Effect of Diet before Bariatric Surgery on Ghrelin Level through DNA Methylation.

INTRODUCTION: The ghrelin system, which generates the appetite hormone, is harmed by obesity, a problem of worldwide public health. An efficient way to cure obesity is through bariatric surgery. This randomized controlled study's objective was to assess preoperative diet-related DNA methylation of Ghrelin (GHRL) levels in patients undergoing bariatric surgery. METHODS: The 50 patients who volunteered to participate in the trial were randomly divided into two groups. The study group followed the very low-calorie diet for 2 weeks. The control group did not follow any diet. The physiological parameters, weight, and DNA methylation levels of the patients were assessed. RESULTS: The percentage of excess weight loss (EWL) in the control and study groups was determined as 47.1% and 51.5%, respectively. The study group's GHRL percentage of methylated reference was 76.8%, whereas the control group's was 67.3%. It was concluded that the EWL and GHRL gene DNA methylation of the diet-treated study group were significantly higher than the control group (p < 0.05). CONCLUSION: According to the findings, the pre-op diet had a favorable effect on the patient's behavior modification. It has also been shown to increase postoperative weight loss and DNA methylation of the Ghrelin gene. The ghrelin gene has been muted by methylation, making hunger regulation more manageable.

Insulin-Like Growth Factor-I Might be a Predictor for Severe Non-Alcoholic Fatty Liver Disease in Morbidly Obese Patients.

The aim of the study was to compare the IGF-1 levels, metabolic and clinical parameters among the ultrasonographically classified non-alcoholic fatty liver disease (NAFLD) groups and determine the factors that may predict the NAFLD severity in patients with morbid obesity. This study was conducted on 316 morbidly obese patients (250 F/66 M). The data of patients before and 1st-year after bariatric surgery were recorded. According to the ultrasonographically NAFLD screening, patients with normal hepatic features were classified as Group 1(n=57), with mild and moderate NAFLD were classified as Group 2(n=219), and with severe NAFLD were classified as Group 3(n=40). IGF-1 standard deviation scores (SDSIGF1) were calculated according to age and gender. Parameters that could predict the presence and severity of NAFLD were evaluated. IGF-1 levels were significantly associated with Group 3 than Group 1(p=0.037), and the significance remained between the same groups when IGF-1 levels were standardized as SDSIGF1(p=0.036). Decreased levels of SDSIGF1 explained 5% of severe NAFLD than the normal group (p=0.036). Liver Diameter, FPG, ALT, AST, and GGT were also found as significant predictors for severe NAFLD. There were significant differences between pre-and postop values in all groups (p<0.001). This study showed that IGF-1 might be considered a sgnificant predictor of severe NAFLD in morbidly obese patients. It is crucial in clinical practice to determine predictive factors of NAFLD that could support the diagnosis accompanied by non-invasive imaging methods.

The effects of weight loss after sleeve gastrectomy on left ventricular systolic function in men versus women.

PURPOSE: To evaluate and compare the effects of weight lost after sleeve gastrectomy on left ventricular (LV) systolic function using both two-dimensional speckle tracking (2D-STE) and three-dimensional echocardiography (3DE) in men versus women. METHODS: In 53 obese patients referred for sleeve gastrectomy, 2D-STE and 3DE were performed prior to and 6 months after surgery. RESULTS: The study included 53 obese patients (62.3% female; mean age 36.8 ± 10.7 years). Six months after surgery, all patients demonstrated a significant decrease in body mass index, body weight, blood pressure, heart rate, LV end-diastolic dimension, myocardial wall thickness, LV mass, LV mass index, LV mass/height(2.7) , LV end-diastolic volume, LV end-systolic volume, and stroke volume as well as an increase in SV index and ejection fraction. There was no significant difference in measured variables between men and women at baseline or postsurgery, except for baseline LV end-diastolic dimension, and baseline and after surgery LV mass, LV mass index, and LV mass/height(2.7) , which were all significantly higher in men. CONCLUSIONS: Sleeve gastrectomy improves LV systolic function and contributes to reverse LV remodeling in both genders. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:492-499, 2016.

Can We Predict Gastric Leaks After Laparoscopic Sleeve Gastrectomy by Evaluating the Complete Blood Count on Postoperative Day 1?

INTRODUCTION: We assessed whether postoperative day-1 (POD-1) complete blood count (CBC) test parameters, including red cell distribution width (RDW), mean platelet volume (MPV), plateletcrit (PCT), platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio (NLR), could identify patients with gastric leaks after laparoscopic sleeve gastrectomy (LSG). METHODS: Patients with postoperative gastric leaks (n=36) and patients with no complications who were selected by age-sex-BMI matching (n=254) were included in the study. The levels of RDW, MPW, PCT, PLR, and NLR were compared between groups in univariate analyses. Receiver operating characteristic (ROC) curve analysis was run for CBC parameters with a P-value<0.05 in univariate analyses. The area under the curve (AUC) was evaluated, and a cutoff value was determined. Sensitivity, specificity, likelihood ratio (LR), positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated. RESULTS: The level of PCT was significantly lower, while levels of PLR and NLR were significantly higher in patients with postoperative gastric leaks as compared with those without (P<0.05). The AUC of both PCT and PLR was <0.750, while the AUC of NLR was 0.911. NLR cutoff at 3.6 yielded 80% sensitivity, 92% specificity, and an LR of 10. In the study cohort, PPV of 59%, NPV of 97%, and an accuracy of 90% were found. CONCLUSIONS: Our results suggest that NLR at POD-1, with a cutoff value of 3.6, is a useful indicator of postoperative gastric leak who underwent LSG. We recommend the use of this easily calculated parameter in clinical practice.

Post-ERCP Pancreatitis Risk Factors: Is Post-Sphincterotomy Bleeding Another Risk Factor?

BACKGROUND: Despite advancements in technology and expertise, ERCP carries risks of significant complications, such as pancreatitis, bleeding, and perforation. Post-ERCP pancreatitis is the most common and important complication following ERCP. In our study, we aimed to examine the relationship between patient and procedure-related parameters and the development of pancreatitis. METHODS: Four hundred patients who underwent ERCP between January 1, 2019 and December 31, 2020, at the General Surgery Clinic of the Bakirköy Dr. Sadi Konuk Health Application and Research Center of the University of Health Sciences Faculty of Medicine were retrospectively evaluated. Patient and procedure-related factors were analyzed statistically through univariate and multivariate analyses. RESULTS: Age, urgent indication, ERCP history, cholangitis, precut sphincterotomy, common bile duct diameter, pancreatic cannulation, pancreatic stent, and bleeding were statistically significant risk factors for post-ERCP pancreatitis (+). In multivariate analysis, the effects of urgent indication, ERCP history, cholangitis, precut sphincterotomy, common bile duct diameter, and pancreatic cannulation on post-ERCP pancreatitis were statistically significant risk factors ( P <0.05). DISCUSSION: This study demonstrates that emergency indication, ERCP history, cholangitis, precut sphincterotomy, and pancreatic cannulation are significant risk factors for the development of post- ERCP pancreatitis. One notable contribution of our study to the existing literature is the unique analysis of post-sphincterotomy bleeding as an independent factor.

Effects of pre-surgical aerobic dance-based exercise on lower extremity in people with morbid obesity awaiting bariatric surgery: Randomized controlled study.

To investigate what are the effects of pre-surgical aerobic dance-based exercise programme (PSADBE) and physical activity counselling (PAC) programme on lower extremity functions after surgery in people with morbid obesity awaiting bariatric surgery (PMOABS). This study was a single-blind, randomized controlled study. Groups were divided into Group I (PSADBE and PAC) and Group II (PAC). Both groups received PAC, Group I completed the PSADBE programme accompanied by music for 60 min/2 days/8 weeks. Thirty-four PMOABS were included in the study. The 6-Minute Walking Test, as primary outcomes, and The Stair Climbing Up-Down Test for evaluating functional capacity, Biodex Isokinetic Test and Exercise System® for evaluating muscle strength were used. Besides, muscle endurance, physical activity (PA) level, fatigue and quality of life (QoL) were also assessed. All measurements were repeated three times; pre-treatment, post-treatment and the fifth-month post-surgery. After 8 weeks, significant changes were found in functional capacity, muscle strength and endurance, PA level, fatigue and QoL in both groups (p < .05). Comparing the groups, the changes in functional capacity, muscle strength and endurance, PA and fatigue scores after treatment and the fifth-month post-surgery were statistically superior in Group I (p < .05). Adding an 8-week PSADBE programme to PAC is an effective treatment option for improving postoperative functional capacity, muscle strength and endurance, PA level and fatigue in PMOABS.

Is Helicobacter pylori eradication required after laparoscopic sleeve gastrectomy?

Introduction: Helicobacter pylori is the most common bacterial infection in humans. H. pylori is now known to be responsible for chronic gastritis, peptic ulcer, B-cell gastric lymphoma, and gastric adenocarcinoma. Laparoscopic sleeve gastrectomy (LSG) is increasingly preferred among surgical treatment methods in obese patients. Aim: To discuss the detection and treatment of H. pylori in patients undergoing LSG surgery. Material and methods: Patients who underwent biopsy with upper gastrointestinal endoscopy in the preoperative and postoperative period of LSG between 2014 and 2019 were included in the study, resulting in a sample of 162 patients who underwent preoperative and postoperative endoscopy. Endoscopic biopsies of these patients were collected in accordance with the preoperative Sydney protocol. The patients did not receive H. pylori-related eradication treatment. Endoscopy was performed to investigate dyspeptic complaints in the postoperative period. The biopsy results obtained in the endoscopy in the postoperative period were compared to those obtained in the preoperative period. Results: Of the 162 patients in our study, 39 were male and 123 were female. All patients were assigned to one of two groups in the preoperative period: H. pylori (+) and H. pylori (-). H. pylori was found to be positive in 99 patients in the preoperative period. H. pylori was negative in 62 patients in the biopsy results of these patients after the LSG. H. pylori was found to be negative in 63 patients in the preoperative period, and 51 patients were H. pylori-negative in the biopsy results of these patients following LSG. These changes were found to be statistically significant when the preoperative and postoperative pathology results were evaluated (p < 0.01). Conclusions: This study showed that LSG reduced the presence of H. pylori.

Changes in the gut microbiota of morbidly obese patients after laparoscopic sleeve gastrectomy.

Aims: Permanent treatment of morbid obesity with medication or diet is nearly impossible. Laparoscopic sleeve gastrectomy (LSG) is becoming a widely accepted treatment option. This study profiled and compared gut microbiota composition before and after LSG. Methods & results: A total of 54 stool samples were collected from 27 morbidly obese individuals before and after LSG. The gut microbiota was profiled with 16S amplicon sequencing. After LSG, patients demonstrated a significant decrease (p < 0.001) in BMI and an increase in bacterial diversity. An increased Firmicutes/Bacteroidetes ratio was also noticed after LSG. The families Prevotellaceae and Veillonellaceae predominated in preoperative samples but were markedly lowered after LSG. A marked increase in Akkermansia, Alistipes, Streptococcus, Ruminococcus and Parabacteroides was observed after LSG. Conclusion: In addition to lowering BMI, LSG remodeled gut microbiota composition.

The effects of core stabilization exercise program in obese people awaiting bariatric surgery: A randomized controlled study.

OBJECTIVE: The aim of this study was the effects of the core stabilization exercise program (CSEP) and physical activity counseling on functional capacity, physical fitness, physical activity, fatigue and quality of life (QoL) in obese people awaiting bariatric surgery. METHODS: Twenty-one patients were divided into two groups: an exercise group (n = 10) and a control group (n = 11). Both groups received physical activity counseling, but the exercise group also performed an 8-week CSEP. Functional capacity, physical fitness, physical activity, fatigue and QoL were assessed at baseline and after 8 weeks. RESULTS: After eight weeks, results showed significant improvements in all parameters except for body composition for the exercise group, comparing to the control group (effect size = 0.40-0.87, p < 0.05). CONCLUSIONS: Implementing an 8-week adding CSEP to physical activity counseling provided significant improvements in functional capacity, physical fitness, physical activity, fatigue and QoL compared to physical activity counseling in obese people awaiting bariatric surgery.

Granulomatous mastitis: clinical, pathological features, and management.

This clinical study was conducted to present clinical, radiologic, and histopathologic features of Granulomatous Mastitis (GM) and evaluate the result of surgical and steroid treatment. Sixteen cases diagnosed histologically as GM were reviewed. Patient characteristics, clinical presentation, radiologic imaging, microbiologic, histopathologic assessment, treatment modalities, recurrence, morbidity, and follow-up data were analyzed. Majority of the patients were child bearing age and all of the patients had a history of breast feeding. Radiologic findings were nonspecific. Histopathology showed the characteristic distribution of granulomatous inflammation in all cases. In 12 cases, surgical excision of the lesion with negative margins was performed. Four cases required quadranectomy because of wideness of the disease. Three patients who had local reoccurrence and three resistant patients were treated by oral prednisone after surgical attempt. Complete remission was obtained and no further recurrence was observed in this patients. GM predominantly occurs in premenopausal women and the clinical symptoms might be misjudged as breast cancer. Histopathologic examination remains the gold standard for the diagnosis. Wide excision of the lesions is the recommended therapy and we suggest steroid therapy in resistant or recurrent disease following the idea that the disease has an autoimmune component.

Is the Resected Gastric Volume Effective in the Complication of Laparoscopic Sleeve Gastrectomy?

BACKGROUND: To determine the relationship between the resected gastric volume (RGV) and the results of laparoscopic sleeve gastrectomy (LSG). METHODS: The study included 333 patients with LSG. Patients were divided into 4 groups according to RGV: 600 to 999 cm as Group 1, 1000 to 1499 cm as Group 2, 1500 to 1999 cm as Group 3, and ≥2000 cm consists the Group 4. Prospectively collected data at first month, sixth month, and at first year were retrospectively reviewed. The percentage of the reduction in body mass index and the excess weight loss and remission of comorbid diseases were recorded. RESULTS: Preoperative demographic data were similar within groups. No statistically significant difference was observed between the groups in terms of the changes in excess weight loss. The major complication rates were highest in Group 4 and the difference between the groups was statistically significant (P=0.012). CONCLUSIONS: The results of this study showed that different RGV do not affect the results of LSG, furthermore in patients with RGV ≥2000 cm, surgeons should be careful for major complications.

Five-year outcomes for laparoscopic sleeve gastrectomy from a single center in Turkey.

BACKGROUND: There are no long-term results for laparoscopic sleeve gastrectomy (LSG) from Turkey. OBJECTIVES: Assess the outcomes of LSG at 5 years. DESIGN: Retrospective. SETTING: Training and research hospital. PATIENTS AND METHODS: The study included patients with LSG performed from August 2012 to December 2013. The data was prospectively collected with the aim of providing 5-year outcomes. MAIN OUTCOME MEASURES: Changes in percentage excessive weight loss (%EWI) and BMI. Changes in the pharmacological treatment status of patients with type 2 diabetes mellitus and hypertension. SAMPLE SIZE AND CHARACTERISTICS: 120 patients (89 female) completed follow up; mean age 37 years (range, 19-63 years), mean preoperative BMI 48.3 kg/m2 (range 40-80.4 kg/m2). RESULTS: After a mean 5.6-year follow-up, the mean (SD) postoperative weight loss was 43.5 (11.8) kg and the mean (SD) BMI loss was 16.1 (4.4). The mean %EWL value was 62.9% (range, 30-101%). Most patients (87.5%, n=105) achieved satisfactory %EWL values. The major complication rate was 6.6%. After surgery, 74.2% of patients taking medication for hypertension were able to stop treatment, while 12.9% reduced the dose, of patients that took medication for diabetes, all had a dosage reduction. CONCLUSIONS: We showed that LSG is an acceptable bariatric procedure, but in the long-term there may be weight gain and frequent reflux symptoms. We think renewed weight gain can be partially prevented by close clinical follow-up. There is a need for long-term randomized controlled studies with long-term follow-up to clearly define the indications for LSG. LIMITATIONS: Retrospective, incomplete clinical visits, GERD symptoms not objectively assessed. CONFLICT OF INTEREST: None.

Outcomes of laparoscopic sleeve gastrectomy by means of esophageal manometry and pH-metry, before and after surgery.

INTRODUCTION: Gastroesophageal reflux is a major problem after sleeve gastrectomy. There is still insufficient understanding of how it occurs and whether it is due to the sphincter length, relaxation, or pressure differences. AIM: This study evaluates the effect on the lower esophageal sphincter of the laparoscopic sleeve gastrectomy (LSG) technique applied in surgery in cases of morbid obesity using ambulatory 24-h pH monitoring (APM) and esophageal manometry (EM). MATERIAL AND METHODS: A retrospective examination was carried out on the APM and EM tests performed preoperatively and postoperatively in cases of LSG. The parameters examined were the body mass index (BMI), amplitude pressure of the esophagus (AP), total length of the lower esophageal segment (LESL), resting pressure of the LES (LESP), residual pressure of the LES (LESR), relaxation time of the LES, intragastric pressure, and the DeMeester score. RESULTS: A total of 62 cases with available data were evaluated. A statistically significant difference was determined between the preoperative values and the 3-month postoperative values of BMI, LESP, and relaxation time of the LES. A statistically significant increase was determined in the DeMeester score, and the increase in the total number of reflux episodes longer than 5 min was found to be the most responsible for this increase. No significant difference was determined in the other parameters. CONCLUSIONS: The LSG was found to cause a reduction in LESP, and an increase in acid reflux causing an extended relaxation time of the LES. This was confirmed by the increase seen in the DeMeester score.

Direct Trocar Insertion with Elevation of the Rectus Sheath in Bariatric Surgery: A Novel Technique.

INTRODUCTION: Initial trocar entry, the first step in laparoscopic surgery, is associated with several complications. In morbidly obese patients, initial trocar placement is associated with a greater number of complications compared to non-obese patients. Materials and Surgical Technique. In this study, we describe our use of an initial trocar entry technique which is direct trocar insertion with elevation of the rectus sheath by a single Backhaus towel clamp and we would like to evaluate the sa fety and efficacy of its administration in bariatric surgery. DISCUSSION: Our results indicate that gaining initial trocar entry using our technique leads to successful laparoscopic bariatric surgery. Our technique is a safe, effective, and reliable first step in successful laparoscopic surgery for almost all patients, and is only contraindicated in patients with severe hepatomegaly.

An alternative view on the necessity of EGD before sleeve gastrectomy.

BACKGROUND: Esophagogastroduodenoscopy (EGD) is particularly recommended for choosing a surgical method to be used with asymptomatic patients and for the assessment of symptomatic patients prior to sleeve gastrectomy. The presence of hiatal hernia, for instance, is a relative contraindication. EGD is used for malignancy scanning as well as surgical planning, but seems inefficient in determining postoperative complications. OBJECTIVE: Our aim was to investigate the effectiveness of the pathological evaluation of endoscopic biopsies obtained with esophagogastroduodenoscopy (EGD) according to Sydney classification prior to sleeve gastrectomy in identifying the risk of staple line leak, independently of clinical diagnosis. SETTING: Bakirköy Dr. Sadi Konuk Training and Research Hospital, Department of General Surgery. METHODS: Patients who underwent laparoscopic sleeve gastrectomy between January 2014-December 2016 received preoperative EGD as per the clinic's protocol and upon obtaining ethics board approval and patient consent. Biopsies were taken from the patients according to the Sydney protocol. The pathology results were examined retrospectively by considering the exclusion criteria. The results were given in line with the Sydney classification, and patients with and without Staple Line Leak were statistically compared. RESULTS: A total of 630 patients were enrolled in the study. Of these, 71.1% (n = 448) were female and 28.9% (n = 182) were male. Mean age was 38.9 years (17-68), mean body weight was 130.8kg (94-240) and body mass index (BMI) values were 47.4kg/m2 (36-106). In evaluation of median values, no statistically significant relationship was found between staple line leak and H. pylori occurrence grade (P = 0.438; P>0.05), activation grade (P = 0.568; P>0.05) or intestinal metaplasia grade (P = 0.319; P>0.05). Atrophy (P = 0.001; P<0.01) and chronic inflammation grade (P = 0.026; P<0.05) were significantly higher in Staple Line Leak patients. CONCLUSIONS: EGD prior to sleeve gastrectomy and biopsies obtained in line with the Sydney protocol predict Staple Line Leak risk.

Colonoscopic Perforations, What is Our Experience in a Training Hospital?

The aim of this study was to describe our experience in patients treated with the diagnosis of colonoscopic perforation. A retrospective institutional computer-based search of the patients treated with the diagnosis of colonoscopic perforation between July 2009 and May 2014 was undertaken. Our study included 16 patients. In 9 (56%) patients, perforations occurred during the diagnostic colonoscopy. Snare polypectomy was the causative factor in 5 patients associated with therapeutic colonoscopy. The perforation was significantly higher in patients who underwent therapeutic colonoscopy than those had diagnostic colonoscopy (P<0.007). The sigmoid colon was the most common perforation site (62.5%). Twelve patients (75%) were treated by surgically, 3 (19%) patients by conservatively, and 1 (6%) by endoscopic clipping. Early recognition of the perforation is critical. Therefore, a high index of suspicion is essential for the prompt and accurate diagnosis.

Encapsulating peritoneal sclerosis as a late complication of peritoneal dialysis.

INTRODUCTION: Encapsulating peritoneal sclerosis (EPS) is a rare cause of intestinal obstruction which is characterized by fibrotic encapsulation of the bowel. Although its pathogenesis is still not clear, many etiological factors have been stated. PRESENTATION OF CASE: In this report, we present a 26-year old woman with peritoneal dialysis related EPS. Because of the unresolving intestinal obstructive symptoms, she underwent surgical intervention in which the thick dense whitish membranous sac was excised from the surrounding intestine along with adhesiolysis. She recovered uneventfully. She is symptom-free on the eight months of follow-up. DISCUSSION: EPS should be born in mind as a complication of the long term peritoneal dialysis in patients with progressive obstructive ileus and recurrent peritonitis. Its treatment either medically or surgically varies depending on the stage of this entity. CONCLUSION: Early identification of EPS is important in order to achieve better prognosis.

Prevention of Postoperative Bile Leak in Partial Cystectomy for Hydatid Liver Disease: Tricks of the Trade.

BACKGROUND: The presence of postoperative bile leak is the major outcome measure for the assessment of operative success in partial cystectomy for hydatid liver disease. However, the optimal operative strategy to reduce the postoperative bile leak rate is yet to be defined. METHODS: Medical records of patients who underwent partial cystectomy for hydatid liver disease between January 2013 and January 2015 were reviewed in this retrospective analysis. All patients were managed with a specific operative protocol. The primary outcome measure was the rate of persistent postoperative bile leak. The secondary outcome measures were the morbidity and mortality rate, and the length of hospital stay. RESULTS: Twenty-eight patients were included in the study. Only one patient (3.6 %) developed persistent postoperative bile leak. The overall morbidity and mortality rate was 17.8 and 0 %, respectively. The median length of hospital stay was 5 days. CONCLUSION: Aggressive preventative surgical measures have led to low persistent bile leak rates with low morbidity and mortality.