Comparison of upper gastrointestinal series and symptom questionnaires with intraoperative diagnosis of hiatal hernia during sleeve gastrectomy.

BACKGROUND: Hiatal hernias are common in bariatric surgery patients, but the utility of preoperative hiatal hernia diagnosis prior to sleeve gastrectomy (SG) is debated. OBJECTIVE: This study compared preoperative and intraoperative hiatal hernia detection rates in patients undergoing laparoscopic SG. SETTING: University hospital, United States. METHODS: As part of a randomized trial evaluating the role of routine crural inspection during SG, an initial cohort was prospectively studied to assess the correlation between preoperative upper gastrointestinal (UGI) series, reflux and dysphagia symptoms, and intraoperative hiatal hernia diagnosis. Preoperatively, patients completed the Gastroesophageal Reflux Disease Questionnaire (GerdQ), the Brief Esophageal Dysphagia Questionnaire (BEDQ), and a UGI series. Intraoperatively, patients with an anteriorly visible defect underwent hiatal hernia repair followed by SG. All others were randomized to standalone SG or posterior crural inspection with repair of any hiatal hernia identified prior to SG. RESULTS: Between November 2019 and June 2020, 100 patients (72 female patients) were enrolled. Preoperative UGI series identified hiatal hernia in 28% (26 of 93) of patients. Intraoperatively, hiatal hernia was diagnosed during initial inspection in 35 patients. Diagnosis was associated with older age, lower body mass index, and Black race but did not correlate with GerdQ or BEDQ. Using the standard conservative approach, compared with intraoperative diagnosis, sensitivity and specificity of the UGI series were 35.3% and 80.7%, respectively. Hiatal hernia was identified in an additional 34% (10 of 29) of patients randomized to posterior crural inspection. CONCLUSION: Hiatal hernias are highly prevalent in SG patients. However, GerdQ, BEDQ, and a UGI series unreliably identify hiatal hernia in the preoperative setting and should not influence intraoperative evaluation of the hiatus during SG.

Postoperative marijuana use and disordered eating among bariatric surgery patients.

BACKGROUND: Current literature is scarce in documenting marijuana use after bariatric weight loss surgery (WLS). OBJECTIVES: The objective of this study was to explore the association among marijuana use patterns, disordered eating, and food addiction behaviors in patients 2 years after WLS. SETTING: A university hospital in the United States. METHODS: Participants (N = 50, mean age 28 y, standard deviation = 5.8) were administered a structured assessment that included the Addiction Severity Index, Yale Food Addiction Scale, Eating Disorder Examination Questionnaire, and Disordered Eating Questionnaire. Marijuana use was defined based on the Addiction Severity Index as current use (within 30 d), recent use (use in last year), and increased use (increased use since surgery). Data were analyzed using Fisher's exact tests and linear regression methods adjusting for age, gender, race/ethnicity, time since surgery, and change in body mass index. RESULTS: The majority of the sample was female (76%) and underwent Roux-en-Y gastric bypass (62%). Eighteen percent (18%) of the sample reported current marijuana use; 38% reported recent use; and 21.4% reported increased use post-WLS. A loss of controlled food intake was associated with current (P = .02) and increased post-WLS use (P = .01). Increased use and/or regular marijuana use predicted higher scores on eating disorder subscales compared with respective counterparts (P<.05). Current use did not significantly predict higher scores on the Yale Food Addiction Scale. CONCLUSIONS: Findings indicated marijuana use in post-WLS patients despite recommendations against use. A subgroup of WLS patients may be at risk for disordered eating post-WLS, particularly those who used marijuana before surgery, and should be closely monitored for several years post-WLS.

Review of family-based approaches to improve postoperative outcomes among bariatric surgery patients.

BACKGROUND: Bariatric surgery must be partnered with postoperative lifestyle modifications for enduring weight loss and related health effects to be fully appreciated. Little is known about how these lifestyle modifications may be affected by the involvement of other family members living in the household; therefore, this review describes current family-based approaches to improving postoperative outcomes in bariatric surgery patients and their families. METHODS: A MEDLINE search of publications from 1999 to 2014 was conducted in January 2014. Retrieved titles and abstracts were assessed by 2 authors to determine relevance to the topic surrounding family-based approaches to improve postbariatric surgery outcomes. All study designs except case studies were considered if they included some aspect of family as a predictor in relation to improved health outcomes after surgery. RESULTS: Initial searches yielded 650 publications (bariatric surgery+family, n = 193; bariatric surgery+child, n = 338; bariatric surgery+spouse, n = 4; bariatric surgery+social support, n = 115). Two studies met criteria for a family-based approach to improving metabolic outcomes in bariatric patients. Seven studies discussed the impact of bariatric surgery on families. All other studies were excluded for not discussing family-based approaches. CONCLUSION: Despite limited documentation of family-based approaches on improving health outcomes in patients who underwent bariatric surgery, evidence suggests that such an approach may be advantageous if planned a priori to occur before, during, and after bariatric surgery. Future studies could test the combination of bariatric surgery and a family-based approach for improved metabolic outcomes in both the patient and involved family member(s).

Closure of mesenteric defect can lead to decrease in internal hernias after Roux-en-Y gastric bypass.

BACKGROUND: Although most surgeons believe that internal hernia (IH) defects should be closed, no general consensus has yet been reached. The published studies have reported conflicting obstruction incidence estimates and variations in location. Some have also argued that closed hernia sites recur. METHODS: A retrospective review of 2079 Roux-en-Y gastric bypass procedures performed by 1 surgeon from 2001 to 2009 was conducted. Chi-square analysis compared those performed from 2001 to August 2003 (group 1) with those from September 2003 to 2009 (group 2) for the incidence of IH. Since September 2003, the jejunojejunal anastomotic mesenteric defect has been closed with a running, permanent suture. In contrast, before September 2003, the defect was not closed. RESULTS: A total of 37 patients presented with symptomatic IH from 2001 to 2009. A significant difference was found in the proportion of those patients who experienced IH in group 1 (n = 36) compared with those who did so in group 2 (n = 1; P <.001). Group 1 developed 35 IHs (10%) at the jejunojejunal anastomotic mesenteric defect and 6 (1.7%) at Petersen's defect. The median interval to presentation was 20 months (range 5-34). Of the 35 patients, 5 (1.4%) presented acutely with pain or bowel obstruction. Group 2 developed no IHs at the mesenteric defect (0%) and 1 at Petersen's defect (.1%). The interval to presentation was 9 months. CONCLUSION: The incidence of IH after laparoscopic Roux-en-Y gastric bypass can be reduced with closure of mesenteric defects. IHs can present either acutely with pain and obstructive symptoms or chronically with vague, intermittent postprandial pain.

Four-year weight outcomes of laparoscopic gastric bypass surgery and adjustable gastric banding among multiethnic adolescents.

BACKGROUND: Extreme obesity among U.S. adolescents is a serious problem and has disproportionally affected ethnic minorities. Recently, surgical intervention for morbid obesity in adolescents has gained increasing support. Little information is available on the long-term effectiveness of bariatric surgery among ethnic minority adolescents. We have reported the weight and body mass index (BMI) results for a large cohort of predominantly Hispanic adolescents who underwent bariatric surgery in a private practice setting. METHODS: A retrospective medical chart analysis of 78 adolescents (77% Hispanic, 19% non-Hispanic white, 1% non-Hispanic black, and 3% other; 77% female; 16-19 years old), who had undergone gastric bypass or banding surgery from 2002 to 2009, was conducted. All patients had met the National Institutes of Health criteria for bariatric surgery. Repeated measures mixed linear modeling was used to assess the changes in weight/BMI from baseline to 4 years after surgery. RESULTS: Non-Hispanic whites had lost 104.81 lb and 17.29 BMI units at 1 year after surgery (P <.001 for both). Hispanics had lost 91.55 lb and 15.06 BMI units at 1 year after surgery (P <.001 for both). The non-Hispanic whites had lost 18.56 BMI units and Hispanics 16.15 units during the 4 year postoperative period. A weight loss plateau occurred at 12 months for the non-Hispanic whites and at 18 months for the Hispanics; both groups had maintained their weight loss at 4 years after surgery. CONCLUSION: Bariatric surgery resulted in significant weight loss that was maintained at 4 years postoperatively among obese ethnic minority adolescents. Our results have shown that bariatric surgery is a safe and effective treatment option for permanent weight improvements in this demographic.

Distinct molecular pathways for development of telencephalic interneuron subtypes revealed through analysis of Lhx6 mutants.

Here we analyze the role of the Lhx6 lim-homeobox transcription factor in regulating the development of subsets of neocortical, hippocampal, and striatal interneurons. An Lhx6 loss-of-function allele, which expresses placental alkaline phosphatase (PLAP), allowed analysis of the development and fate of Lhx6-expressing interneurons in mice lacking this homeobox transcription factor. There are Lhx6+;Dlx+ and Lhx6-;Dlx+ subtypes of tangentially migrating interneurons. Most interneurons in Lhx6(PLAP/PLAP) mutants migrate to the cortex, although less efficiently, and exhibit defects in populating the marginal zone and superficial parts of the neocortical plate. By contrast, migration to superficial parts of the hippocampus is not seriously affected. Furthermore, whereas parvalbumin+ and somatostatin+ interneurons do not differentiate, NPY+ interneurons are present; we suggest that these NPY+ interneurons are derived from the Lhx6-;Dlx+ subtype. Striatal interneurons show deficits distinct from pallial interneurons, including a reduction in the NPY+ subtype. We provide evidence that Lhx6 mediates these effects through promoting expression of receptors that regulate interneuron migration (ErbB4, CXCR4, and CXCR7), and through promoting the expression of transcription factors either known (Arx) or implicated (bMaf, Cux2, and NPAS1) in controlling interneuron development.