Assessment of the Role of Omentopexy in Laparoscopic Sleeve Gastrectomy: A Tertiary Center Experience.

Background: Laparoscopic sleeve gastrectomy is one of the most common bariatric procedures due its high success and low complication rates. However, acid reflux and food intolerance remain drawbacks of the procedure, with high frequency of postoperative gastroesophageal reflux disease (GERD) and eating disorders reported by previous studies. Omentopexy is not a standard technique in laparoscopic sleeve gastrectomy and showed promising results in preventing these sequelae. The present study aimed to evaluate whether omentopexy would decrease the incidence of postoperative GERD, food intolerance, and gastric volvulus without increasing additional complications rates in comparison with laparoscopic sleeve gastrectomy (LSG) without omentopexy. Patients and Methods: Our study included all the patients undergoing laparoscopic sleeve gastrectomy in our bariatric unit, who were divided into two groups. Group II had the added step of omentopexy. Comparison between both groups was done regarding incidence of acid reflux, food tolerance, and postoperative complications. Results: Omentopexy decreased the incidence of acid reflux, gastric kink, volvulus, and intrathoracic migration. Moreover, food tolerance significantly improved in patients, which in turn led to higher compliance with the postoperative dietary plan and better outcome with regard to weight loss. In addition, omentopexy showed lower incidence of postoperative leakage. Conclusion: Omentopexy is a valuable step in laparoscopic sleeve gastrectomy, which should be considered a standard step in all cases.

Development and validation of the paediatric Carbohydrate Perception Questionnaire (pCPQ), an instrument for the assessment of carbohydrate-induced gastrointestinal symptoms in the paediatric population.

BACKGROUND: There is an unmet need for a validated, test-specific symptom questionnaire to evaluate carbohydrate perception during breath tests. Our aim was to develop and validate a questionnaire for the assessment of symptoms after a provocative carbohydrate load. METHODS: After a literature search and initial focus group-style interviews, five relevant complaints were identified. Responses were given on a Likert-type faces scale with a language children use and understand. Reliability, validity and responsiveness to change were established by the implementation of the questionnaire during breath tests in 215 pediatric subjects. Correlation between the questionnaire and a medical interview by a pediatrician who was blinded to the results of the questionnaire (n = 19) was determined. KEY RESULTS: The questionnaire had good face and content validity (Lawshe ratio = 1). Intraclass correlation coefficients for test-retest reliability (n = 116) demonstrated good repeatability (P < .001), and effect sizes were small (Cohen's d < 0.15 for all symptoms). Convergent validity and discriminant validity were supported according to the multitrait-multimethod matrix method. The results obtained by the questionnaire correlated highly with the result of the medical interview (P < .001; Fisher's exact test). Cronbach's alpha was 0.81. Responsiveness was verified for the whole patient group and subgroups with medium to high effect sizes. CONCLUSIONS AND INFERENCES: The paediatric Carbohydrate Perception Questionnaire (pCPQ) is a simple, test-specific questionnaire for a pediatric population. It is a valid instrument with excellent psychometric properties to assess gastrointestinal symptoms after carbohydrate ingestion. The pCPQ can replace non-validated symptom assessment during carbohydrate breath tests and allows a standardized diagnosis of carbohydrate intolerance.

Gastrointestinal symptoms before and after laparoscopic Roux-en-Y gastric bypass: a longitudinal assessment.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is an effective treatment for morbid obesity, but many patients have increased gastrointestinal symptoms. OBJECTIVES: To evaluate gastrointestinal symptoms and food intolerance before and after RYGB over time in a large cohort of morbidly obese patients. SETTING: A high-volume bariatric center of excellence. METHODS: A prospective cohort study was performed in patients who underwent RYGB between September 2014 and July 2015, with 2-year follow-up. Consecutive patients screened for bariatric surgery answered the Gastrointestinal Symptom Rating Scale (GSRS) and a food intolerance questionnaire before RYGB and 2 years after surgery. The prevalence of gastrointestinal symptoms before and after surgery and the association between patient characteristics and postoperative gastrointestinal symptoms were assessed. RESULTS: Follow-up was 86.2% (n = 168) for patients undergoing primary RYGB and 93.3% (n = 28) for revisional RYGB. The total mean GSRS score increased from 1.69 to 2.31 after surgery (P < .001), as did 13 of 16 of the individual scores. Preoperative GSRS score is associated with postoperative symptom severity (B = .343, P < .001). Food intolerance was present in 16.1% of patients before primary RYGB, increasing to 69.6% after surgery (P < .001). Patients who underwent revisional RYGB had a symptom severity and prevalence of food intolerance comparable with that among patients with primary RYGB, even though they had more symptoms before revisional surgery. CONCLUSIONS: Two years after surgery, patients who underwent primary RYGB have increased gastrointestinal symptoms and food intolerance compared with the preoperative state. It is important that clinicians are aware of this and inform patients before surgery.

Relationship between duration of preoperative symptoms and postoperative ileus for small bowel obstruction.

BACKGROUND: Factors associated with postoperative ileus and increased resource utilization for patients who undergo operative intervention for small-bowel obstruction are not extensively studied. We evaluated the association between total duration of preoperative symptoms and postoperative outcomes in this population. MATERIALS AND METHODS: We performed a retrospective review of patients who underwent surgery for small-bowel obstruction (2013-2016). Clinical data were recorded. Total duration of preoperative symptoms included all symptoms before operation, including those before presentation. Primary endpoint was time to tolerance of diet. Secondary endpoints included length of stay, total parenteral nutrition use, and intensive care unit admission. Association between variables and outcomes was analyzed using univariable analysis, multivariable Poisson modeling, and t-test to compare groups. RESULTS: Sixty-seven patients were included. On presentation, the median duration of symptoms before hospitalization was 2 d (range 0-18 d). Total duration of preoperative symptoms was associated with time to tolerance of diet on univariable analysis (Pearson's moment correlation: 0.28, 95% confidence interval: 0.028-0.5, P = 0.03). On multivariable analysis, ascites was correlated with time to tolerance of diet (P < 0.01), but total duration of preoperative symptoms (P = 0.07) was not. Length of stay (Pearson's correlation: 0.24, 95% confidence interval: -0.02 to 0.47, P = 0.07) was not statistically different in patients with longer preoperative symptoms. Symptom duration was not statistically associated with intensive care unit (P = 0.18) or total parenteral nutrition (P = 0.3) utilization. CONCLUSIONS: Our findings demonstrate that preoperative ascites correlated with increased time to tolerance of diet, and duration of preoperative symptoms may be related to postoperative ileus.

Postoperative Outcomes, Weight Loss Predictors, and Late Gastrointestinal Symptoms Following Laparoscopic Sleeve Gastrectomy.

OBJECTIVE: To evaluate the outcomes, weight loss predictors, and gastrointestinal symptoms of patients after laparoscopic sleeve gastrectomy (LSG). METHODS: The postoperative medical status of the patients was obtained retrospectively using a questionnaire and was compared to existing medical data before the surgery. RESULTS: We included 201 candidates, 178 patients completed mean of 3 years of follow-up. Mean excess body weight loss (%EWL) was 65.14% ± 15.74 at 6 months, 78.53% ± 20.28 at 12 months, and 74.32% ± 23.92 at 3 years after LSG. Older age (P = 0.018), higher baseline BMI (P = 0.003), and higher number of medications (P < 0.001) were negative predictors for EWL%. Total weekly hours of physical activity was found to be a positive predictor for EWL% (P = 0.008). Remission rates of co-morbidities were 83.5% for dyslipidemia (P < 0.001), 65.8% for hypertension (P < 0.001), 62.1% for type 2 diabetes mellitus (T2DM) (P < 0.001), and 60.7% for gastroesophageal reflux (GERD) (P < 0.001). Late gastrointestinal symptoms were as follows: emesis in 25.9%, constipation in 24.7%, diarrhea in 4.5%, food intolerance in 22.5% and alopecia in 42.7% of the patients. CONCLUSION: Our study shows LSG as a potential tool in achieving almost 75% of EWL% with significant remission of co-morbidities, along with various late gastrointestinal symptoms.

Utilidad del test de ALCAT en la intolerancia alimentaria / Usefulness of the ALCAT test in food intolerance

CONTEXTO CLÍNICO: La alergia alimentaria se estima que afecta al 8% de la población y se caracteriza por una respuesta inmunológica clásica, como por ejemplo una reacción mediada por inmunoglobulina (Ig) E, en respuesta a una proteína específica. Esta reacción puede manifestarse con síntomas leves, como urticaria y estomatitis, hasta con un cuadro de anafilaxis. Otro tipo de reacción inmunológica causada por un alimento es la sensibilización de tipo IgG. Se trata de una forma alérgica que expresa un estado de sensibilización del paciente a un alérgeno alimentario determinado. Según varios autores, tiene escaso valor clínico, de modo que tan sólo la subclase IgG4 se ha relacionado con ciertos tipos de alergia. Por otro lado, la intolerancia alimentaria es una reacción fisiológica disparada por un aditivo alimentario o un alimento en particular, en la que no participa el sistema inmune. Presenta una frecuencia entre cinco y diez veces superior a la alergia. Inmediatamente tras la exposición se produce una reacción de microtoxicidad de carácter individual cuyas dianas son los linfocitos, granulocitos y plaquetas de la sangre. Se manifiesta por síntomas inespecíficos y crónicos como molestias abdominales, cefalea, fatiga y dolores músculo-esqueléticos. En este último caso la identificación del alimento disparador del cuadro puede ser difícil dada la naturaleza crónica de los síntomas. Se considera que la mejor manera para hacerlo es eliminando de la dieta los alimentos potencialmente causantes del cuadro. Se elimina un alimento o grupo de alimentos específicos por un período de tiempo determinado, y se observa si hay disminución o desaparición de los síntomas. Posteriormente pueden reintroducirse y evaluar si los síntomas reaparecen. Para el diagnóstico de intolerancia alimentaria también se propone el uso de diferentes tests de laboratorio, dentro de los cuales se encuentra el test de ALCAT (por sus siglas en inglés antigen leukocyte cellular antibody test). TECNOLOGÍA: El test de ALCAT es una técnica de laboratorio para valorar in vitro la intolerancia alimentaria. Se parte de una muestra de sangre total del paciente, a la cual se le agrega citrato sódico al 3,8 % como anticoagulante. La muestra se reparte en alícuotas de volumen idéntico y cada una de ellas se incuba con un extracto alimentario o aditivo, en condiciones optimizadas, durante un período estandarizado. Una alícuota es sometida al mismo proceso que el resto pero en ausencia de extracto, como control negativo específico para el paciente. OBJETIVO: Evaluar la evidencia disponible acerca de la eficacia, seguridad y aspectos relacionados a las políticas de cobertura del test de ALCAT. MÉTODOS: Se realizó una búsqueda en las principales bases de datos bibliográficas (incluyendo Medline, Cochrane y CRD), en buscadores genéricos de Internet, agencias de evaluación de tecnologías sanitarias y financiadores de salud utilizando la siguiente estrategia: ((Alcat test OR antigen leukocyte cellular antibody test) AND (intolerance to food OR food hypersensitivity OR food allergy)). Se priorizó la inclusión de revisiones sistemáticas (RS), ensayos clínicos controlados aleatorizados (ECAs), evaluaciones de tecnologías sanitarias y económicas, guías de práctica clínica y políticas de cobertura de otros sistemas de salud cuando estaban disponibles. RESULTADOS: Para el siguiente informe se incluyeron dos ECAs, dos estudios observacionales, cuatro recomendaciones internacionales y ocho políticas de cobertura. CONCLUSIONES: La evidencia es escasa y de baja calidad metodológica, no permitiendo estimar la precisión diagnóstica, la efectividad y seguridad del test de ALCAT (por sus siglas en inglés antigen leukocyte cellular antibody test), en condiciones clínicas consideradas manifestaciones de intolerancia alimentaria. Diferentes sociedades científicas internacionales consideran a este test en etapa experimental y no recomiendan su uso. Las políticas de cobertura internacionales relevadas no contemplan su cobertura.