Morphology, localization, and patterns of ghrelin-producing cells in stomachs of a morbidly obese population.

BACKGROUND: The role of the hormone ghrelin in the pathogenesis of morbid obesity is unclear. Researchers have identified its involvement in multifunctional activities that include appetite regulation, intestinal motility, release of growth hormone, and cell proliferation. The purpose of this study is to investigate and distinguish a pattern, if present, in ghrelin-producing cells and to record their distribution and quantity in a heterogenic morbidly obese population. SETTING: The Bariatric & Metabolic Institute, Section of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, FL. MATERIALS AND METHODS: Thirty-six patients who underwent sleeve gastrectomy for morbid obesity were evaluated for number and distribution of gastric ghrelin. Sections of fundus, body, and antrum were evaluated by using a ghrelin antibody staining technique. The gross specimens were divided into the following 3 zones: (1) fundus; (2) body; and (3) antrum. Three sections were then submitted from each zone. The ghrelin cells were counted using an image analyzer (MetaMorph; Universal Imaging Corporation, Downingtown, PA) after staining the blocks with antighrelin antibody. Counting ghrelin cells was standardized, and for each section 10 high-power fields were examined at ×4000. Our statistical analysis entailed a Student t test to compare the number of cells by age, sex, race, diabetic/nondiabetic, and body mass index. A P-value <0.05 was considered statistically significant. RESULTS: Thirty-six patients (female 20/male 16) were studied. The average age of these patients was 45.6 (18 to 71) years. Race distribution was as follows: whites, 50% (18); African American, 13.9% (5); and Hispanic, 36.1% (13). Patients with diabetes comprised 13.9% of the cohort (5). Average body mass index was 44.9 kg/m (31 to 70). Significant differences in ghrelin cell distribution were found when comparing gastric anatomy location. Ghrelin cells were significantly more abundant in the gastric fundus when compared with the body and the antrum. Quantities of cells in the antrum were significantly higher in the Hispanic population (P=0.0054). No significant differences among other groups were observed. CONCLUSIONS: In conclusion, ghrelin-producing cells seem to be more abundant in the fundus of morbidly obese patients. No significant differences were found in terms of number of cells by age, sex, presence of diabetes, or body mass index. There was an incidental finding of a higher concentration of these cells located in the antrum of the Hispanic population when compared with the white cohort.

Association of obesity with risk of coronary heart disease: findings from the National Health and Nutrition Examination Survey, 1999-2006.

BACKGROUND: Obesity is a well-known risk factor for the development of coronary heart disease (CHD). The aim of the present study was to examine the differences in the 10-year CHD risk with increasing severity of obesity in men and women participating in the latest National Health and Nutrition Examination Survey. METHODS: Data from a representative sample of 12,500 U.S. participants in the National Health and Nutrition Examination Survey from 1999 to 2006 were reviewed. The Framingham risk score was calculated for men and women according to a body mass index (BMI) of <25.0, 25.0-29.9, 30.0-34.9, and ≥ 35.0 kg/m(2). RESULTS: The prevalence of those with hypertension increased with an increasing BMI, from 24% for a BMI <25.0 kg/m(2) to 54% for a BMI of ≥ 35.0 kg/m(2). The prevalence of an abnormal total cholesterol level (>200 mg/dL) increased from 40% for a BMI <25.0 kg/m(2) to 48% for a BMI of ≥ 35.0 kg/m(2). The 10-year CHD risk for men increased from 3.1% for a BMI <25.0 kg/m(2) to a peak of 5.6% for a BMI of 30.0-34.9 kg/m(2). The 10-year CHD risk for women increased from .8% for a BMI <25.0 kg/m(2) to a peak of 1.5% for a BMI of ≥ 35.0 kg/m(2). Both diabetes and hypertension were independent risk factors for an increasing CHD risk. CONCLUSIONS: The 10-year CHD risk, calculated using the Framingham risk score, substantially increased with an increasing BMI. An important implication from our findings is the need to implement surgical and medical approaches to weight reduction to reduce the effect of morbidity and mortality from CHD on the U.S. healthcare system.

Inhibition of intraluminal pancreatic enzymes with nafamostat mesilate improves clinical outcomes after hemorrhagic shock in swine.

BACKGROUND: Recent studies suggest that intraluminal pancreatic enzymes play a major role in the initiation of the inflammatory cascade by the gut after hemorrhagic shock. Previous animal models have shown that the inhibition of enteral pancreatic enzymes with a serine protease inhibitor, nafamostat mesilate (NM), decreases leukocyte activation and transfusion requirements after hemorrhagic shock. The objective of this study was to determine whether enteroclysis with NM would improve the clinical outcomes in swine after hemorrhagic shock and intestinal hypoperfusion. METHODS: Thirty-three male Yucatan minipigs weighing 25 kg to 30 kg underwent a controlled hemorrhage of 25 mL/kg with mesenteric clamp for further gut ischemia. Animals were allocated to three groups: (1) shock only (n = 15), (2) shock + enteroclysis with 100 mL/kg GoLYTELY (GL) as a carrier (n = 11), and (3) shock + enteroclysis with GL + 0.37 mmol/L NM (GL+NM, n = 7). Animals were resuscitated, recovered from anesthesia, observed for 3 days, and graded on a daily 4-point clinical scoring system. A score of 0 indicated a moribund state or early death, and a score of 4 indicated normal behavior. RESULTS: Pigs treated with GL + NM had significantly higher mean postoperative recovery scores (3.8 +/- 0.4, essentially normal behavior with no early deaths) compared with animals within the shock only and shock + GL groups (2.1 +/- 1 with one early death and 2.2 +/- 1.2 with two early deaths, respectively, analysis of variance p < 0.003). CONCLUSION: The inhibition of intraluminal pancreatic enzymes using enteroclysis with the serine protease inhibitor, NM, after hemorrhagic shock significantly improves the clinical outcome.

Improved bariatric surgery outcomes for Medicare beneficiaries after implementation of the medicare national coverage determination.

OBJECTIVE: To compare the outcomes of Medicare beneficiaries who underwent bariatric surgery within 18 months before and after implementation of the national coverage determination (NCD) for bariatric surgery. DESIGN: Analysis of the University HealthSystem Consortium database from October 1, 2004, through September 31, 2007. SETTING: A total of 102 academic medical centers and approximately 150 of their affiliated hospitals, representing more than 90% of the nation's nonprofit academic medical centers. PATIENTS: Medicare and Medicaid patients who underwent bariatric surgery to treat morbid obesity. MAIN OUTCOME MEASURES: Demographics, length of stay, 30-day readmission, morbidity, observed-to-expected mortality ratio, and costs. RESULTS: A total of 3196 bariatric procedures were performed before and 3068 after the NCD. After the implementation of the NCD, the volume of gastric banding doubled and the proportion of laparoscopic gastric bypass increased from 60.0% to 77.2%. Patients who underwent bariatric surgery after the NCD benefited from a shorter length of stay (3.5 vs 3.1 days, P < .001) and lower overall complication rates (12.2% vs 10.0%, P < .001), with no significant differences in the in-hospital mortality rates (0.28% vs 0.20%). Among Medicare patients, there was a 29.3% reduction in the number of bariatric procedures performed within the first 2 quarters after the NCD. However, the number of procedures returned to baseline volume within 1 year and exceeded baseline volume after 2 years of the NCD. CONCLUSION: The bariatric surgery NCD resulted in improved outcomes for Medicare beneficiaries without limiting access to care for individuals with medical disability.

Comparison study of conventional laparoscopic gastric banding versus laparoendoscopic single site gastric banding.

BACKGROUND: Laparoscopic gastric banding is commonly performed using 5-6 abdominal trocars with enlargement of the largest trocar for implantation of the subcutaneous port. The aim of the present study was to compare the outcomes of conventional laparoscopic gastric banding with those of gastric banding performed through a single or duel incision. METHODS: From April 2008 to May 2009, 23 patients underwent laparoscopic gastric banding through a single, 3.5-4.5-cm incision with implantation of the port through the same incision. The 2 study cohorts were matched for age, gender, and body mass index. The outcome measures included the operative time, blood loss, need for conversion to 5-trocar laparoscopy, and perioperative morbidity. RESULTS: Each group included 6 men and 17 women. No significant differences were found between the 2 groups with regard to preoperative body mass index (40 versus 39 kg/m(2)), operative time, blood loss, or length of hospital stay. Of the 23 patients in the single incision group, 3 (13%) required conversion to conventional 5-trocar laparoscopy. No intraoperative or postoperative complications developed in either group. CONCLUSION: The present results have shown that in a subset of patients with a lower body mass index, adjustable gastric banding performed through a single laparoscopic incision is technically feasible and safe and does not prolong the operative time. The procedure can be performed with mostly existing ports, laparoscopic instrumentation, and visualization platforms. A prospective randomized trial is necessary to determine the clinical advantages of this less-invasive technique.

Minimally invasive esophagectomy without the use of postoperative nasogastric tube decompression.

A nasogastric tube (NGT) is commonly used in the postoperative period after esophagectomy for decompression of the gastric conduit. The aim of this study was to evaluate the safety of a minimally invasive esophagectomy without the use of NGT decompression. We performed a retrospective review of 124 patients who underwent minimally invasive esophagectomy. Ninety-eight patients had an NGT placed for postoperative decompression and 26 patients did not. The main outcome measure was postoperative complications in regard to the gastric conduit and esophageal anastomosis. There were 96 males with a mean age of 65 +/- 11 years. Three (3%) of 98 patients with operative NGT placement developed postoperative complications directly related to the NGT, which included perforation of the gastric conduit (n = 1) and perforation of the anastomosis (n = 2). In the 26 patients without operative NGT decompression, one patient (3.8%) had distention of the gastric conduit requiring placement of a NGT under fluoroscopic guidance on postoperative Day 1. There was no significant difference in the leak rate between the groups with NGT decompression compared with the group without NGT decompression (9.2 vs 7.7%, respectively). In conclusion, the use of NGT decompression during minimally invasive esophagectomy can be safely omitted. In cases with postoperative gastric conduit distention, an NGT can be safely placed under fluoroscopic guidance.

A prospective randomized trial of laparoscopic gastric bypass versus laparoscopic adjustable gastric banding for the treatment of morbid obesity: outcomes, quality of life, and costs.

BACKGROUND: Gastric bypass and adjustable gastric banding are the 2 most commonly performed bariatric procedures for the treatment of morbid obesity. The aim of this study was to compare the outcomes, quality of life, and costs of laparoscopic gastric bypass versus laparoscopic gastric banding. STUDY DESIGN: Between 2002 and 2007, 250 patients with a body mass index of 35 to 60 kg/m2 were randomly assigned to gastric bypass or gastric banding. After exclusion, 111 patients underwent gastric bypass and 86 patients underwent gastric banding. Outcome measures included demographic data, operative time, blood loss, length of hospital stay, morbidity, mortality, early and late reoperation rate, weight loss, changes in quality of life, and cost. Treatment failure was defined as losing less than 20% of excess weight or conversion to another bariatric operation for failure of weight loss. RESULTS: There were no deaths at 90 days in either group. The mean body mass index was higher in the gastric bypass group (47.5 vs. 45.5 kg/m2, respectively, P < 0.01) while the mean age was higher in the gastric band group (45 vs. 41 years, respectively, P < 0.01). Compared with gastric banding, operative blood loss was higher and the mean operative time and length of stay were longer in the gastric bypass group. The 30-day complication rate was higher after gastric bypass (21.6% vs. 7.0% for gastric band); however, there were no life-threatening complications such as leaks or sepsis. The most frequent late complication in the gastric bypass group was stricture (14.3%). The 1-year mortality was 0.9% for the gastric bypass group and 0% for the gastric band group. The percent of excess weight loss at 4 years was higher in the gastric bypass group (68 ± 19% vs. 45 ± 28%, respectively, P < 0.05). Treatment failure occurred in 16.7% of the patients who underwent gastric banding and in 0% of those who underwent gastric bypass, with male gender being a predictive factor for poor weight loss after gastric banding. At 1-year postsurgery, quality of life improved in both groups to that of US norms. The total cost was higher for gastric bypass as compared with gastric banding procedure ($12,310 vs. $10,766, respectively, P < 0.01). CONCLUSIONS: Laparoscopic gastric bypass and gastric banding are both safe and effective approaches for the treatment of morbid obesity. Gastric bypass resulted in better weight loss at medium- and long-term follow-up but was associated with more perioperative and late complications and a higher 30-day readmission rate. There was a wide variation in weight loss after gastric banding with a small proportion of patients considered as treatment failure, and male gender was a predictive factor for poor weight loss.

Laparoscopic transumbilical gastrojejunostomy: an advanced anastomotic procedure performed through a single site.

BACKGROUND: Single-site laparoscopic surgery and natural orifice transumbilical surgery (NOTUS) have become exciting areas of surgical development. However, most reported case series consist of basic laparoscopic procedures, such as cholecystectomy and appendectomy. In this paper, we present the case of an advanced laparoscopic operation-construction of a gastrointestinal anastomosis-that was performed through ports placed entirely within the umbilicus. METHODS: In this paper, we describe a 61-year-old male with a history of advanced pancreatic carcinoma who was referred with a gastric outlet obstruction. A laparoscopic gastrojejunostomy bypass, using a linear stapler with suture closure of the enterotomy, was performed through three abdominal trocars placed entirely within the umbilicus. Some potential advantages of NOTUS palliative gastrojejunostomy include reduced postoperative pain and the lack of visible abdominal scars. RESULTS: The operation was completed uneventfully in 40 minutes. The patient recovered without complications and was discharged on postoperative day 2. At 1-month follow-up, the patient had improved oral intake without any further vomiting symptoms. CONCLUSION: This case report documents the feasibility of an advanced anastomotic gastrojejunostomy procedure which can be performed through a single site. However, benefits of this approach, compared to conventional laparoscopic procedures, will require a prospective randomized clinical trial.

Laparoscopic transgastric access to the biliary tree after Roux-en-Y gastric bypass.

Gallstone disease, common after Roux-en-Y gastric bypass (RYGBP), may be complicated by biliary duct obstruction and gallstone pancreatitis. Although endoscopic retrograde cholangiopancreatography plays an important role in management of biliary duct obstruction, the altered anatomy of patients who have had a RYGBP makes this procedure technically difficult. With the increased number of patients undergoing RYGBP for morbid obesity, bariatric surgeons may benefit from an alternative laparoscopic technique for accessing the biliary tree. We describe a laparoscopic technique of accessing the biliary tree through the bypassed stomach.