[Cholecystolithiasis and intestinal bypass procedures]. / Cholezystolithiasis und intestinale Bypassverfahren.

With the increasing number of surgical interventions for obesity, the numbers of associated complications, such as gallstones after bariatric surgery are also increasing. The incidence of postbariatric symptomatic cholecystolithiasis is 5-10%; however, the numbers of severe complications due to gallstones and the probability of a necessary extraction of gallstones are low. For this reason, a simultaneous or preoperative cholecystectomy should only be carried out in symptomatic patients. Treatment with ursodeoxycholic acid reduced the risk of gallstone formation in randomized trials but not the risk of complications related to gallstones in cases of pre-existing gallstones. The most frequently used access route to bile ducts after intestinal bypass procedures is the laparoscopic approach via the stomach remnants. Other possible access routes are the enteroscopic approach as well as the endosonography-guided puncture of the stomach remnants.

Duodenal-Jejunal Bypass Liner for the management of Type 2 Diabetes Mellitus and Obesity: A Multicenter Randomized Controlled Trial.

OBJECTIVE: The aim of this study was to examine the clinical efficacy and safety of the duodenal-jejunal bypass liner (DJBL) while in situ for 12 months and for 12 months after explantation. SUMMARY BACKGROUND DATA: This is the largest randomized controlled trial (RCT) of the DJBL, a medical device used for the treatment of people with type 2 diabetes mellitus (T2DM) and obesity. Endoscopic interventions have been developed as potential alternatives to those not eligible or fearful of the risks of metabolic surgery. METHODS: In this multicenter open-label RCT, 170 adults with inadequately controlled T2DM and obesity were randomized to intensive medical care with or without the DJBL. Primary outcome was the percentage of participants achieving a glycated hemoglobin reduction of ≥20% at 12 months. Secondary outcomes included weight loss and cardiometabolic risk factors at 12 and 24 months. RESULTS: There were no significant differences in the percentage of patients achieving the primary outcome between both groups at 12 months [DJBL 54.6% (n = 30) vs control 55.2% (n = 32); odds ratio (OR) 0.93, 95% confidence interval (CI): 0.44-2.0; P = 0.85]. Twenty-four percent (n = 16) patients achieved ≥15% weight loss in the DJBL group compared to 4% (n = 2) in the controls at 12 months (OR 8.3, 95% CI: 1.8-39; P = .007). The DJBL group experienced superior reductions in systolic blood pressure, serum cholesterol, and alanine transaminase at 12 months. There were more adverse events in the DJBL group. CONCLUSIONS: The addition of the DJBL to intensive medical care was associated with superior weight loss, improvements in cardiometabolic risk factors, and fatty liver disease markers, but not glycemia, only while the device was in situ. The benefits of the devices need to be balanced against the higher rate of adverse events when making clinical decisions. TRIAL REGISTRATION: ISRCTN30845205. isrctn.org; Efficacy and Mechanism Evaluation Programme, a Medical Research Council and National Institute for Health Research (NIHR) partnership reference 12/10/04.

Evaluation of the Efficacy of Single Anastomosis Sleeve Ileal (SASI) Bypass for Patients with Morbid Obesity: a Multicenter Study.

BACKGROUND: Single anastomosis sleeve ileal (SASI) bypass is a newly introduced bariatric and metabolic procedure. The present multicenter study aimed to evaluate the efficacy of the SASI bypass in the treatment of patients with morbid obesity and the metabolic syndrome. METHODS: This is a retrospective, seven-country, multicenter study on patients with morbid obesity who underwent the SASI bypass. Data regarding patients' demographics, body mass index (BMI), percentage of total weight loss (%TWL), percentage of excess weight loss (%EWL), and improvement in comorbidities at 12 months postoperatively and postoperative complications were collected. RESULTS: Among 605 patients who underwent the SASI, 54 were excluded and 551 (390; 70.8% female) were included. At 12 months after the SASI, a significant decrease in the BMI was observed (43.2 ± 12.5 to 31.2 ± 9.7 kg/m2; p < 0.0001). The %TWL was 27.4 ± 13.4 and the %EWL was 63.9 ± 29.5. Among the 279 patients with type 2 diabetes mellitus (T2DM), complete remission was recorded in 234 (83.9%) patients and partial improvement in 43 (15.4%) patients. Eighty-six (36.1%) patients with hypertension, 104 (65%) patients with hyperlipidemia, 37 (57.8%) patients with sleep apnea, and 70 (92.1%) patients with GERD achieved remission. Fifty-six (10.1%) complications and 2 (0.3%) mortalities were recorded. Most complications were minor. All patients had 12 months follow-up. CONCLUSIONS: The SASI bypass is an effective bariatric and metabolic surgery that achieved satisfactory weight loss and improvement in medical comorbidities, including T2DM, hypertension, sleep apnea, and GERD, with a low complication rate.

Copper deficiency related myelopathy 40 years following a jejunoileal bypass.

Introduction: Acquired copper deficiency myelopathy is a rare disorder associated with hematologic abnormalities, peripheral neuropathy, and sensory ataxia. Although its clinical presentation and radiographic findings are similar to other nutrient deficiencies, practitioners often fail to diagnose copper deficiency. This report describes a case of copper deficiency decades after a jejunoileal bypass (JIB) to draw attention to potential long-term sequelae associated with this now abandoned procedure. Case presentation: A 67-year-old female presented with bilateral paresthesias of her hands and legs, accompanied by gait instability and frequent falls. The individual had a significant history of malabsorption and malnutrition related to a 40 years prior JIB for weight loss. MRI demonstrated T2 hyperintense signal in the dorsal spinal cord between C3 and C5. She was found to have copper deficiency, underwent IV repletion, prescribed oral repletion, and was discharged home. She subsequently developed progressive symptoms over the following year and remained unable to function at home. Treatment required inpatient copper repletion followed by inpatient rehabilitation. Following rehabilitation, the individual demonstrated significant improved independence. Discussion: Although JIB surgery is not currently performed, it is important to recognize the metabolic consequences of nutrient deficiencies related to this procedure and the potential for the development of neurological sequelae including myelopathy. Furthermore, additional causes of copper deficiency to consider in cases of undifferentiated myelopathy include congenital metabolic syndromes, zinc toxicity, and malabsorption. This case demonstrates the potential of intensive physical and occupational therapy regimens, along with symptomatic treatment and nutrient repletion, to help an individual regain independence and improve activities of daily living.

Clinical Outcomes of Laparoscopic Greater Curvature Plication and Laparoscopic Sleeve Gastrectomy: a Case-Matched Control Study.

BACKGROUND: Laparoscopic greater curvature plication (LGCP) is a new bariatric procedure that is similar to laparoscopic sleeve gastrectomy (LSG) in that it uses a restrictive mechanism. Comparative studies between LGCP and LSG were still limited. The aim of this study was to compare the clinical outcomes of the two procedures based on the same clinical conditions. METHODS: From January 2012 to December 2015, 260 patients with morbid obesity underwent LGCP and LSG in a single center. Data on patient demography, operation time, complications, hospital stay, body mass index loss, percentage of excess weight loss (%EWL), and improvement in comorbidities were collected. A propensity-matched analysis, incorporating pre-operative variables, was used to compare the short-term outcomes between LGCP and LSG. RESULTS: Propensity matching produced 48 patients in each group. Patients who underwent LGCP were predominately female (75.5%, 41.1% of the LSG patients were female, p = 0.028). Baseline BMI and excess weight were significantly lower in the LGCP group (p < 0.001). The LSG group showed a greater decrease in excess body weight than the LGCP group (LSG, 47.36 ± 12.95% in 3 months, 57.97 ± 19.28% in 6 months, 66.28 ± 25.42% in 12 months; LGCP, 39.67 ± 12.58% in 3 months, 47.40 ± 19.30% in 6 months, 48.02 ± 20.17% in 12 months, p = 0.008, 0.032, 0.010). Perioperative complications and resolution of obesity-related comorbidities were not significantly different between the two groups. CONCLUSION: LGCP and LSG are both feasible and safe procedures for surgical weight reduction. In short-term follow-ups, LSG demonstrates a better excess body weight reduction while having perioperative complications similar to LGCP.

Outcomes of Reoperation After Laparoscopic Gastric Plication Failure.

BACKGROUND: Management of failed laparoscopic gastric plication (LGP), defined as weight regain or inadequate weight loss, is a challenging issue. METHODS: This prospective investigation was conducted in individuals with morbid obesity who had undergone LGP from 2000 to 2016. Patients with weight loss failure, weight regain, and regain-prone cases were indicated for reoperation. Re-plication, laparoscopic one anastomosis gastric bypass (LOAGB), and modified jejunoileal bypass were done as revisional surgery. RESULTS: Revisional surgery was performed in 102 of 124 patients who needed reoperation. Overall, 39 re-plication, 38 LOAGB, and 25 malabsorptive procedures were performed. Re-plication was the shortest surgery and had the shortest length of hospital stay. The percentage of TWL at 6, 12, and 24 months of follow-up was 20.5%, 25%, and 26.8% for re-plication; 20.2%, 27%, and 30.5% for LOAGB; and 22.9%, 28.9%, and 32.6% for the malabsorptive procedure, respectively. In addition, the percentage of EWL at 6, 12, and 24 months of follow-up was 62%, 74.6%, and 79.6% for re-plication; 51.6%, 68.2%, and 75.9% for LOAGB; and 55.4%, 70.1%, and 79.1% for malabsorptive procedure, respectively. In long-term follow-up, according to %TWL, LOAGB and malabsorptive procedure had better outcome compared to re-plication, whereas there was no statistically significant difference in %EWL among the three surgical approaches. CONCLUSIONS: In terms of weight loss, reoperation on failed LGP was completely successful and no treatment failure was reported. All three revisional procedures, including re-plication, LOAGB, and malabsorptive procedure showed promising results and provided substantial weight loss. Since there is little information about the long-term efficacy and safety of revisional surgery on failed LGP, we highly recommend further investigations to confirm our results.

Resolution of late-onset heart and liver failures after reversion of jejuno-ileal bypass: a case report.

OBJECTIVES: Jejuno-ileal bypass (JIB) was a kind of bariatric surgery performed from 1960s to 1980s, able to induce sustainable weight loss by creating a surgical short bowel syndrome. MATERIALS AND METHODS: We report a case of an octogenarian woman who underwent in the early eighties this kind of surgery with consequent 40 kg weight loss. After 27 years, she first developed a reversible metabolic cardiomyopathy that began with signs and symptoms of heart failure. Thereafter, she was diagnosed with severe intractable liver insufficiency. RESULTS: Despite her old age, the patient underwent reversal of JIB with consequent early improvement of hepatic function. CONCLUSIONS: This case demonstrate that in case of long-term and life-threatening complications, it is possible to successfully reverse JIB surgery after upto 30 years. The hypothesis on pathophysiology of heart and liver insufficiency are discussed.

Revisional Malabsorptive Bariatric Surgery: 29-Year Follow-up in a Brazilian Public Hospital.

BACKGROUND: This study aimed to evaluate the outcomes of 67 patients who underwent revisional bariatric surgeries over a 29-year period in a Brazilian public hospital. METHODS: The records of all patients who underwent revisional bariatric surgery from January 1987 to December of 2016 at our hospital were analyzed for weight loss and complications. Descriptive statistics and paired t tests were computed. RESULTS: Sixty-seven patients were included in the study. The primary surgeries previously performed on these patients were biliopancreatic diversion with duodenal switch (BPD-DS) (37 cases, 55.2%), jejunoileal bypass (JIB) (24 cases, 35.8%), sleeve gastrectomy (4 cases, 5.9%), Roux-en-Y gastric bypass (RYGB) (1 case, 1.5%), and laparoscopic adjustable gastric band (1 case, 1.5%). The indications for revisional surgery were as follows: malnutrition in 29 cases (43.3%), failure to lose weight in 27 cases (40.3%), weight regain in 5 cases (7.5%), and untreatable diarrhea in 6 cases (9.2%). Most revisional surgeries were performed using JIB or BPD-DS. Operative mortality was higher after the revisional procedures compared with that following the primary bariatric surgeries. CONCLUSIONS: Most patients requiring a revisional surgery had undergone a primary BPD-DS or JIB. Severe and untreatable malnutrition and diarrhea were the main indications for the revisional procedures. RYGB produced significant and sustainable weight loss and exhibited a low risk of malnutrition or requiring revisional surgery.

Safety and Effectiveness of Single-Anastomosis Duodenal Switch Procedure: 2-Year Result from a Single US Institution.

BACKGROUND: Single-anastomosis duodenal switch (DS) was introduced by Sanchez-Pernaute et al. as a modification of the biliopancreatic diversion with duodenal switch. We have published preliminary results of the loop DS as the first report of the procedure in the USA. This study aims to evaluate the loop DS procedures again, in terms of weight loss, comorbidity resolution, complication rate, and address the nutritional concerns. METHODS: A retrospective chart review was performed on initial 128 patients who underwent laparoscopic or robot-assisted laparoscopic single-stage loop DS between December 17, 2013 and September 23, 2016. Sixteen additional patients were prospectively enrolled from September 24, 2016 to May 4, 2017. RESULTS: A total of 102 female and 38 male patients were included in this study with a mean age of 41.2 ± 9.6 years. The mean body mass index (BMI) at the time of procedure was 57.3 ± 9.2 kg/m2. Percentage of total weight loss was 23.1, 37.1, 42.9, and 44.7% at 6, 12, 18, and 24 months, respectively. Percentage of excess BMI loss was 41.9, 68.1, 76.6, and 80.8% at 6, 12, 18, and 24 months, respectively. Mean levels of HbA1c, triglyceride, and LDL-cholesterol decreased significantly after the loop DS. Regarding the fat-soluble vitamins, majority of patients had vitamin A and E levels in the normal range. However, 42 to 56% of the patients had low levels of vitamin D at 6, 12, and 24 months following the procedure. Mean length of hospital stay was 4.1 ± 2.7 days. Thirty-day readmission rate was 7.6% (n = 11), and 30-day reoperation rate was 6.9% (n = 10). CONCLUSIONS: Loop DS seems to be effective in weight loss and is a feasible operation in the super-obese population. However, close monitoring of liver enzymes is warranted in addition to nutritional follow-up.

The Role of Gastrojejunostomy Size on Gastric Bypass Weight Loss.

BACKGROUND: The laparoscopic Roux-en-Y gastric bypass (LRYGB) has been considered a reference procedure in the bariatric surgery. The linear-stapled gastrojejunostomy (GJ) has proved to be safe and effective, but its optimal size referred to postoperative weight loss remains poorly understood. OBJECTIVES: Evaluate the role of the linear-stapled GJ size in the mid-term post-LRYGB weight loss and occurrence of complications. MATERIALS AND METHODS: From January to April 2014, 128 patients underwent LRYGB with linear-stapled GJ in a 2-year follow-up. The LRYGB were carried out with the same technical steps, except for the length of the GJ. In GJ-15-mm group (n = 64), the GJ was constructed with white 45-mm cartridge in an extension of only 15 mm whereas in GJ-45-mm group (n = 64), the GJ was achieved using full extension of the cartridge. The body mass index (BMI) reduction was recorded for 24 months after procedure. RESULTS: The mean ages were 38 ± 10.6 and 41.3 ± 12.3 years, and there were 45 (70.3%) and 51 (79.7%) females in the GJ-15-mm and GJ-45-mm groups, respectively. The analysis on raw BMI data showed that both groups had significant reduction of BMI over time (p ≤ 0.05); however, reduction was greater in the GJ-15-mm group from 18 months onwards (p ≤ 0.05). The only complication observed was a case (1.56%) of stenosis in the group GJ-15 mm. CONCLUSION: The global analysis of BMI reduction indicated that the narrower GJ used (GJ-15-mm group) represented a favoring factor decreasing significantly more the BMI when compared to the wider one (GJ-45-mm group).

Five-Year-Results of Laparoscopic Sleeve Gastrectomy with Duodenojejunal Bypass for Weight Loss and Type 2 Diabetes Mellitus.

BACKGROUND: Laparoscopic sleeve gastrectomy with duodenojejunal bypass (LSG-DJB) has been designated as a novel bariatric surgery procedure. This combination of sleeve gastrectomy and proximal intestinal bypass theoretically offers an effective and prolonged anti-diabetes effect. This is a follow-up of our institution's previous report on the short-term effects of LSG-DJB on type 2 diabetes mellitus (T2DM), which a 68.7 % remission (HbA1c <6 % without diabetes medication) rate 1 year after surgery. The aforementioned result was comparable to the reported remission rates of laparoscopic Roux-en-Y gastric bypass. However, the durability of remission remains unknown. OBJECTIVE: The objective of this study is to investigate the medium-term (up to 5 years) effects of LSG-DJB on weight loss and T2DM. METHODS: In this analysis, consecutive 120 patients (female to male ratio = 61:59, mean age = 44.8 years) with T2DM who underwent LSG-DJB from April 2007 to November 2013 and were followed up beyond 1 year were included. The preoperative mean body weight and BMI were 105.7 kg and 38.5 kg/m2, respectively. The mean HbA1c and fasting blood glucose values were 8.9 % and 194 mg/dL, respectively. The mean duration of T2DM was 7.3 years. Fifty-five patients (46 %) were being treated with insulin prior to surgery. RESULTS: The follow-up rate was 97.5 % at 1 year, 73.3 % at 3 years, and 50.0 % at 5 years. The mean body weight was 74.9 kg at 1 year, 76.8 kg at 3 years, and 72.8 kg at 5 years (p < 0.001, compared to the baseline). The mean percent of total body weight loss (%TWL) was 28.9, 28.6, and 30.7 % at 1, 3, and 5 years, respectively. Remission of T2DM was achieved at 63.6, 55.3, and 63.6 % at 1, 3, and 5 years, respectively. Among those who achieved diabetes remission at 1 year, 10.8 % of them experienced recurrence during the subsequent follow-up period. CONCLUSION: Although recurrence of T2DM is observed in some patients over time, LSG-DJB is an effective procedure for achieving significant weight loss and improvement of glycemic control, and the effects seem to be durable up to 5 years.

Effect of the EndoBarrier Gastrointestinal Liner on obesity and type 2 diabetes: a systematic review and meta-analysis.

Compared with bariatric surgery, less invasive and reversible techniques to counteract obesity and type 2 diabetes (T2D) have been developed, including the EndoBarrier Gastrointestinal Liner [duodenal-jejunal bypass sleeve (DJBS)]. We conducted a systematic review and meta-analyses of eligible trials to evaluate the efficacy and safety of the DJBS. Five randomized controlled trials (RCTs; 235 subjects) and 10 observational studies (211 subjects) were included. The risk of bias was evaluated as high in all studies. The mean body mass index ranged from 30 to 49.2 kg/m(2) and 10-100% of the subjects had T2D. Meta-analysis showed that the DJBS was associated with significant mean differences in body weight and excess weight loss of -5.1 kg [95% confidence interval (CI) -7.3, -3.0; four trials; n = 151; I(2) = 37%] and 12.6% (95% CI 9.0, 16.2; four trials; n = 166; I(2) = 24%), respectively, compared with diet modification. The mean differences in glycated haemoglobin (-0.9%; 95% CI -1.8, 0.0) and fasting plasma glucose (-3.7 mM; 95% CI -8.2, 0.8) among subjects with T2D did not reach statistical significance. Adverse events consisted mainly of abdominal pain, nausea and vomiting. No deaths occurred. Future high-quality long-term RCTs are needed to further assess efficacy and safety.

Effect of three different bariatric obesity surgery procedures on nutrient and energy digestibility using a swine experimental model.

Morbid obesity is a worldwide health concern that compromises life quality and health status of obese human subjects. Bariatric surgery for treating morbid obesity remains as one of the best alternatives to promote excess weight loss and to reduce co-morbidities. We have not found studies reporting nutrients and energy balance considering digestibility trials in humans following surgery. The purpose of this study was to determine protein, lipid, fiber, energy, calcium, and phosphorous digestibility in a swine model that underwent ileal transposition (IT), sleeve gastrectomy with ileal transposition (SGIT), Roux-en-Y gastric bypass (RYGBP), and with sham operated animals (SHAM). Thirty-two pigs were randomly assigned to four laparoscopic procedures: IT (n = 8), RYGBP (n = 8), SGIT (n = 8), and Sham-operated pigs (n = 8). From day 0 postsurgery to 130, pigs were weighed monthly to determine live weight and weight gain was calculated for each month postsurgery until day 130. Food intake in a metabolic weight basis was calculated by measuring ad libitum food intake at day 130. Swine were fitted into metabolic crates to determine digestibility coefficients of dry matter, protein, fat, fiber, ash, energy, calcium, and phosphorous from day 130. A one-way ANOVA and Student-Newman-Keuls were used to detect differences in weight, food intake, and digestibility coefficients. Digestibility values for dry matter, fiber, phosphorus, and energy showed no differences among groups (P > 0.05). However, significant differences (P ≤ 0.05) were encountered among groups for fat, protein, ash, and calcium digestibilities. The RYGBP procedure, when applied to the pig model, significantly reduced calcium, fat, and ash digestibility, which did not occur with SGIT or IT procedure, when compared with Sham-operated animals.

Second-stage robot-assisted biliopancreatic diversion with duodenal switch after sleeve gastrectomy.

Biliopancreatic diversion (BPD) was initially described in 1979 and consisted of a distal gastrectomy with a 250-mL stomach pouch and a distal intestinal bypass with a 50 to 100-cm common channel resulting in malabsorption of dietary fat (Scopinaro et al. Br J Surg. 66(9):618-20, 1979). Later, several modifications (sleeve gastrectomy, pylorus preservation, and duodenal switch) were proposed to improve incidence of postoperative dumping syndrome, diarrhea, and anastomotic ulcerations (Lagacé et al. Obes Surg. 5(4):411-8, 1995). Gagner et al. developed a simplified and reproducible approach for laparoscopic BPD with duodenal switch (BPD-DS) after sleeve gastrectomy (Ren et al. Obes Surg. 10(6): 514-23, 2000). BPD-DS has been considered as one of the most difficult bariatric procedures for its surgical complexity and postoperative metabolic complications management. In this regard, the number of BPD-DS has remained extremely low (<4 %). We hypothesize that robotic approach could facilitate the feasibility of BPD-DS procedure. In this multimedia video (8 min), we present a step-by-step robotic BPD-DS.

[Comparative results of surgical treatment of patients with morbid obesity].

It was performed a comparative analysis of treatment of 62 patients who were operated for morbid obesity. Patients were divided into 3 groups depending on kind of surgery: jejunal-iliac intestinal bypass, restrictive operations and combined operations. The complications in early postoperative period were diagnosed in 16.6% of patients after jejunal-iliac intestinal bypass and in 10% of patients after combined operations. Regardless of the kind of surgery there was rapid reduction of the body mass in the first year of observation with gradual increase of weight by an average of 5% in the subsequent period. The highest rate of weight loss by the second year was revealed after combined operations (up to 73.4%). Thus it was 1.1 times more than after jejunal-iliac intestinal bypass and 1.3 times more than after restrictive operations.