Identifying novel regulatory effects for clinically relevant genes through the study of the Greek population.

BACKGROUND: Expression quantitative trait loci (eQTL) studies provide insights into regulatory mechanisms underlying disease risk. Expanding studies of gene regulation to underexplored populations and to medically relevant tissues offers potential to reveal yet unknown regulatory variants and to better understand disease mechanisms. Here, we performed eQTL mapping in subcutaneous (S) and visceral (V) adipose tissue from 106 Greek individuals (Greek Metabolic study, GM) and compared our findings to those from the Genotype-Tissue Expression (GTEx) resource. RESULTS: We identified 1,930 and 1,515 eGenes in S and V respectively, over 13% of which are not observed in GTEx adipose tissue, and that do not arise due to different ancestry. We report additional context-specific regulatory effects in genes of clinical interest (e.g. oncogene ST7) and in genes regulating responses to environmental stimuli (e.g. MIR21, SNX33). We suggest that a fraction of the reported differences across populations is due to environmental effects on gene expression, driving context-specific eQTLs, and suggest that environmental effects can determine the penetrance of disease variants thus shaping disease risk. We report that over half of GM eQTLs colocalize with GWAS SNPs and of these colocalizations 41% are not detected in GTEx. We also highlight the clinical relevance of S adipose tissue by revealing that inflammatory processes are upregulated in individuals with obesity, not only in V, but also in S tissue. CONCLUSIONS: By focusing on an understudied population, our results provide further candidate genes for investigation regarding their role in adipose tissue biology and their contribution to disease risk and pathogenesis.

Radiofrequency ablation assisted resection for hepatocellular carcinoma: morbidity, mortality and long term survival.

PURPOSE: Hepatic resection is the mainstay of the curative treatment of primary hepatic tumors, with constantly improving short and long term results. Radiofrequency ablation (RFA)-assisted liver resection is a relatively new method of transection of the liver parenchyma with favorable intra- and perioperative results. The aim of this study was to investigate the oncological efficacy (long term overall survival/OS and disease free survival/DFS) and to confirm the favorable short term morbidity and mortality. METHODS: Between May 2004 and January 2007, 28 patients underwent 32 resections with removal of 50 hepatocellular carcinoma (HCC) lesions. The technique of parenchymal transection has been described previously as RFA-assisted liver resection. RESULTS: Thirty-day morbidity and mortality were 42.8 and 0%, respectively. Blood transfusion was necessary for 28.5% of the patients. The median hospital stay was 16.5 days (range 5-34). The 1- and 3-year OS were 92.9 and 65.7%, respectively. The 1- and 3-year DFS were 62.3 and 54.6- respectively. No patient developed metastatic disease or local recurrence at the margin site. Twelve patients (42.9%) developed in-the-liver recurrence away from the resection area. CONCLUSION: RFA-assisted liver resection is a safe and oncologically efficacious method for the surgical treatment of HCC with results comparable to other surgical techniques.

Growth of Intestinal Neomucosa on Pedicled Gastric Wall Flap, a Novel Technique in an Animal Model.

Background: Short bowel syndrome (SBS) remains an unsolved issue in modern medicine. Numerous experimental surgical techniques have been proposed in the attempt to increase the intestinal absorptive capacity.Materials and Methods: Ten female Landrace pigs, divided in two groups of 5 (A and B), were explored through a midline incision. A spindle-shaped vascularized full-thickness gastric wall flap (GWF) consisting of part of the major curvature with the gastroepiploic arch preserved was de-epithelialized and then placed as a "patch" to cover an antimesenteric border defect of either a nonfunctional blind intestinal loop (group A) or a functional intestinal loop of the gastrointestinal tract (group B). A spindle-shaped curved, rigid, low density polyethylene (LDPE) splint was sutured on the external surface of the patch in order to prevent shrinkage of GWF and collapse of the intestinal wall in group A.Results: There was a decrease of both dimensions of the patch. Microscopically a thin layer of columnar epithelial cells covered the center of the patch, evolving in shorter, blunt, poorly developed villi with increasing maturation laterally. The patch surface was covered by nearly 90%. In the three animals that died prematurely the coverage of GWF was negligent or suboptimal directly dependent on the length of survival.Conclusions: The hereby-described patching technique demonstrated the growth of intestinal neomucosa on the GWF. The capability of the stomach to provide large flaps and the advantages of the use of native tissues render this animal model valuable for the future research in the field.

Fibrinolytic and coagulation pathways after laparoscopic and open surgery: a prospective randomized trial.

BACKGROUND: Tissue injury poses increased risk for postoperative thromboembolic complications. Laparoscopic surgery, by causing limited tissue injury, is associated with lower risk for thromboembolism than is open surgery. We conducted a prospective randomized study in order to detect potentially existing differences in activation of coagulation and fibrinolytic pathways between open and laparoscopic surgery. METHODS: Forty patients with chronic cholelithiasis were randomly assigned to undergo open (group A) or laparoscopic cholecystectomy (group B). Blood samples were taken preoperatively, at the end of the procedure, and at 24 and 72 h postoperatively. Prothrombin time (PT), activated partial thromboplastin time (APTT), international normalized ratio (INR), platelets (PLT), soluble fibrin monomer complexes (F.S. test), fibrin degradation products (FDP), D-dimers (D-D), and fibrinogen (FIB) were measured and compared within each group and between groups: Thrombin-antithrombin complexes (TAT) and prothrombin fragments (F1 + 2) were measured at 24 and 72 h postoperatively. RESULTS: Demographics were comparable between groups. Immediately postoperatively, TAT and F1 + 2 were significantly higher in group A (p < 0.05). They also increased significantly postoperatively as compared with preoperative levels within each group (p < 0.05). D-dimers were significantly higher in group A (p < 0.01) immediately postoperatively. D-dimers also increased significantly postoperatively in group B as compared with preoperative levels (p < 0.001). FIB decreased slightly in both groups at 24 h postoperatively but there was a significant increase in group A (p < 0.01). Soluble fibrin monomer complexes (SFMC) were detected twice in group A and only once in group B. FDP levels over 5 µg/ml were detected more often in group A (p < 0.05). There was not any case of thromboembolism or abnormal bleeding. CONCLUSIONS: Open surgery leads to higher activation of the clotting system than do laparoscopic procedures. Although of a lower degree, hypercoagulability is still observed in patients undergoing laparoscopic surgery and therefore routine thromboembolic prophylaxis should be considered.

Roux-en-Y Gastric Bypass Is More Effective than Sleeve Gastrectomy in Improving Postprandial Glycaemia and Lipaemia in Non-diabetic Morbidly Obese Patients: a Short-term Follow-up Analysis.

PURPOSE: We aimed to compare the effects of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) on postprandial glucose and lipid metabolism in addition to weight loss and fasting metabolic profile, in non-diabetic patients undergoing bariatric surgery. METHODS: Seventy-one patients were consecutively recruited and studied preoperatively, 3 and 6 months after surgery. Of these, 28 underwent RYGB (7 males, age 38 ± 9 years, BMI 46.9 ± 5.0 kg/m2), and 43 SG (9 males, age 38 ± 9 years, BMI 50.2 ± 7.0 kg/m2). A semi-liquid mixed meal was consumed, and blood samples were taken before, and every 30 min after meal ingestion up to 180 min postprandially, for measurement of glucose, insulin, and lipids. The overall postprandial response was assessed as area under the concentration-time curve (AUC). RESULTS: Baseline metabolic parameters were similar between RYGB and SG. Both groups experienced comparable weight loss, and a similar improvement in fasting glucose, insulin, and insulin resistance. Total and LDL cholesterol levels were lower at 6 months after RYGB compared to SG, while there was no difference in HDL cholesterol or triglycerides. Glucose AUC was lower after RYGB compared to SG at both 3 (p = 0.008) and 6 months (p = 0.016), without any difference in postprandial insulin response. Triglyceride AUC was also lower in RYGB vs. SG at 3 and 6 months (p ≤ 0.001). CONCLUSIONS: RYGB is superior to SG in improving postprandial glycaemia and lipaemia and cholesterol profile 6 months postoperatively in non-diabetic, severely obese patients. These findings imply procedure-specific effects, such as the malabsorptive nature of RYGB, and less likely a different incretin postoperative response.

Laparoscopic esophagomyotomy for achalasia without a complementary antireflux procedure.

BACKGROUND: Achalasia is a progressive motility disorder of the esophagus, without a definitive cure. The principal method of palliation is myotomy of the distal esophagus. We analyzed the 5-year experience at our institution with laparoscopic Heller myotomy without an antireflux procedure to determine its results, particularly regarding postoperative gastroesophageal reflux. MATERIALS AND METHODS: Thirty-three patients, mean age 43 years (range, 29-62 years) with clinical, manometric, x-ray, and endoscopic proof of achalasia were operated on and followed up for 24 months. Prior to being referred to surgery they had all undergone at least one pneumatic balloon dilation. The operative technique was a 7-cm myotomy that included the lower esophageal sphincter but did not exceed 5 mm of the gastric cardia. Follow-up consisted of clinical observation, cineesophagography, and 24-hour pHmetry. RESULTS: All patients reported satisfactory to excellent results regarding dysphagia and no heartburn two years after the operation. The 24-hour pHmetry and the radiographic investigation showed no evidence of gastroesophageal reflux. CONCLUSION: It seems that the risk of gastroesophageal reflux is very low when the cardiomyotomy does not exceed the length of 5 mm. Our results are in accordance with other observational studies as well as larger cohort and meta-analysis studies. Prospective randomized studies are needed to clarify the role of an antireflux procedure after laparoscopic Heller myotomy.

Pancreatic tuberculosis: a medical disease posing surgical dilemmas.

Pancreatic tuberculosis is a rare clinical setting manifesting in various ways. Most often, enlarged peripancreatic lymph nodes or growing tuberculomas compress adjacent organs, leading to biliary tract or gastrointestinal obstruction. Clinical examination, laboratory data, and imaging are all unspecific. Diagnosis is frequently misguided toward neoplasia requiring surgical intervention. However, the role of surgery in pancreatic tuberculosis ends in tissue sampling, abscess drainage, and bypassing obstruction. We present three cases of pancreatic tuberculosis: two caused by obstructive jaundice and the third caused by gastric outlet obstruction. All patients were operated on. Whipple's procedure was performed in one patient, and biliary and duodenal bypassing in the remaining patients. Diagnosis was decided by histopathology in all three cases. Medical treatment was effective in all patients. Although pancreatic tuberculosis is a medical disease, surgery is frequently used. Maintaining a high level of suspicion can assist in avoiding unnecessary laparotomies and solving this medical dilemma.

Robotic sleeve gastrectomy for morbid obesity: report of a 5 year experience.

BACKGROUND: Robotic bariatric procedures are nowadays in the surgeon's arsenal for the treatment of morbid obesity. With proven efficacy and advantages in gastric bypass procedures, we attempted to employ robotics and study the results in the other major bariatric procedure, sleeve gastrectomy. METHODS: We used the da Vinci S® system to perform 19 robotic sleeve gastrectomies (RSGs) and reviewed the 5-year results as far as excess body weight loss is concerned, and amelioration of obesity-related comorbidities. RESULTS: Mean percentage of excess body weight loss (%EWL) was 64.4%, 67.1%, 61.7%, 63.1%, 64.8% for the first, second, third, fourth and fifth year, respectively. Neither of our two patients with diabetes mellitus (0%) or hypertension (0%) showed remission, while all six of our patients (100%) showed remission of their sleep apnoea after 5 years. CONCLUSIONS: Robotic sleeve gastrectomy is an effective procedure as far as initial excess weight loss is concerned and this loss is well maintained 5 years post-operatively, a finding similar to relevant data after conventional laparoscopic sleeve gastrectomy. Copyright © 2015 John Wiley & Sons, Ltd.

Laparoscopic sleeve gastrectomy for morbid obesity: 5-year results.

BACKGROUND: Data concerning the long-term efficacy of laparoscopic sleeve gastrectomy in the treatment of morbid obesity remain scarce. In this retrospective, the authors present 5-year follow-up of 30 patients having undergone laparoscopic sleeve gastrectomy. METHODS: Since 2004, 30 patients underwent laparoscopic sleeve gastrectomy and completed 5 years of follow-up. Five patients were subsequently subjected to laparoscopic Roux-en-Y gastric bypass and were excluded from further analysis. The remaining 25 patients comprised the study population. RESULTS: Mean excess weight loss was 65.2 ± 6.1%, 64.7 ± 5.6%, 62 ± 4.9%, 58.2 ± 5.5%, and 56.4 ± 5.8% for the first 5 years, respectively. There were no deaths, nor any major morbidity. Remission of comorbidities was observed in 40% to 80.9% of cases. CONCLUSIONS: Laparoscopic sleeve gastrectomy is a safe and effective means of treatment of morbid obesity both in the short and in the long term. More research is needed to better predict which patient will benefit most from this operation.

Determinants of Secondary Hyperparathyroidism in Bariatric Patients after Roux-en-Y Gastric Bypass or Sleeve Gastrectomy: A Pilot Study.

Objective. Nutritional deficiencies are common after bariatric surgery. We aimed to assess the prevalence and possible predictors of secondary hyperparathyroidism (SHPT) in bariatric patients. Methods. A total of 95 patients who had undergone Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) were assessed after a median of 3 years after surgery. Anthropometric/demographic and weight-loss parameters were compared according to the presence of SHPT, independently for men/premenopausal women and postmenopausal women. Results. SHPT was highly prevalent (men/premenopausal women, 52.1%; postmenopausal women, 31.9%). Among men/premenopausal women, multivariate analysis indicated that SHPT was predicted by (a) 25-hydroxyvitamin D levels (Exp(B) = 0.869, P-value = 0.037), independently of age, sex, smoking; (b) calcium (Exp(B) = 0.159, P-value = 0.033) and smoking, independently of age and sex; (c) magnesium (Exp(B) = 0.026, P-value = 0.046) and smoking, independently of age and sex. Among postmenopausal women, SHPT was predicted by menopausal age independently of age, smoking, and levels of 25-hydroxyvitamin D or calcium. The development of SHPT was not associated with the type of surgery. Conclusions. RYGB and SG exhibited similar effects regarding the regulation of the hypothalamus-pituitary-parathyroid axis after surgery. Vitamin D status and menopausal age appear to determine SHPT on the long term. SHPT should be sought and vigorously treated with calcium and vitamin D supplementation.

Early or Delayed Intervention for Bile Duct Injuries following Laparoscopic Cholecystectomy? A Dilemma Looking for an Answer.

Background. To evaluate the effect of timing of management and intervention on outcomes of bile duct injury. Materials and Methods. We retrospectively analyzed 92 patients between 1991 and 2011. Data concerned patient's demographic characteristics, type of injury (according to Strasberg classification), time to referral, diagnostic procedures, timing of surgical management, and final outcome. The endpoint was the comparison of postoperative morbidity (stricture, recurrent cholangitis, required interventions/dilations, and redo reconstruction) and mortality between early (less than 2 weeks) and late (over 12 weeks) surgical reconstruction. Results. Three patients were treated conservatively, two patients were treated with percutaneous drainage, and 13 patients underwent PTC or ERCP. In total 74 patients were operated on in our unit. 58 of them underwent surgical reconstruction by end-to-side Roux-en-Y hepaticojejunostomy, 11 underwent primary bile duct repair, and the remaining 5 underwent more complex procedures. Of the 56 patients, 34 patients were submitted to early reconstruction, while 22 patients were submitted to late reconstruction. After a median follow-up of 93 months, there were two deaths associated with BDI after LC. Outcomes after early repairs were equal to outcomes after late repairs when performed by specialists. Conclusions. Early repair after BDI results in equal outcomes compared with late repair. BDI patients should be referred to centers of expertise and experience.

Bsm1 vitamin D receptor polymorphism and calcium homeostasis following bariatric surgery.

PURPOSE/AIM: To evaluate the association between the Bsm1 vitamin D receptor polymorphism and the calcium-vitamin D-parathormone axis following bariatric surgery. MATERIALS AND METHODS: This cross-sectional study included 86 morbidly obese patients, who underwent either gastric bypass or sleeve gastrectomy, with a mean follow-up of four years. Calcium metabolism indices and bone turnover markers were assessed according to the presence of secondary hyperparathyroidism and the Bsm1 vitamin D receptor genotypes. RESULTS: Secondary hyperparathyroidism (42.2% of sample) was associated with lower levels of 25hydroxyvitamin D and elevated markers of bone turnover. In subjects without secondary hyperparathyroidism, presence of the unfavorable B allele resulted in higher levels of parathormone (Bb and BB vs. bb genotype: 50.3 ± 8.2 pg/dl vs. 44.4 ± 10.7 pg/dl, p = .011, adjusted for weight loss, baseline body mass index, 25hydroxyvitamin D, surgical procedure, and duration after surgery). In the whole sample, patients bearing the unfavorable B allele exhibited lower weight loss, a parameter that was negatively associated with markers of bone resorption. CONCLUSIONS: Secondary hyperparathyroidism is highly prevalent after bariatric surgery. Bsm1 vitamin D receptor polymorphism may have an effect in early stages of calcium metabolism imbalance, while no association is detected in patients who have already developed secondary hyperparathyroidism. Moreover, vitamin D receptor polymorphism is associated with post-surgery weight loss, a process related to bone turnover.

Clinical significance of serum and urinary c-erbB-2 levels in colorectal cancer.

In this study we measured serum and urinary c-erbB-2 levels in 63 patients with colorectal cancer and 29 healthy controls, assessing their role in cancer-specific survival and the effects of resectional surgery. Serum and urinary c-erbB-2 levels were measured by an enzyme-linked immunosorbent assay, preoperatively and 7 days following tumor resection. Preoperative serum c-erbB-2 concentrations were significantly higher in the cancer patients and correlated with disease stage and the presence of liver metastases. Urinary c-erbB-2 was detected more often in cancer patients, although levels did not differ from controls and there was no association with any clinicopathological variable. Serum c-erbB-2 levels decreased significantly in those patients resected for cure and were an independent prognostic factor for cancer-specific survival with higher preoperative concentrations correlating with worse overall survival. These findings suggest that serum assessment of c-erbB-2 concentration may be valuable in defining colorectal cancer prognosis.

Clinical significance of soluble c-erbB-2 levels in the serum and urine of patients with gastric cancer.

BACKGROUND: Both tissue c-erbB-2 expression and serum levels the shed protein have been shown to correlate with tumour stage in a range of adenocarcinomas. This study measured serum and urinary c-erbB-2 levels in patients with gastric cancer, assessing their role in cancer-specific survival and the effects of resectional surgery. PATIENTS AND METHODS: Serum and urinary c-erbB-2 concentrations were measured with commercial enzyme-linked immunosorbent assay in 41 healthy controls and in 54 gastric cancer patients. Serum and urinary c-erbB-2 levels in cancer patients were determined before and 7 days following tumour surgery. RESULTS: Preoperative serum and urinary c-erbB-2 levels in gastric cancer patients were significantly higher than those in controls although there were no significant associations between these levels and tumour pathology. Serum c-erbB-2 levels decreased significantly after radical resection of the primary tumour and were an independent prognostic factor for survival, whereas there were no changes in urinary c-erbB-2 levels after surgery or an association with patient survival. CONCLUSION: Gastric cancer patients show higher serum and urinary c-erbB-2 levels compared to healthy controls. Preoperative serum c-erbB-2 concentration decreases significantly after radical resection of the primary tumour and is an independent prognostic factor for patient survival.

Radio-frequency tissue ablation in liver trauma: an experimental study.

The liver is the most frequently injured intra-abdominal organ. Radio-frequency tissue ablation (RFA) with cooled tip electrodes is here experimentally used for the treatment of liver trauma. A grade III and a grade III to IV trauma each were produced in the livers of 10 domestic pigs. RFA was applied around the sites of injury until hemostasis was achieved. The animals were sacrificed at 0, 3, 7, 14, and 21 days and examined. The livers were subjected to histologic and radiologic examination. Two similar traumas were created in the livers of two more animals and were left surgically untreated as a control group. The two untreated animals died immediately postoperatively, proving the severity of the injuries. Hemostasis was achieved in all treated animals. Mortality and morbidity were zero. No blood, pus, bile, or other fluid was found in the abdomen at sacrifice. A three-zone pattern of lesion was recognized around the electrode placement at histology. RFA is an efficient and safe hemostatic method for grade III and grade III to IV hepatic trauma. Further studies are required for its use in humans.

Cross-sectional long-term micronutrient deficiencies after sleeve gastrectomy versus Roux-en-Y gastric bypass: a pilot study.

BACKGROUND: Nutritional deficiencies are highly prevalent in obese patients. Bariatric surgery has been associated with adverse effects on homeostasis of significant vitamins and micronutrients, mainly after gastric bypass. The aim of the present study was to compare the extent of long-term postsurgical nutritional deficiencies between Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). METHODS: This cross-sectional, pilot study included 95 patients who underwent RYGB or SG surgery with a mean follow-up of 4 years. Demographic, anthropometric, and biochemical parameters were compared according to the type of surgery. RESULTS: Both types of surgery were associated with significant nutritional deficiencies. Vitamin B12 deficiency was significantly higher in patients with RYGB compared with SG (42.1% versus 5%, P = .003). The type of surgery was associated neither with anemia nor with iron or folate deficiency (SG versus RYGB: anemia, 54.2% versus 64.3%, P = .418; folate deficiency, 20% versus 18.4%, P = .884; iron deficiency, 30% versus 36.4%, P = .635). CONCLUSION: During a mean follow up period of 4 years postRYGB or SG, patients were identified with several micronutrient deficiencies, including vitamin D, folate, and vitamin B12. SG may have a more favorable effect on the metabolism of vitamin B12 compared with RYGB, being associated with less malabsorption. Adherence to supplemental iron and vitamin intake is of primary significance in all cases of bariatric surgery.

Review of long-term weight loss results after laparoscopic sleeve gastrectomy.

Sleeve gastrectomy (SG) has gained enormous popularity both as a first-stage procedure in high-risk super-obese patients and as a stand-alone procedure. The objective of this study was to evaluate the long-term weight loss results after SG published in the literature and compare them with the well-documented short-term and mid-term weight loss results. A detailed search in PubMed using the keywords "sleeve gastrectomy" and "long-term results" found 16 studies fulfilling the criteria of this study. A total of 492 patients were analyzed, with a follow-up of at least 5 years after laparoscopic sleeve gastrectomy (LSG) (373 at 5 years, 72 at 6 years, 13 at 7 years, and 34 at 8 or more years). Of the total number of patients, 71.1% were women (15 studies, n = 432 patients). Mean patient age was 45.1 years (15 studies, n = 432 patients). Mean preoperative body mass index in all 16 studies was 49.2 kg/m(2). The mean percentage excess weight loss (%EWL) was 62.3%, 53.8%, 43%, and 54.8% at 5, 6, 7, and 8 or more years after LSG, respectively. The overall mean %EWL (defined as the average %EWL at 5 or more years after LSG) was 59.3% (12 studies, n = 377 patients). The overall attrition rate was 31.2% (13 studies). LSG seems to maintain its well-documented weight loss outcome at 5 or more years postoperatively, with the overall mean %EWL at 5 or more years after LSG still remaining>50%. The existing data support the role of LSG in the treatment of morbid obesity.

Efficacy and safety of laparoscopic mini gastric bypass. A systematic review.

BACKGROUND: Laparoscopic mini-gastric bypass (LMGB) is a relatively new bariatric procedure; published studies are accumulating in various settings. The objective of this study was to summarize the available evidence about the efficacy and safety of LMGB. METHODS: A systematic search in the literature was performed , and PubMed and reference lists were scrutinized (end-of-search date: July 15, 2013). For the assessment of the eligible articles, the Newcastle-Ottawa quality assessment scale was used. RESULTS: Ten eligible studies were included in this study, reporting data on 4,899 patients. According to all included studies, LMGB induced substantial weight and body mass index reduction, as well as substantial excess weight loss. Moreover, resolution or improvement in all major associated medical illnesses and improvement in overall Gastrointestinal Quality of Life Index score were recorded. Major bleeding and anastomotic ulcer were the most commonly reported complications. Readmission rate ranged from 0%- 11%, whereas the rate of revision operations ranged from .3%- 6%. The latter were conducted due to a variety of medical reasons such as inadequate or excessive weight loss, malnutrition, and upper gastrointestinal bleeding. Finally, the mortality rate ranged between 0% and .5% among primary LMGB procedures. CONCLUSION: LMGB represents an effective bariatric procedure; its safety and minimal postoperative morbidity seem remarkable. Randomized comparative studies seem mandatory for the further evaluation of LMGB.

Improvement in cardiovascular indices after Roux-en-Y gastric bypass or sleeve gastrectomy for morbid obesity.

BACKGROUND: Morbidly obese patients display cardiac abnormalities which are partially reversed after weight loss. The aim of the present study was to assess the potential difference in cardiovascular disease indices between patients who underwent either gastric bypass surgery or sleeve gastrectomy. METHODS: Thirty-seven morbidly obese patients who underwent either Roux-en-Y gastric bypass (RYGB) (n = 14) or SG (n = 23) were examined before, 3 and 6 months after surgery. Indices of cardiac autonomic nervous system activity were evaluated, namely baroreflex sensitivity (BRS) and heart rate variability (HRV). A complete echocardiographic study was performed in a subgroup of 17 patients (RYGB 8, SG 9) preoperatively and 6 months after surgery, evaluating epicardial fat thickness, aortic distensibility, left ventricular (LV) Tei index, left atrium diameter, ejection fraction, and LV mass. RESULTS: All subjects experienced significant (p < 0.001) and similar weight loss independently of the type of operation. BRS and HRV indices improved significantly and to the same degree after surgery in both groups. In the echocardiographic study, all parameters improved significantly at 6 months in comparison with the baseline values. In addition, the RYGB group displayed significantly greater reduction in epicardial fat thickness (p = 0.007) and also tended to have a better LV performance as expressed by the lower values of the Tei index (p = 0.06) compared to the SG group 6 months after surgery. CONCLUSIONS: Both RYGB and SG exert comparable effects on weight loss and improvement of cardiovascular parameters. RYGB displays a more beneficial influence on epicardial fat thickness and left ventricular performance than SG.

Initial experience with robotic sleeve gastrectomy for morbid obesity.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is used with increasing frequency for the treatment of morbid obesity. The application of robotic techniques has been reported for bariatric operations like laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding, but not for LSG. We report herein our initial experience with LSG performed with the use of the Da Vinci surgical system. METHODS: Nineteen consecutive patients underwent LSG with the use of the Da Vinci surgical system by the same surgical team. Surgical techniques followed the principles of standard LSG. Preparation of the stomach was performed by the console surgeon and its division with the staplers by the patient-side surgeon. RESULTS: Seventeen women and two men with a mean age of 39.4 years and a mean body mass index (BMI) of 48.2 kg/m(2) were operated. Mean operative time was 95.5 ± 11.5 min. Docking time was 16 ± 4.2 min. There were no conversions. Peri-operative morbidity and mortality was zero. Time to BMI ratio for robotic LSG was 2 ± 0.3 min/kg/m(2) and it was equal to the respective of our standard LSGs. When the docking time was excluded, the same ratio was 1.7 ± 0.2, significantly shorter than the respective 2.0 ± 0.5 of our conventional LSGs (p = 0.018). Mean excess body weight loss 1 year post-operatively was 65.5 ± 25.6%. CONCLUSIONS: Robotic laparoscopic sleeve gastrectomy is a feasible, safe, and efficient surgical technique for the treatment of morbid obesity and it does not add to the operating time of the procedure.