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Video 1XXX.
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BACKGROUND: Food intake is regulated by homeostatic and hedonic systems that interact in a complex neuro-hormonal network. Dysregulation in energy intake can lead to obesity (OB) or anorexia nervosa (AN). However, little is known about the neurohormonal response patterns to food intake in normal weight (NW), OB, and AN. MATERIAL & METHODS: During an ad libitum nutrient drink (Ensure®) test (NDT), participants underwent three pseudo-continuous arterial spin labeling (pCASL) MRI scans. The first scan was performed before starting the NDT after a > 12 h overnight fast (Hunger), the second after reaching maximal fullness (Satiation), and the third 30-min after satiation (postprandial fullness). We measured blood levels of ghrelin, cholecystokinin (CCK), glucagon-like peptide (GLP-1), and peptide YY (PYY) with every pCASL-MRI scan. Semiquantitative cerebral blood flow (CBF) maps in mL/100 gr brain/min were calculated and normalized (nCBF) with the CBF in the frontoparietal white matter. The hypothalamus (HT), nucleus accumbens [NAc] and dorsal striatum [DS] were selected as regions of interest (ROIs). RESULTS: A total of 53 participants, 7 with AN, 17 with NW (body-mass index [BMI] 18.5-24.9 kg/m2 ), and 29 with OB (BMI ≥30 kg/m2 ) completed the study. The NW group had a progressive decrease in all five ROIs during the three stages of food intake (hunger, satiation, and post-prandial fullness). In contrast, participants with OB showed a minimal change from hunger to postprandial fullness in all five ROIs. The AN group had a sustained nCBF in the HT and DS, from hunger to satiation, with a subsequent decrease in nCBF from satiation to postprandial fullness. All three groups had similar hormonal response patterns with a decrease in ghrelin, an increase in GLP-1 and PYY, and no change in CCK. CONCLUSION: Conditions of regulated (NW) and dysregulated (OB and AN) energy intake are associated with distinctive neurohormonal activity patterns in response to hunger, satiation, and postprandial fullness.
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Anorexia Nerviosa , Hambre , Humanos , Hambre/fisiología , Ghrelina , Saciedad/fisiología , Obesidad , Péptido YY , Colecistoquinina , Péptido 1 Similar al Glucagón , Periodo Posprandial/fisiologíaRESUMEN
Endoscopic retrograde cholangiopancreatography (ERCP) is frequently used for diagnosis and therapeutic interventions in recipients of liver transplantation (LT) who develop biliary complications. Post-endoscopic retrograde cholangiopancreatography acute pancreatitis (PEP) is the most common major adverse event after ERCP; however, the frequency of PEP in LT recipients is not well established. We aimed to determine the rate of PEP in this population and to identify its predictors, especially among immunosuppressive agents. We reviewed all ERCP procedures performed in LT recipients after duct-to-duct biliary anastomoses at 2 high-volume transplant centers. Patients who had undergone sphincterotomy or had a surgically altered pancreaticobiliary anatomy before LT were excluded. Electronic medical records and endoscopy databases were used to obtain clinical, endoscopic, and medication data. A multivariate logistic regression analysis was used to determine predictors of PEP in this cohort. In all, 730 ERCP procedures were performed in 301 patients during the study period with an observed PEP rate of 3% (22/730). A univariate analysis revealed an increased risk of PEP with index ERCP after LT [odds ratio (OR) = 4.04, 95% confidence interval (CI) = 1.40-11.65] and in cases with difficult biliary cannulation (OR = 2.89, 95% CI = 1.10-7.65), whereas prednisone use was found to have a protective effect in both univariate (OR = 0.34, 95% CI = 0.14-0.84) and multivariate analyses (OR = 0.22, 95% CI = 0.09-0.57) after adjustments for difficult biliary cannulation and post-LT index ERCP. This retrospective analysis demonstrates that corticosteroid therapy has a protective role in the development of PEP in LT recipients. Further studies are warranted to confirm our findings.
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Corticoesteroides/uso terapéutico , Colangiopancreatografia Retrógrada Endoscópica/efectos adversos , Inmunosupresores/uso terapéutico , Trasplante de Hígado/efectos adversos , Pancreatitis/prevención & control , Prednisona/uso terapéutico , Enfermedad Aguda , Adulto , Anciano , Distribución de Chi-Cuadrado , Femenino , Hospitales de Alto Volumen , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Minnesota , Análisis Multivariante , Oportunidad Relativa , Pancreatitis/diagnóstico , Pancreatitis/etiología , Estudios Retrospectivos , Factores de Riesgo , España , Factores de TiempoRESUMEN
BACKGROUND: Roux-en-Y gastric bypass (RYGB) is a recognized, safe bariatric procedure with minimal complications. Marginal ulceration, however, remains a challenging problem with an incidence of 8-12%. While chronic NSAID use is an established risk factor for ulcer formation, aspirin use itself as a cause for marginal ulceration is still unclear. We aim to compare the rates of marginal ulceration in RYGB with and without aspirin use. METHODS: PubMed, ScienceDirect, Cochrane, Web of Science, and Google Scholar were searched for articles between 2008 and 2021 by two independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). The risk of bias was assessed using Newcastle-Ottawa Scale. Meta-analysis was conducted using a fixed-effect model. RESULTS: From 5324 studies screened, we included 3 studies. Two studies had a low risk of bias, and the other one presented a high risk of bias on the Newcastle-Ottawa Scale. We included 24,770 patients, 1911 with aspirin use and 22,859 without aspirin use. After the meta-analysis, patients who used aspirin had a significantly higher marginal ulceration rate than those who did not (OR = 1.33 [95% CI 1.08 to 1.63], P < .002; I2 = 39%). CONCLUSIONS: Aspirin use is associated with increased rates of marginal ulceration after RYGB.
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Derivación Gástrica , Obesidad Mórbida , Humanos , Derivación Gástrica/efectos adversos , Derivación Gástrica/métodos , Úlcera , Obesidad Mórbida/cirugía , Aspirina/efectos adversos , Factores de Riesgo , Estudios RetrospectivosRESUMEN
INTRODUCTION: Gastrojejunal anastomosis (GJA) dilation is an independent predictor of weight regain (WR) after Roux-en-Y gastric bypass (RYGB). However, the role of planimetric measurements in this context remains unknown. METHODS: This is a retrospective cohort study including adult RYGB patients who underwent a diagnostic endoscopy with Endoflip assessment of the GJA. We excluded patients in the early postoperative period and those with abnormal endoscopic findings (marginal ulcers and gastro-gastric fistulas). RESULTS: Thirty-four patients were initially included. Endoscopic GJA diameter had a moderate positive correlation with WR (r=+0.438, p=0.011). However, after excluding the 7 patients with GJA> 30 mm, there was no significant correlation. There was a moderate agreement between the EndoFLIP-GJA diameter at 60mL and endoscopic diameter (ICC=0.576, p=0.049). The distensibility index (DI) showed a consistent moderate negative correlation with WR. Considering the maximum DI at 40 ml, we found a cutoff of DI = 7 mm2/mmHg that split the sample in two significantly different populations in terms of WR (67.4% vs. 43.2%, p=0.04). CONCLUSION: Visual estimation of the GJA diameter correlates with EndoFLIP at 60mL. In the subset of patients with GJA ≤ 30 mm, more distensible GJAs are associated with lower rates of WR. Larger studies are needed to confirm this correlation and to validate its utility for clinical management.
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Derivación Gástrica , Obesidad Mórbida , Adulto , Humanos , Obesidad Mórbida/cirugía , Aumento de Peso , Estudios Retrospectivos , Endoscopía , Reoperación , Anastomosis en-Y de Roux , Resultado del TratamientoRESUMEN
BACKGROUND: Gastrojejunal (GJ) anastomotic stenosis is a well-described complication after Roux-en-Y gastric bypass (RYGB); however, its impact on weight loss outcomes is not well elucidated. METHODS: We performed a retrospective cohort study of adult patients who underwent RYGB at our institution between 2008 and 2020. Propensity score matching was used to match 30 patients who developed GJ stenosis within the first 30 days post-RYGB with 120 control patients who did not develop this outcome. Short and long-term complications and mean percentage of total body weight loss (TWL) were recorded at 3 months, 6 months, 1 year, 2 years, 3 to 5 years, and 5 to 10 years postoperatively. Hierarchical linear regression modeling was used to analyze the association between early GJ stenosis and the mean percentage of TWL. RESULTS: Patients who developed early GJ stenosis had a 13.6% increase in the mean percentage of TWL when compared with controls in the hierarchical linear model [ P < 0.001 (95% CI: 5.7; 21.5)]. These patients were also more likely to present to an intravenous infusion center (70% vs 4%; P < 0.01), require readmission within 30 days (16.7% vs 2.5%; P < 0.01), and/or develop an internal hernia (23.3% vs 5.0%) postoperatively. CONCLUSIONS: Patients who develop early GJ stenosis after RYGB have a greater degree of long-term weight loss compared with patients who do not develop this complication. Although our findings support the key contribution that restrictive mechanisms play in maintaining weight loss after RYGB, GJ stenosis remains a complication associated with significant morbidity.
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Derivación Gástrica , Obesidad Mórbida , Adulto , Humanos , Derivación Gástrica/efectos adversos , Obesidad Mórbida/cirugía , Obesidad Mórbida/complicaciones , Estudios Retrospectivos , Constricción Patológica/etiología , Pérdida de Peso , Índice de Masa Corporal , Resultado del TratamientoRESUMEN
INTRODUCTION: Severe adhesions in patients with previous abdominal operations may lead to a more challenging subsequent bariatric surgery [1, 2]. In this context, sleeve gastrectomy (SG) is the preferred weight loss surgery since it solely involves stomach resection (without bowel involvement) in one abdominal compartment. Additionally, SG has lower complication rates and a shorter operative time than other bariatric procedures [3, 4]. In this paper, we present a multimedia video of the management of a pancreatic leak after SG in a patient with multiple previous abdominal surgeries. MATERIALS AND METHODS: A 40-year-old female with a BMI of 36 kg/m2 and obesity-related comorbidities presented to our clinic for bariatric surgery evaluation. The patient had a history of a motor vehicle accident requiring a splenectomy, a liver laceration requiring packing and reoperation with an open abdomen for more than a month. This was followed by a hernia repair with component separation. Preoperative workup was completed, including an upper endoscopy (EGD) that was negative for esophagitis. The computed tomography (CT) scan showed an area in the left upper quadrant with no bowel loops adherent to the abdominal wall, thus a safer area for accessing the abdominal cavity (Fig. 1). The SG itself was challenging due to severe adhesions. These adhesions were between the bowel and abdominal wall, bowel and bowel, stomach and liver, and posterior stomach and pancreas (video). Once adhesiolysis was completed, the stomach was tailored successfully without intraoperative complications. The patient was discharged on postoperative day 1 with stable vitals and laboratory exams while tolerating a liquid diet. RESULTS: On postoperative day 2, the patient returned to the emergency department with abdominal pain, increased heart rate (120 per minute), and a white blood cell count (WBC) of 20,000 th/µL. The CT scan showed a left upper quadrant collection with no evidence of air or contrast extravasation from the sleeve, as shown in Fig. 2. The patient became unstable and did not respond adequately to resuscitation efforts. Due to the extensive dissection in the primary operation, we elected to perform a laparoscopic exploration on an urgent basis. A collection (dark fluid) was noted in the left upper quadrant, but no sleeve staple line leak was found even with the air leak test (Fig. 2). Drainage and wash out were completed, and 2 abdominal drains were placed. Although the patient had symptomatic improvement postoperatively, an EGD with fluoroscopy was repeated, and no leak was noted (Fig. 3). The fluid evaluation showed increased lipase suggesting the diagnosis of a pancreatic leak. A liquid diet was initiated, and the initial drain in the left upper quadrant was exchanged to a higher caliber one (16F 40 cm locking loop drain). The patient was stable and eventually discharged home on postoperative day 6. Eventually, the drains were draining less than 10 mL and then downsized and removed. The patient's weight loss journey continued afterward with no other complications at 10-month follow-up. CONCLUSIONS: Pancreatic leak is a rare but potentially severe complication after SG, especially in the difficult abdomen.
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Cirugía Bariátrica , Laparoscopía , Obesidad Mórbida , Adulto , Fuga Anastomótica/etiología , Fuga Anastomótica/cirugía , Cirugía Bariátrica/métodos , Femenino , Gastrectomía/efectos adversos , Gastrectomía/métodos , Humanos , Laparoscopía/métodos , Obesidad Mórbida/cirugía , Páncreas , Estudios RetrospectivosRESUMEN
BACKGROUND: Although revisions account for 17% of cases performed at bariatric centers of excellence, scarce data exists on whether index operation type influences outcomes after secondary operations. OBJECTIVE: We designed a study investigating the effect of primary procedure type on weight loss and perioperative complications after conversion bariatric surgery. SETTING: Tertiary Referral Hospital, USA. METHODS: We performed a retrospective review of patients undergoing conversion from sleeve gastrectomy (SG) or adjustable gastric band (AGB) to Roux-en-Y gastric bypass (RYGB) from 2009 to 2019. Post-operatively, we measured short- and medium-term complications and changes in body weight at various time points. Univariate and regression analyses were performed. RESULTS: Forty-two (SG) patients and 116 (AGB) patients underwent conversion to RYGB, most commonly for GERD (57.1%) in SG patients vs. weight regain (77.6%) in AGB patients. Mean pre-conversion BMI was 36.7 kg/m2 (SG) vs 43.8 kg/m2 (AGB). Mean time to conversion (months) was 52.9 (SG) vs 94.7 (AGB). Complication rate was 9.5% (SG) vs 6% (AGB) at 30 days (p = 0.48) and 31%(SG) vs 14.5% (AGB) (p = 0.02) at 2 years. Mean post conversion %TWL was 11.6% (SG) vs 24.6% (AGB) in patients with GERD/dysphagia (p = 0.014) and 20.7% (SG) vs 27.6% (AGB) in patients converted for weight-related reasons (p = 0.027) at 1 year. Overall mean %TWL was 13.2% (SG) vs 24.7% (AGB) at 2 years (p < 0.0035). CONCLUSION: After conversion to RYGB, patients with AGB experience better short- and medium-term weight loss than those with SG, even after accounting for conversion indications. SG to RYGB conversions have a higher resolution of reflux disease.
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Cirugía Bariátrica , Derivación Gástrica , Reflujo Gastroesofágico , Obesidad Mórbida , Cirugía Bariátrica/efectos adversos , Cirugía Bariátrica/métodos , Gastrectomía/efectos adversos , Gastrectomía/métodos , Derivación Gástrica/efectos adversos , Derivación Gástrica/métodos , Reflujo Gastroesofágico/etiología , Reflujo Gastroesofágico/cirugía , Humanos , Obesidad Mórbida/complicaciones , Obesidad Mórbida/cirugía , Reoperación/efectos adversos , Estudios Retrospectivos , Resultado del Tratamiento , Pérdida de PesoRESUMEN
INTRODUCTION: Endoscopic gastroplasty and gastric volume reduction techniques have been shown to achieve significant weight loss and improvement in comorbid conditions. The objective of this study is to assess the feasibility and safety of a novel fully automated, operator-independent endoscopic suturing system (EndoZip™) for minimally invasive treatment of obesity. DESIGN: Single-center pilot feasibility study. PATIENTS: Eleven patients with a body mass index (BMI) of 30 to 40 kg/m2 with or without obesity-associated comorbidity. INTERVENTIONS: Gastric volume reduction with EndoZip™ system. MAIN OUTCOME MEASUREMENTS: Primary outcome was to assess the technical feasibility and safety. The secondary outcome was to determine %total body weight loss (TBWL) and %excess weight loss (EWL) at 6 months. RESULTS: The mean ± SD age was 42.7 ± 5.6 years, and the mean ± SD BMI was 36.9 ± 2.8 kg/m2. A majority (64%) were men. The procedure was technically successful (100%) in all patients. A median of 3 (range, 2-4) full-thickness sutures were placed, and the mean procedure time was 54.6 ± 23.9 (23-100) min. No immediate complications occurred, and all were discharged in 24 h. One patient developed respiratory infection 3 days after the procedure and required hospitalization. The infection was mild and resolved with antibiotic treatment. At 6-month follow-up, the mean ± SD TBWL, %TBWL, and %EWL were 17.8 ± 6.7 kg, 16.2 ± 6.0%, and 54.3 ± 28.4%, respectively (p < 0.001). LIMITATIONS: Limited number of patients. CONCLUSION: Our first-in-human study showed that the Endozip™ device could be safely used for the treatment of obesity. The early weight loss results are promising. An extended feasibility study on a larger sample size is being planned (Clinicaltrials.gov. NCT03472196).
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Gastroplastia , Obesidad Mórbida , Adulto , Índice de Masa Corporal , Estudios de Factibilidad , Humanos , Masculino , Persona de Mediana Edad , Obesidad/cirugía , Obesidad Mórbida/cirugía , Resultado del TratamientoRESUMEN
PURPOSE OF REVIEW: In the treatment of epidemic obesity and metabolic disorders, conservative approaches often fail to achieve the treatment goal in patients with very high BMI. To date, bariatric surgery accomplishes the most sustainable results in patients with morbid obesity. This leads to a treatment gap for lower and middle classes of obesity defined by BMI. Primary endoscopic procedures, which are less invasive than surgery, may be able to sufficiently fill this gap. Furthermore, secondary endoscopic procedures have developed into an essential addition regarding complication management of bariatric surgeries. The purpose of this review was to point out the latest developments in the field of bariatric endoscopy, including both primary and secondary procedures. RECENT FINDINGS: Innovative devices and their possible applications will be discussed. These include various endoscopic suturing techniques as well as newly developed implants for the upper gastrointestinal tract to counteract the obesity epidemic. The growing understanding of the pathophysiology of obesity and the role of the gastrointestinal tract allows for the development of more effective endoscopic procedures regarding obesity treatment.