Evolution in the management of acute cholecystitis in the elderly: population-based cohort study.

BACKGROUND: Acute cholecystitis is a life-threatening emergency in elderly patients. This population-based cohort study aimed to evaluate the commonly used management strategies for elderly patients with acute cholecystitis as well as resulting mortality and re-admission rates. METHODS: Data from all consecutive elderly patients (≥ 80 years) admitted with acute cholecystitis in England from 1997 to 2012 were captured from the Hospital Episode Statistics database. Influence of management strategies upon mortality was analyzed with adjustment for patient demographics and treatment year. RESULTS: 47,500 elderly patients were admitted as an emergency with acute cholecystitis. On the index emergency admission the majority of patients (n = 42,620, 89.7%) received conservative treatment, 3539 (7.5%) had cholecystectomy, and 1341 (2.8%) underwent cholecystostomy. In the short term, 30-day mortality was increased in the emergency cholecystectomy group (11.6%) compared to those managed conservatively (9.9%) (p < 0.001). This was offset by the long-term benefits of cholecystectomy with a reduced 1-year mortality [20.8 vs. 27.1% for those managed conservatively (p < 0.001)]. Management with percutaneous cholecystostomy had increased 30-day and 1-year mortality (13.4 and 35.0%, respectively). The annual proportion of cholecystectomies performed laparoscopically increased from 27% in 2006 to 59% in 2012. Within the cholecystectomy group, laparoscopic approach was an independent predictor of reduced 30-day mortality (OR 0.16, 95% CI 0.10-0.25). Following conservative management, there were 16,088 admissions with further cholecystitis. Only 11% of patients initially managed conservatively or with cholecystostomy received subsequent cholecystectomy. CONCLUSION: Acute cholecystitis is associated with significant mortality in elderly patients. Potential benefits of emergency cholecystectomy in selected elderly patients include reduced rate of readmissions and 1-year mortality. Laparoscopic approach for emergency cholecystectomy was associated with an 84% relative risk reduction in 30-day mortality compared to open surgery.

Benefits and drawbacks of SILS cholecystectomy: a report of 60 SILS cholecystectomies with conventional instrumentation from an academic center.

BACKGROUND: Single-incision laparoscopic surgery is a rapidly emerging approach to gallbladder disease. METHODS: From February 2009 to September 2010, 60 patients were subjected to single-incision laparoscopic cholecystectomy. In all the patients, a 12-mm incision was made in the umbilicus and a 2-trocar technique was applied. Gallbladder was suspended with 2 sutures and the procedure was accomplished with standard partly reusable laparoscopic instruments. RESULTS: In all, 41 women (68.3%) and 19 men (31.7%) were enrolled in this study. Mean age was 50.7 years (range = 17-72 years), mean body mass index was 26.2 kg/m(2) (range = 18.3-37.7 kg/m(2)) and mean operative time was 52.6 minutes (range = 30-120 minutes). No mortality or morbidity was recorded and hospital stay was less than 24 hours. At follow-up visits, no complications were recorded and cosmesis was excellent. CONCLUSION: Single-incision laparoscopic cholecystectomy can be safely performed with conventional instrumentation with minimal cost.

Comparison of early and late complications after various bariatric procedures: incidence and treatment during 15 years at a single institution.

BACKGROUND: Bariatric procedures are effective in the life-long treatment of clinically severe obesity, but they are technically demanding and have known complications. The present study presents mortality and morbidity with different procedures from the prospective 15-year bariatric database of the University Hospital of Patras in Greece. METHODS: From June 1994 through December 2008, 1,162 morbidly obese patients underwent various bariatric procedures at our institution (35 vertical banded gastroplasties, 151 laparoscopic sleeve gastrectomies, 90 open and 137 laparoscopic Roux-en-Y gastric bypasses, 699 biliopancreatic diversions with long limbs, and 50 reoperations). Postoperative metabolic deficiencies and causes of early and late morbidity for various bariatric procedures were compared by using the z-test for the comparison of proportions. Logistic regression analysis was used to model the occurrence of early and late death and complications. RESULTS: Total mortality was 1.81% (early 0.6%, intermediate 0.26%, late 0.95%). No significant predictors for early death were found, but age (odds ratio (OR), 1.077; 95% confidence interval (CI), 1.024-1.133; P = 0.004) and BMI (OR, 1.156; 95% CI, 1.023-1.306; P = 0.02) were predictors for late death. Early and late morbidity were 8% and 27.71%, respectively. The total leakage incidence was 1.98% and was significantly higher (P < 0.05) after reoperation. Fifteen of the 23 leaks were successfully treated conservatively. Most late complications were incisional hernias (18.85%)--almost all after open procedures. Hypoalbuminemia incidence was significantly higher after biliopancreatic diversion with long limbs (3.58%) and reoperation (8%). CONCLUSIONS: Bariatric procedures, even in specialized centers, may have serious complications because of their technical complexity in a high-risk population. Almost all can be managed successfully.

Percutaneous Cholecystostomy for Acute Cholecystitis: A Three-Year Single-Centre Experience Including During COVID-19.

Introduction Percutaneous cholecystostomy is a recognised treatment modality for acute cholecystitis. Traditionally, its use was reserved for patients deemed unfit for surgery. However, the coronavirus disease 2019 (COVID-19) pandemic had a detrimental effect on both elective and emergency surgery. The utilisation of cholecystostomy thus increased. Unanswered questions remain over timing with respect to interval cholecystectomy. We evaluated our local practice over the preceding three years. Methods A retrospective analysis was performed of all patients who had a percutaneous cholecystostomy inserted over a three-year period (1 January 2018-1 January 2021). The primary outcome was time to cholecystectomy. Secondary outcomes were cholecystostomy-related complications, 30-day mortality, cholecystectomy-related complications and length of postoperative hospital stay. Results A total of 31 patients were identified during the period. Thirteen (42%) patients went on to have a laparoscopic cholecystectomy. The median time interval from cholecystostomy to cholecystectomy was 97 days (interquartile range [IQR]: 81-140, minimum: 47 and maximum: 791). One case was complicated by small bowel perforation; this occurred after an interval of 106 days. The median length of postoperative stay was one day (IQR: 1-1, minimum: 0 and maximum: 4). Cholecystostomy-related complications were observed in four (13%) patients, whereby three became displaced and one developed blockage. Thirty-day mortality following cholecystostomy insertion was zero. Conclusions Percutaneous cholecystostomy is a safe and effective intervention for the management of acute cholecystitis. Interval cholecystectomy should be carefully considered; it may be safer to perform prior to 90 days.

Instituting a Green Zone for Elective Surgery During the Second Wave of COVID-19.

Objective Elective surgery came to a standstill during the first wave of COVID-19. The safe resumption of elective surgery with COVID-19 prevalent in the community remains a significant challenge. The aim of this study was to look into the outcomes of elective general surgery in a dedicated 'Green Zone (GZ)' during the second wave of COVID-19 in the United Kingdom. Method A 'Green Zone' pathway, meant to provide a COVID-free environment, was created. A retrospective review of prospectively collected data was done on consecutive patients who underwent an elective general surgical procedure at a single NHS trust over a six-month period (September 1, 2020, to February 28, 2021). The primary outcome was 30-day COVID-19 mortality. Secondary outcomes included 30-day non-COVID-19 mortality, readmissions, and complications. Results The study included 331 patients with a median age of 55 years (interquartile range, IQR, 41-67); 169 (51%) were females. The majority of the patients were American Society of Anaesthesiologists grade 2 (ASA 2; n=177, 53%) followed by ASA 3 (n=76, 23%). Forty-seven patients (14%) had been shielding earlier in the year. Most of the cases were day cases (n=224, 67%). There was no 30-day COVID-19 or non-COVID-19 mortality. One patient developed COVID-19 three weeks after the index operation. Thirty-day readmission and complication rate were 4% (n=14) and 6% (n=21). Most of the complications were Clavien-Dindo grade 2 (n=10, 3%) followed by an equal number of grades 1 and 3b (n=5, 1.5%). Conclusion This study has shown that a dedicated 'Green Zone' elective operating pathway is safe and feasible provided a balanced risk assessment approach is adopted.

Prospective evaluation of laparoscopic Roux en Y gastric bypass in patients with clinically severe obesity.

AIM: To evaluate and present our experience with laparoscopic Roux en Y gastric bypass (RYGB) in a selected patient population. METHODS: A cohort of 130 patients with a body mass index (BMI) between 35 and 50 kg/m(2) were evaluated in relation to postoperative morbidity, weight loss and resolution of co-morbidities for a period of 4 years following laparoscopic RYGB. RESULTS: Early morbidity was 10.0%, including 1 patient with peritonitis who was admitted to Intensive Care Unit (ICU) and 1 conversion to open RYGB early in the series. There was no early or late mortality. Maximum weight loss was achieved at 12 mo postoperatively, with mean BMI 30 kg/m(2), mean percentage of excess weight loss (EWL%) 66.4% and mean percentage of initial weight loss (IWL%) 34.3% throughout the follow-up period. The majority of preexisting comorbidities were resolved after weight loss and no major metabolic disturbances or nutritional deficiencies were observed. CONCLUSION: Laparoscopic RYGB appears to be a safe and effective procedure for patients with BMI 35-50 kg/m(2) with results that are comparable to previously published data mostly from the USA but from Europe as well.

Laparoscopic versus open appendectomy: which way to go?

AIM: To compare the outcome of laparoscopic versus open appendectomy. METHODS: Prospectively collected data from 293 consecutive patients with acute appendicitis were studied. These comprised of 165 patients who underwent conventional appendectomy and 128 patients treated laparoscopically. The two groups were compared with respect to operative time, length of hospital stay, postoperative pain, complication rate and cost. RESULTS: There were no statistical differences regarding patient characteristics between the two groups. Conversion to laparotomy was necessary in 2 patients (1.5%). Laparoscopic appendectomy was associated with a shorter hospital stay (2.2 d vs 3.1 d, P = 0.04), and lower incidence of wound infection (5.3% vs 12.8%, P = 0.03). However, in patients with complicated disease, intra-abdominal abscess formation was more common after laparoscopic appendectomy (5.3% vs 2.1%, P = 0.002). The operative time and analgesia requirements were similar in the two groups. The cost of treatment was higher by 370 EUR in the laparoscopic group. CONCLUSION: Laparoscopic appendectomy is as safe and efficient as open appendectomy, provided surgical experience and equipment are available.

Laparoscopic cholecystectomy: a report from a single center.

AIM: To review and evaluate our experience in laparoscopic cholecystectomy. METHODS: A retrospective analysis was performed on data collected during a 13-year period (1992-2005) from 1220 patients who underwent laparoscopic cholecystectomy. RESULTS: Mortality rate was 0%. The overall morbidity rate was 5.08% (n = 62), with the most serious complications arising from injuries to the biliary tree and the cystic artery. In 23 (1.88%) cases, cholecystectomy could not be completed laparoscopically and the operation was converted to an open procedure. Though the patients were scheduled as day-surgery cases, the average duration of hospital stay was 2.29 d, as the complicated cases with prolonged hospital stay were included in the calculation. CONCLUSION: Laparoscopic cholecystectomy is a safe, minimally invasive technique with favorable results for the patient.

Efficacy of sleeve gastrectomy as sole procedure in patients with clinically severe obesity (BMI ≤50 kg/m(2)).

BACKGROUND: Sleeve gastrectomy (SG) is increasingly indicated as a stand-alone procedure for the treatment of clinically severe obesity. Our objective was to present the outcomes of SG in relation to weight loss, resolution of co-morbidities, and procedural morbidity/mortality for ≤5 years postoperatively. The study was conducted at a university hospital, bariatric referral center. METHODS: From January 2005 to December 2010, 208 patients underwent SG at our institution. Per standard protocol, SG was the sole surgery indicated for weight reduction in patients with a body mass index of ≤50 kg/m(2) who were not "sweet-eaters" and had no symptoms of gastroesophageal reflux disease. The study endpoints were weight loss, perioperative and late morbidity/mortality, and clinical improvement in co-morbidities and consequential nutritional deficiencies. RESULTS: SG was performed laparoscopically in 203 of the patients. The mean age and body mass index was 34.3 ± 10.3 years and 43.2 ± 2.8 kg/m(2), respectively. No deaths were recorded. Early morbidity (≤30 d) was 9.6%, chiefly owing to staple line closure leaks, and late morbidity was 4.8%. A mean excess weight loss of 71.1% was documented in 90 (89.4%) of 106 patients, available for follow-up after 3 years. The excess weight loss slowly declined to 57.6% in 21 (77.7%) of 27 patients at 5 years of follow-up. No major metabolic deficiencies were apparent. Statistically significant improvements in pre-existing hypertension, diabetes mellitus, and dyslipidemia were achieved. After laparoscopic SG, gastroesophageal reflux disease symptoms developed in 9.8% of patients within the first postoperative year but lessened over time to 7.4% at the 5-year mark. CONCLUSIONS: SG is a reproducible procedure associated with significant weight reduction, resolution of obesity-related co-morbidities, and minor nutritional deficits at 5 years of follow-up. Laparoscopic SG can thus be safely used as the sole surgical treatment of clinically severe obesity (body mass index ≤50 kg/m(2)). The chief complication of postoperative leakage can be managed nonoperatively in most patients.

Totally laparoscopic management of gallstone ileus--technical report and review of the literature.

PURPOSE: Gallstone ileus is an uncommon complication of gallstone disease. It occurs in elderly patients in up to 25% of the cases. The management of gallstone ileus remains controversial. Open surgery has been the mainstay of treatment, but laparoscopic surgery has recently been used. In this study we report a case of an 87-year-old female patient with gallstone ileus who has been managed totally laparoscopically, detailing the technique and discussing the advantages of the laparoscopic approach with a review of the literature. METHODS: The pneumoperitoneum was established with a Veress needle. A three-port approach (one 5-mm and two 10-mm trocars) and a 30° 10-mm laparoscope were used. The site of obstruction was 5 cm below the ligament of Treitz, and a single gallstone was identified. A 3-cm longitudinal enterotomy was created just above the site where the gallstone was located. An 8-cm-long gallstone was extracted. The enterotomy was closed transversely in a single layer of two sets of continuous sutures. RESULTS: The procedure was safely performed with all the advantages of minimally invasive surgery. Previous studies often described laparoscopically assisted procedures for the treatment of gallstone ileus, using a small abdominal incision. In recent years, some reports have been published on the efficacy of the totally laparoscopic approach in the management of gallstone ileus. CONCLUSIONS: Totally laparoscopic management of gallstone ileus could be safe and effective with suggested benefits for the elderly patients.

Randomized clinical trial of laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for the management of patients with BMI < 50 kg/m2.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is currently the gold standard bariatric procedure for the treatment of morbid obesity. Laparoscopic sleeve gastrectomy (LSG) is a relatively innovative procedure which has been increasingly applied lately as a sole bariatric procedure. A randomized trial was conducted in a Greek population to evaluate perioperative safety and 3-years results. METHODS: Sixty patients with body mass index (BMI) ≤ 50 Kg/m(2) were randomized to LRYGB or LSG. Patients were monitored for 3 years postoperatively and throughout the study period weight loss, in terms of percent excess weight loss (%EWL), early and late complications, improvement of obesity related comorbidities and nutritional deficiencies were compared between groups. RESULTS: There was no death in either group and there was no significant difference in early (10% after LRYGB and 13% after LSG, P > 0.05) and late morbidity (10% in each group). Weight loss was significantly better after LSG in the first years of the study and at 3 years %EWL reached 62% after LRYGB and 68% after LSG (p = 0.13). There was no significant difference in the overall improvement of comorbidities. Nutritional deficiencies occurred at the same rate in the two groups except to vitamin B(12) deficiency which was more common after LRYGB (P = 0.05). CONCLUSION: LSG and LRYGB are equally safe and effective in the amelioration of comorbidities, while LSG is associated with fewer postoperative metabolic deficiencies, without the need of supplementation. Furthermore, LSG is a promising bariatric procedure, equally effective to LRYGB at 3 years follow up on weight reduction.

Biliopancreatic diversion with Roux-en-Y gastric bypass and long limbs: advances in surgical treatment for super-obesity.

BACKGROUND: Over the past 14 years, we have used different malabsorptive bariatric operations to treat super-obesity. We compared the efficacy and safety of our preferred procedure for the last 8 years with previous methods used in super-obese. METHODS: Our first procedure was distal Roux-en-Y gastric bypass (distal RYGBP) (gastric pouch 15 ± 5 mL, 80 cm biliopancreatic limb, 100 cm common limb [CL]). The second was distal RYGBP with short alimentary limb (distal RYGBP-sAL) (gastric pouch 15 ± 10 mL, alimentary limb [AL] 250 cm, CL 100 cm). Our preferred procedure for the past 8 years has been biliopancreatic diversion with RYGB and long limbs (BPD-RYGB-LL) (gastric pouch 40 ± 10 mL, AL 400 cm, CL 100 cm). RESULTS: Seventy-five patients underwent distal RYGBP, 44 distal RYGBP-sAL, and 841 BPD-RYGB-LL. Eight years postoperatively, the mean BMIs were 39.0, 29.4, and 29.2, respectively. The greatest reduction of 47.6% was achieved with BPD-RYGB-LL (distal RYGBP 30.6%; distal RYGBP-sAL 43.1%). Mean excess weight loss was 51.3% for distal RYGBP, 76.5% for distal RYGBP-sAL, and 80.9% for BPD-RYGB-LL. Six patients died at the early postoperative period. Sixteen patients died during the first eight postoperative years, of whom significantly more were after distal RYGBP-sAL (P = 0.0003). Complications were significantly more frequent after distal RYGBP-sAL (P = 0.001). All procedures led to rapid and sustained resolution of major comorbidities in almost all patients affected. Metabolic and nutritional deficiencies were similar and manageable. CONCLUSIONS: Our variant of biliopancreatic diversion (BPD-RYGB-LL) results in substantial and sustained weight loss in super-obese, without compromising safety.

Laparoscopy in the emergency setting: a retrospective review of 540 patients with acute abdominal pain.

BACKGROUND: Laparoscopy has been widely accepted among surgeons for the diagnosis and management of acute abdominal conditions. In this study, we aim to evaluate and summarize the experience in laparoscopic procedures, both diagnostic and interventional, for emergency nontraumatic abdominal conditions, in a tertiary academic center. METHODS: From June 2005 to June 2009, a total of 1414 patients were subjected to a variety of emergency procedures at the university hospital of Patras and 540 of these patients were managed laparoscopically (38.2%). Indications for operations in the laparoscopic group were abdominal pain mimicking appendicitis in 229 patients (42.4%), acute cholecystitis in 248 patients (45.9%), gastroduodenal perforated ulcer in 14 patients (2.6%), small bowel obstruction in 24 patients (4.4%), and nonspecific abdominal pain in 25 patients (4.6%). RESULTS: Diagnosis was established in 530 patients (98.2%) and definitive laparoscopic treatment was offered to 514 patients (95.2%). The conversion rate was 2.2%. Total mortality was 1.1% and total morbidity was 7.9%. CONCLUSIONS: Laparoscopic approach to abdominal emergency provides high diagnostic accuracy and therapeutic options. Surgical experience, optimal procedural timing, and appropriate patient selection criteria diminish perioperative mortality and morbidity, and are associated with nominal conversion.

Complications and risk factors related to the extent of surgery in thyroidectomy. Results from 2,043 procedures.

OBJECTIVE: To evaluate the rate of complications and the risk factors in relation to the extent of surgery in patients undergoing thyroidectomy in a tertiary university center. DESIGN: Data were collected retrospectively from 2,043 consecutive patients who underwent thyroid surgery for various thyroid diseases at the University Hospital of Patras, Greece, between January 1996 and December 2007. Recurrent laryngeal nerve palsy (RLNP) and hypoparathyroidism were set as the primary end points, while hematoma and wound infection were set as the secondary endpoints. RESULTS: Total, near-total and subtotal thyroidectomy was performed in 1,149,777 and 117 patients, respectively. Transient RLNP occurred in 34 (1.6%) and permanent in 19 (0.9%) patients. Multivariate logistic regression analysis showed that extended resection (OR-odds ratio-1.6), Graves' disease (OR 2.7), thyroiditis (OR 2.1), recurrent goiter (OR 2.3) and thyroid malignancy (OR 1.7) were all independent risk factors for transient RLNP, whereas Graves' disease (OR 2.2) and recurrent goiter (OR 1.7) emerged as independent risk factors for permanent RLNP. The rates of transient and permanent hypoparathyroidism were 27.8% and 4.8%, respectively. Multivariate analysis for transient hypoparathyroidism revealed that the extent of surgical resection (OR 2.2), Graves' disease (OR 2.1), recurrent goiter (OR 1.7), female gender (OR 1.5) and specimen weight (OR 1.6) were independent predictors. However, the extent of surgical resection (OR 2.7), Graves' disease (OR 1.8), recurrent goiter (OR 1.5) and malignant disease (OR 1.5) were independent risk factors for permanent hypoparathyroidism. Postoperative wound infection and hematoma occurred in 6 (0.3%) and 27 (1.3%) patients, respectively. No correlation was observed between wound infection or postoperative hemorrhage and the extent of surgery. CONCLUSIONS: Despite the higher morbidity, total thyroidectomy is emerging as an attractive surgical option even for benign thyroid disease due to the risk of subclinical (occult) malignancy, the possibility of goiter relapse as well as of the increased risk of complications following reoperation.

A rare case of intussusception leading to the diagnosis of acquired immune deficiency syndrome: a case report.

INTRODUCTION: Although a common cause of intestinal obstruction in children, intussusception is a rare event in the adult population living in temperate regions. It has long been known that various acquired immune deficiency syndrome related conditions of the bowel such as lymphoma, lymphoid hyperplasia, cytomegalovirus colitis and Kaposi's sarcoma can lead to intussusception. The diagnosis is particularly difficult in this population of patients due to the non-specific nature of the symptoms as well as the depressed immune response obscuring inflammation or ischemia. Though the reported acquired immune deficiency syndrome associated cases of intussusception refer to patients with known human immunodeficiency virus infection, in our case we present an intestinal intussusception as the first manifestation of human immunodeficiency virus infection. CASE PRESENTATION: A 58-year-old white heterosexual Greek man with a clean medical record and no history of abdominal operation presented to the emergency department with symptoms and signs of bowel obstruction. Plain abdominal radiographs were highly suspicious for intussusception which was eventually confirmed on a computed tomography scan. Due to the patients clean medical record as well as the radiologic diagnosis of intussusception, we promptly undertook further serologic tests for human immunodeficiency virus and eventually established the diagnosis of acquired immune deficiency syndrome. The patient was operated 3 days later and this confirmed the diagnosis of small-bowel invagination due to a 4 cm polypoid growing intraluminal tumor, the pathologic examination of which revealed a diffuse high-grade B cell lymphoblastic lymphoma. CONCLUSION: Human immunodeficiency virus infection may have a silent course and gastrointestinal manifestations of the disease leading to intussusception might be the first clinical sign. Patients with intestinal intussusception, and the presence of risk factors for human immunodeficiency virus infection should be eligible for serologic tests for human immunodeficiency virus infection.

Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy: a prospective, double blind study.

BACKGROUND: Bariatric surgery is currently the most effective treatment in morbidly obese patients, leading to durable weight loss. OBJECTIVE: In this prospective double blind study, we aim to evaluate and compare the effects of laparoscopic Roux-en-Y gastric bypass (LRYGBP) with laparoscopic sleeve gastrectomy (LSG) on body weight, appetite, fasting, and postprandial ghrelin and peptide-YY (PYY) levels. METHODS: After randomization, 16 patients were assigned to LRYGBP and 16 patients to LSG. Patients were reevaluated on the 1st, 3rd, 6th, and 12th postoperative month. Blood samples were collected after an overnight fast and in 6 patients in each group after a standard 420 kcal mixed meal. RESULTS: Body weight and body mass index (BMI) decreased markedly (P < 0.0001) and comparably after either procedure. Excess weight loss was greater after LSG at 6 months (55.5% +/- 7.6% vs. 50.2% +/- 6.5%, P = 0.04) and 12 months (69.7% +/- 14.6% vs. 60.5% +/- 10.7%, [P = 0.05]). After LRYGBP fasting ghrelin levels did not change significantly compared with baseline (P = 0.19) and did not decrease significantly after the test meal. On the other hand, LSG was followed by a marked reduction in fasting ghrelin levels (P < 0.0001) and a significant suppression after the meal. Fasting PYY levels increased after either surgical procedure (P < or = 0.001). Appetite decreased in both groups but to a greater extend after LSG. CONCLUSION: PYY levels increased similarly after either procedure. The markedly reduced ghrelin levels in addition to increased PYY levels after LSG, are associated with greater appetite suppression and excess weight loss compared with LRYGBP.