with stricture of gastrojejunal anastomosis (1.3%) and six patients complicated with incomplete intestinal obstruction (7.8%). BMI and HbA1c determined at 3, 6, 12, 24 mo during follow up period were significantly reduced compared with preoperative baselines respectively. The percentage of patients who maintain HbA1c (%) < 6.5% without taking antidiabetic drugs reached to 61.0%, 63.6%, 75.0%, and 63.6% respectively. The outcome parameters of concomitant diseases were significantly improved too. CONCLUSION: Present surgery is a safety and feasibility procedure. It is effective to lighten the body weight of patients and improve type 2 diabetes and related complications.

Effect of Roux-en-Y gastric bypass surgery on intestinal Akkermansia muciniphila.

AIM: To investigated changes in intestinal Akkermansia muciniphila (A. muciniphila) and explored the mechanism underlying the therapeutic effects of Roux-en-Y gastric bypass (RYGB) surgery on type 2 diabetes in diabetic Goto-Kakizaki (GK) rats. METHODS: Male diabetic GK rats (n = 12) aged 8 wk were randomly assigned to the surgery group (GK-RYGB) or sham surgery group (GK-Sham) (n = 6 per group), and another 6 male Wistar rats aged 8 wk served as controls (WS-Sham). In the surgery group, RYGB surgery was conducted, and a sham operation was performed in both sham groups. Fasting blood glucose (FBG) levels before and after surgery, fasting levels of serum insulin and serum glucagon-like peptide-1 (GLP-1) and levels 30 min after intragastric injection of glucose, and the amount of A. muciniphila in the stool were determined. Insulin and GLP-1 were measured by enzyme-linked immunosorbent assay, and A. muciniphila were detected by fluorescence-based quantitative polymerase chain reaction. RESULTS: The FBG was improved, and serum GLP-1 and insulin increased significantly (P < 0.05) in the GK-RYGB group after surgery compared to levels before surgery and to levels in the GK-Sham group. Before surgery, the amounts of A. muciniphila in the GK-RYGB and GK-Sham groups were significantly lower than in the WS-Sham group (P < 0.05). After surgery, the amount of A. muciniphila in the GK-RYGB group increased markedly compared to that before surgery and to that in the GK-Sham and WS-Sham groups (P < 0.05). In addition, the A. muciniphila amount was positively related to GLP-1 (r = 0.86, P < 0.05). CONCLUSION: Our results demonstrated RYGB surgery may increase GLP-1 secretion, elevate serum insulin after intragastric injection of glucose, and improve insulin resistance in diabetic GK rats, thereby contributing to a significant reduction in blood glucose. The increased amount of A. muciniphila after RYGB surgery may be related to elevated GLP-1 secretion.

[Application of side to side anastomosis between the lesser curvature of stomach and jejunum in laparoscopic Roux-en-Y gastric bypass].

OBJECTIVE: To evaluate the application of side-to-side anastomosis of the lesser curvature of stomach and jejunum in laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: Clinical data of 29 patients with type 2 diabetes mellitus (T2DM) undergoing side to side anastomosis of the lesser curvature of stomach and jejunum in LRYGB from May 2012 to November 2012 in Department of General Surgery, Beijing Tiantan Hospital, Capital Medical University were analyzed retrospectively. RESULTS: All the procedures were successfully completed without conversion to laparotomy. The side-to-side anastomosis of the lesser curvature of stomach and jejunum avoided the laparoscopic suture. No gastrojejunostomy anastomotic bleeding, fistula, obstruction and other complications occurred after operation and no complications of gastrojejunostomy anastomosis were found during a follow up of 1 to 7 months. CONCLUSIONS: Side-to-side anastomosis of the lesser curvature of stomach and jejunum in LRYGB can manipulate the size of anastomosis accurately and avoid the laparoscopic suturing. It is simple and easy to learn.

A crucial role of nitric oxide in acute lung injury secondary to the acute necrotizing pancreatitis.

To investigate the role of nitric oxide (NO) in acute lung inflammation and injury secondary to acute necrotizing pancreatitis (ANP), 5% sodium taurocholate was retrogradely injected into the biliopancreatic duct of rats to ANP model. These ANP rats were given L-Arginine (L-Arg, 100 mg/kg), L-NAME (10 mg/kg), or their combination by intraperitoneal injection 30 min prior to ANP induction. At 1, 3, 6, and 12 hours after ANP induction, lung NO production, and inducible NO synthase (iNOS) expression were measured. Lung histopathological changes, bronchoalveolar lavage (BAL) protein concentration, proinflammatory mediators tumor necrotic factor alpha (TNF-alpha), and lung tissue myeloperoxidase (MPO) activity were examined. Results showed that NO production and iNOS mRNA expression in alveolar macrophages (AMs) were significantly increased along with significant increases in lung histological abnormalities and BAL proteins in the ANP group, all of which were further enhanced by pretreatment with L-Arg and attenuated by pretreatment with L-NAME, respectively. These markers were slightly attenuated by pretreatment with combination of L-Arg + L-NAME, suggesting that NO is required for initiating the acute lung damage in ANP rats, and also that L-Arg-enhanced lung injury is mediated by its NO generation rather than its direct effect. MPO activity and TNF-alpha expression in lung were upregulated in the ANP rats and further enhanced by pretreatment with L-Arg and attenuated by pretreatment with L-NAME, respectively. These results suggest that overproduction of NO mediated by iNOS in the lung is required for the acute lung inflammation and damage secondary to ANP.