Association of preoperative CT-scan features and clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy: a meta-analysis.

BACKGROUND: Clinically relevant postoperative pancreatic fistula (CR-POPF) is a significant complication after pancreaticoduodenectomy. CR-POPF is associated with various adverse outcomes, including high mortality rates. Identifying complication predictors for CR-POPF, such as preoperative CT scan features, including pancreatic attenuation index (PAI) and pancreatic duct diameter (PDD), is critical. This systematic review and meta-analysis consolidate existing literature to assess the impact of these variables on CR-POPF risk. METHODS: Our comprehensive search, conducted in May 2023, covered PubMed, Scopus, Embase, and Web of Science databases. Inclusion criteria encompassed peer-reviewed cohort studies on pancreaticoduodenectomy, focusing on preoperative CT scan data. Case reports, case series, and studies reporting distal pancreatectomy were excluded. The quality assessment of included articles was done using New-Castle Ottawa Scale for cohort studies. Statistical analysis was carried out using Review Manager 5. This study was registered at the International Prospective Register of Systematic Reviews database (PROSPERO) on 12 May 2023 (registration number: CRD42023414139). RESULTS: We conducted a detailed analysis of 38 studies with 7393 participants. The overall incidence of CR-POPF was 24%. Multiple linear regression analyses revealed that PDD and pancreatic parenchymal thickness were significantly associated with CR-POPF. CONCLUSION: Our systematic review and meta-analysis shed light on CT scan findings for predicting CR-POPF after Whipple surgery. Age, PDD, and pancreatic parenchymal thickness significantly correlate with CR-POPF.

The Impact of Metabolic and Bariatric Surgery on Apo B100 Levels in Individuals with high BMI: A Multi-Centric Prospective Cohort Study.

BACKGROUND: Metabolic and Bariatric surgery (MBS) leads to significant weight loss and improvements in obesity-related comorbidities. However, the impact of MBS on Apolipoprotein B100 (Apo-B100) regulation is unclear. Apo-B100 is essential for the assembly and secretion of serum lipoprotein particles. Elevated levels of these factors can accelerate the development of atherosclerotic plaques in blood vessels. This study aimed to evaluate changes in Apo-B100 levels following MBS. METHODS: 121 participants from the Iranian National Obesity and Metabolic Surgery Database (INOSD) underwent Laparoscopic Sleeve Gastrectomy (LSG) (n = 43), One-Anastomosis Gastric Bypass (OAGB) (n = 70) or Roux-en-Y Gastric Bypass (RYGB) (n = 8). Serum Apo-B100, lipid profiles, liver enzymes, and fasting glucose were measured preoperatively and six months postoperatively. RESULTS: Apo-B100 levels significantly decreased from 94.63 ± 14.35 mg/dL preoperatively to 62.97 ± 19.97 mg/dL after six months (p < 0.01), alongside reductions in total cholesterol, triglycerides, LDL, VLDL, AST, and ALT (p < 0.05). Greater Apo-B100 reductions occurred in non-diabetics versus people with diabetes (p = 0.012) and strongly correlated with baseline Apo-B100 (r = 0.455, p < 0.01) and LDL levels (r = 0.413, p < 0.01). However, surgery type did not impact Apo-B100 changes in multivariate analysis (p > 0.05). CONCLUSION: Bariatric surgery leads to a significant reduction in Apo-B100 levels and improvements in lipid profiles and liver enzymes, indicating a positive impact on dyslipidemia and cardiovascular risk in individuals with high BMI.

Metabolic and bariatric surgery in patients with class I obesity; a two-year follow-up.

BACKGROUND: Patients with class I obesity may need metabolic and bariatric surgery (MBS) in the presence of obesity-associated medical problems, but MBS in this class of obesity is under debate. This study aimed to investigate the efficacy and safety of MBS in patients with class I obesity. METHODS AND MATERIALS: This study was a historical cohort carried out on 112 patients with class I obesity with body mass index (BMI) of 30-35 kg/m2 with a 24-month follow-up underwent MBS at Rasoul-e-Akram Hospital. The required data were extracted through the Iran National Obesity Surgery Database. The data required for the study consisted of demographic information such as age, gender, and obesity-associated medical problems like type-2 diabetes mellitus (T2DM), hypertension, obstructive sleep apnea, and dyslipidemia before surgery, 6, 12, and 24 months after surgery. RESULTS: Mean age of the patients was 38.10 ± 10.04 years; mean BMI was 32.96 ± 1.35 kg/m2 and 83.9% (n = 94) of patients were female. Out of 18 patients with T2DM, 11 patients (61.11%) had complete remission and seven patients (38.88%) had partial remission. Obstructive sleep apnea, hypertension, dyslipidemia, and gastroesophageal reflux disease were observed in 18 (16.07%), 23 (20.53%), 43 (38.39%), and 13 patients (11.60%) before surgery and resolved at 24-month follow-up. Post-operative complications during the 24-month follow-up were checked to assess safety and there were no De novo gastroesophageal reflux disease, intolerance, leakage, pulmonary thromboembolism, deep vein thrombosis, incisional hernia, hypoalbuminemia (Albumin < 3.5 g/dl), excessive weight loss (BMI < 18.5 kg/m2) at any time during 24-months follow-ups and mortality. Early complications occurred as splenic injury in one case (0.89%), wound infection in one patient (0.89%), and extra-luminal bleeding in 10 (8.92%) after surgery, without any mortality. CONCLUSION: MBS is safe and effective in class I obesity and can be considered in selected patients with obesity-associated medical problems.

Comparison of weight loss after Roux-en-Y gastric bypass in Helicobacter pylori-negative and Helicobacter pylori eradicated patients during five years follow-ups.

PURPOSE: Helicobacter pylori (HP) is the most common human infection that has affected up to 50% of the population worldwide. The relationship between HP eradication and weight loss is under debate. The present study aimed to compare weight loss outcomes after Roux-en-Y gastric bypass (RYGB) in HP-negative (HP-) and HP-eradicated (HPe) patients during five years follow-ups. METHODS: This retrospective cohort study was conducted on 305 patients aged 18 and more with severe obesity, who underwent primary RYGB from February 2014 to November 2017. The HP-negative and HP-eradicated patients were evaluated for weight loss outcomes during five years follow-ups. RESULTS: Patients' mean age, mean weight, and mean body mass index were 38.78 ± 9.9, 114.8 ± 13.6, and 43.37 ± 2.55, respectively. 27.2% of patients who were HP-positive were treated before RYGB. There was no significant difference between the HP- and HPe patients in terms of total weight loss percent (%TWL), 12 to 60 months after RYGB. Excess weight loss percent (%EWL) was higher in HPe patients compared to HP- patients (P = 0.04) at 12-month after RYGB. However, there was no difference in %EWL between these two groups of patients, 36 and 60 months after RYGB. CONCLUSION: The results of the present study showed that TWL% had no significant difference in HP- and HPe groups during five years follow-ups after RYGB. The %EWL was higher in HPe patients only at 12 months after RYGB and the difference did not persist over time.

Five-Year BAROS Score Outcomes for Roux-en-Y Gastric Bypass, One Anastomosis Gastric Bypass, and Sleeve Gastrectomy: a Comparative Study.

PURPOSE: Metabolic and bariatric surgery (MBS) has been shown to enhance the quality of life (QoL) in individuals with obesity. The Bariatric Analysis and Reporting Outcome System (BAROS) is a highly reliable scoring system utilized to assess weight loss, obesity-associated medical conditions, and QoL following MBS. This study aimed to assess the efficacy of sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and one anastomosis gastric bypass (OAGB) in improving health outcomes for individuals with severe obesity, employing the BAROS questionnaire. METHODS: A retrospective study was conducted, enrolling 299 patients with a body mass index (BMI) of 40 or higher who had undergone primary MBS (RYGB, OAGB, or SG) and had a 5-year follow-up. Patients were evaluated using the BAROS scoring system, which included measures of % excess weight loss (%EWL), improvement and remission of obesity-related medical problems, and postoperative short-term and long-term complications. RESULTS: The mean age and pre-op BMI of the patients was 39.4 ± 9.4 years and 44.6± 6.5 kg/m2, respectively. The total BAROS score was significantly higher in patients who underwent OAGB compared to those who underwent RYGB and SG (P, 0.02). However, no significant differences were observed in other aspects of the BAROS score, such as QoL. CONCLUSION: This study demonstrated that all three common metabolic and bariatric surgical procedures (SG, RYGB, and OAGB) significantly improved the QoL after surgery. Furthermore, patients who underwent OAGB had a significantly higher total BAROS score at the 5-year follow-up compared to those who underwent RYGB and SG.

Evaluation of laboratory values affecting mortality of end-stage renal disease patients: a competing risks approach.

BACKGROUND: Chronic Kidney Disease (CKD) is a prevalent and life-threatening situation recognized as an emerging health issue. The present study aimed to evaluate the effect of demographic and laboratory parameters on the survival of patients with End-Stage Renal Disease (ESRD) in a hemodialysis (HD) center in Iran. MATERIALS AND METHODS: This study was conducted on patients receiving chronic HD in Iran Helal Pharmaceutical and Clinical Complex between 2014 and 2018. The survival time was considered as the time interval between HD initiation and death. Receiving kidney transplantation was regarded as a competing risk, and an improper form of two-parameter Weibull distribution was utilized to simultaneously model the time to both death and renal transplantation. The Bayesian approach was conducted for parameters estimation. RESULTS: Overall, 29 (26.6%) patients expired, and 19 (17.4%) received kidney transplants. The male gender was related to poor survival, having nearly 4.6 folds higher hazard of mortality (90% HPD region: 1.36-15.49). Moreover, Serum calcium levels [Formula: see text]9.5 mg/dL (adjusted Sub-hazard ratio (S-HR)=2.33, 90% HPD region: 1.05-5.32) and intact parathyroid hormone (iPTH) [Formula: see text]150 pg/mL (adjusted S-HR = 2.56, 90% HPD region: 1.09-6.15) were associated with an elevated hazard of mortality. The cumulative incidence function (CIF) for transplantation was greater than death in the first two years of the study. Subsequently, the CIF for death exceeded transplantation in the following two years. The 4-year cumulative incidence of death and kidney transplantation was 63.7% and 36.3%, respectively. CONCLUSION: Male gender, hypercalcemia, and hypoparathyroidism were associated with worse outcomes. Correcting mentioned laboratory parameters may improve patients' survival in the HD population.

Reasons for Preoperative Patient Attrition among Bariatric Surgery Candidates: Patients' Point of View.

PURPOSE: Obesity has become a global health concern, associated with decreased quality of life and life expectancy. Although bariatric surgery has many benefits (e.g., substantial and durable weight loss, amelioration of comorbidities, and improvement in functionality), its patient attrition rate is relatively high. Therefore, we aim to assess the causes of withdrawal from our program. MATERIALS AND METHODS: We interviewed patients who dropped out of our bariatric surgery program between January 2016 and December 2021. A total of 1999 patients were eligible for bariatric surgery during this period, and 255 patients withdrew from the program. We interviewed patients over the phone to find out the reason for withdrawal. We divided participants into two groups: dropouts before and during the COVID-19 pandemic. Several options explaining the reason for leaving the program were presented to the patients to choose from. RESULTS: The number of patients who withdrew from the program before and during the COVID-19 pandemic was 135 (8.9%) and 120 (25.2%), respectively. Before the COVID-19 pandemic, most patients (49.1%) stated that the long waiting time was the cause of withdrawal. Even though during the COVID-19 pandemic, the main causes of attrition were the fear of contracting the disease and COVID-19 infection; the most common reason unrelated to COVID-19 was still the long preoperative preparation. CONCLUSION: Long waiting time was the most common cause of patient attrition before bariatric surgery. To reduce the attrition rate, more studies should be conducted to find an optimized waiting time before bariatric surgery.

Endoscopic Evaluation of De Novo Esophagitis and Barrett's Esophagus, 5 Years After Sleeve Gastrectomy.

PURPOSE: Sleeve gastrectomy (SG) is the most common bariatric procedure worldwide. It has been reported that there is a strong association between SG and the development of gastroesophageal reflux disease (GERD) and Barrett's esophagus (BE). This study was conducted to evaluate esophagogastroduodenoscopy (EGD) findings in patients with a history of SG with more than 5-year follow-up. METHODS: This is a retrospective cohort study of prospectively maintained database. Inclusion criteria included patients who underwent SG between April 2015 and March 2016, aged 18 and above, BMI ≥ 40 kg/m2. Patients with 5 years of follow-up were invited to take part in the study and underwent EGD and biopsy. RESULTS: One hundred twenty-six patients were recruited with a mean age of 44.6 ± 11.1 years. After a 5-year follow-up, there were 31 (29.5%) patients with reflux esophagitis. The grades of GERD were A, B, and C in 16 (15.2), 12 (11.4), and 3 (2.9%) patients, respectively. Incidence of BE was 5.7% after 5 years from SG. There was a 16.6% lost to follow-up at 5 years after SG. CONCLUSION: The diagnosis and severity of GERD and the search for BE justify endoscopic surveillance in all long-term post-sleeve patients, regardless of reflux symptoms.

Predictors of Weight Regain and Insufficient Weight Loss According to Different Definitions After Sleeve Gastrectomy: a Retrospective Analytical Study.

BACKGROUND: Weight regain (WR) and insufficient weight loss (IWL) after sleeve gastrectomy (SG) are challenging issues. This study aimed to evaluate the predictors of WR and IWL after SG. METHODS: In this retrospective analytical study, 568 patients who underwent SG at Hazrat-e Rasool General Hospital, Tehran, Iran, between January 2015 and April 2022 were evaluated. A total of 333 patients were included. WR and IWL were evaluated by multiple criteria such as a BMI of > 35 kg/m2, an increase in BMI of > 5 kg/m2 above nadir, an increase in weight of > 10 kg above nadir, percentage of excess weight loss (%EWL) < 50% at 18 months, an increase in weight of > 25% of EWL from nadir at 36 months, and percentage of total weight loss (%TWL) < 20% at 36 months. All participants were followed up for 36 months. RESULT: The univariate analysis showed that preoperative BMI, obstructive sleep apnea, metformin consumption, and grades 2 and 3 fatty liver disease were associated with WR and IWL (P < 0.05). WR or IWL incidence varied (0-19.3%) based on different definitions. The multivariate analysis showed that a preoperative BMI of > 45 kg/m2 [odds ratioAdjusted (ORAdj) 1.77, 95% CI: 1.12-4.11, P = 0.038] and metformin consumption [ORAdj: 0.48, 95% CI: 0.19-0.78, P = 0.001] were associated with WR and IWL after SG, regardless of the definition of WR or IWL. CONCLUSION: This study showed that preoperative BMI of > 45 kg/m2, obstructive sleep apnea, metformin consumption, and grades 2 and 3 of fatty liver disease were associated with WR or IWL.

Type 2 diabetes remission after Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and one anastomosis gastric bypass (OAGB): results of the longitudinal assessment of bariatric surgery study.

BACKGROUND: Several studies on various bariatric surgeries involving patients with type 2 diabetes mellitus (T2DM) showed an overall rate of remission of hyperglycemia. However, there is little known about predictive factors on remission after different types of surgeries. The aim of this study was to identify the T2DM remission rate and to determine the effects of preoperative factors characteristics of remission of type 2 diabetes in Iran. METHODS: We conducted a retrospective analysis of 1351 patients with T2DM operated by three different types of surgeries (Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and One Anastomosis Gastric Bypass (OAGB)). Diabetes remission was defined according to the American Diabetes Association (ADA) criteria. Binary logistic regression analyses were employed. RESULTS: A total of 1351 patients, 675 patients (50.0%) undergoing OAGB, 475 (35.2%) RYGB, and 201 (14.9%) SG. 80.6%, 84.2% of OAGB, 81.7%, 82.6% of RYGB, and 77.1%, 81.5% of SG participants were in T2DM remission after 1 and 3 years, respectively. 1- and 3-year remission were associated with preoperative age, duration of T2DM, FBS and HbA1c, BMI, insulin therapy, and a family history of obesity (p < 0.05). CONCLUSION: The remission of T2DM after RYGB, SG, and OAGB surgery is dependent on various preoperative factors. Patients with younger age, shorter duration of T2DM, lower preoperative HbA1c and FBS, higher BMI, who were not on insulin therapy, and not having a family history of obesity were the best candidates to achieve a prolonged diabetes remission.

Generalized peritonitis secondary to spontaneous rupture of the urinary bladder in a diabetic patient: A case report.

INTRODUCTION AND IMPORTANCE: Spontaneous rupture of the urinary bladder (SRUB) secondary to emphysematous cystitis(EC) in diabetic patients is extremely rare. Clinical presentations are often non-specific and display the signs and symptoms of peritonitis. The diagnosis is usually made after exploratory laparotomy. CASE REPORT: A 70-year-old diabetic woman presented to the emergency department with sudden diffuse abdominal pain and hematuria of six hours duration. Physical examination revealed generalized peritonitis. Multi-slice abdominal and pelvic CT scans showed free air and fluid in the abdominal cavity. After proper resuscitation, the patient was transferred to the operating room for exploratory laparotomy. A 2 cm full-thickness bladder rupture was noted at the dome of the bladder, which was repaired. CLINICAL DISCUSSION: We noticed free air in the urinary bladder wall postoperatively in the CT scan, which is the radiological sign of EC. The Pathology result was in concordance with the diagnosis. CONCLUSIONS: SRUB in patients with poorly controlled diabetes and EC is highlighted in this case study. Urinary bladder rupture secondary to EC should be considered When a diabetic patient with a history of urinary symptoms presents with an acute onset of abdominal pain suggestive of peritonitis. Uneventful recovery from SRUB is dependent on early diagnosis and treatment.

Predictors for weight loss after Roux-en-Y gastric bypass: the trend and associated factors for weight loss.

BACKGROUND: Historically, Roux-en-Y gastric bypass (RYGB) has been considered the gold standard of bariatric surgery (BS). This procedure acts as a mixed restrictive and malabsorptive operation. METHODS:  This retrospective cohort study included 410 morbidly obese patients (BMI > 40 kg/m2 or BMI > 35 kg/m2 along with at least one major comorbidity) who underwent primary laparoscopic RYGB surgery from 2009 to 2015 by a single surgery team. The patients were 18 years and older with at least 12 months of follow-up. Total weight loss (%TWL) and comorbidity resolution were compared in short-term (12 months) and mid-term (12-60 months) follow-ups. The primary and secondary outcomes were evaluating the effect of Roux-en-Y on weight loss and control of comorbidities, respectively. RESULTS:  The mean ± SD age, weight, and BMI at surgery were 40.1 ± 10.58 years, 123.32 ± 19.88 kg, and 45.78 ± 5.54 kg/m2, respectively, and 329 (80%) were female, and 62 (15%) had T2DM. %TWL was significantly higher in T2DM patients 9 months postoperatively and after that. Patients with lower BMI (< 50 kg/m2) at surgery and non-diabetic patients had a significantly lower %TWL over a short- and long-term follow-up (P < 0.001). CONCLUSIONS: BS remains the most efficacious and durable weight loss treatment. However, a proportion of patients will experience insufficient weight loss following BS.

B1 Vitamin Deficiency After Bariatric Surgery, Prevalence, and Symptoms: a Systematic Review and Meta-analysis.

B1 deficiency is a very prevalent complication of bariatric surgery. This study reviews prevalence and symptoms of B1 vitamin deficiency after bariatric surgery. PubMed, Scopus, and Web of Science published were searched up to 10 Feb 2022, with the following keywords: Roux-en-Y gastric bypass, one anastomosis gastric bypass, Omega bypass, Mini bypass, Bariatric surgery OR Bariatric surgery, metabolic surgery, Weight loss surgery, Classic gastric bypass, Loop gastric bypass, Gastric Bypass, thiamine OR thiamin, beriberi, B1. A total of 11 studies examining 1494 patients were included in this meta-analysis. Twenty-seven percent of patients who underwent bariatric surgeries experience vitamin B1 deficiency. Thiamine supplements should be prescribed for the patients for the rest of their lives, and also standard post-surgery follow-ups are necessary in terms of monitoring dietary factors.

Dry beriberi after sleeve gastrectomy: An undiagnosed case report.

INTRODUCTION AND IMPORTANCE: Sleeve gastrectomy (SG) is a popular surgery for morbid obesity because of minimal complications, while somewhere uncommon micronutrient deficiencies occur that make problems. One of these rare complications is dry beriberi (BB). CASE PRESENTATION: A 20-year-old girl with obesity that a few months after SG had non-specific symptoms like nausea, vomiting, debilitating weakness, burning, and tingling in her feet, which led to more tests and imaging and confused the physicians. During the next two months, she had a 40 kg weight loss. The critical test that helped diagnosis was Electromyography and Nerve Conduction Velocity (EMG/NCV), which showed subacute axonal sensory-motor polyneuropathy and decreased level of vitamin B1, proved the patient's diagnosis was dray BB. CLINICAL DISCUSSION: SG may contribute to vitamin and trace elements deficiency development. One of the micronutrients that deficiencies can disturb the patient is vitamin B1 deficiency. Vitamin B1 deficiencies could be demonstrated with peripheral polyneuropathy, beriberi, or Wernicke-Korsakoff syndrome. Based on decreased vitamin B1 and EMG/NCV results, the diagnosis had been dry beriberi corrected with supplement therapy. CONCLUSION: Thiamine deficiency should be suspected in all patients with vomiting, neurological symptoms, and rapid weight loss post-bariatric surgery (BS), even after restrictive surgery. Especially when a patient reports substantial weight loss and vomiting in short order. Hopefully, this case report will make any patient hospitalized with similar conditions evaluated for beriberi and again multivitamin supplementation therapy after SG is emphasized.

Retroperitoneal duodenal perforation due to COVID-19: An extremely rare case report.

Introduction and importance: Gastrointestinal (GI) symptoms are the most common extrapulmonary presentation of coronavirus disease 2019 (COVID-19) infection. GI perforation may be an unusual manifestation of COVID-19 infection. Case presentation: We report a 45-year-old man who presented with acute abdominal pain without any respiratory symptoms to our emergency department. Investigations revealed retroperitoneal duodenal perforation and fibrotic changes in lung bases. Laboratory findings demonstrated a positive polymerase chain reaction (PCR) test for COVID-19 and mild leukocytosis. Clinical discussion: COVID-19 related perforation of the retroperitoneal part of the duodenum is extremely rare, and to the best of our knowledge, this is the first reported case. With increasing COVID-19 infection, we might see more cases of GI perforation. In the era of COVID-19 pandemic, any abdominal signs and symptoms should alert the clinicians to consider COVID-19 diagnosis in the differential. Conclusion: Conservative management with close monitoring, antibiotic therapy and serial examinations were completely successful. The patient's general condition improved, and he was discharged on day 7 of hospitalization.