Roux-en-Y gastric bypass restores islet function and morphology independent of body weight in ZDF rats.

Reductions in ß-cell number and function contribute to the onset type 2 diabetes (T2D). Roux-en-Y gastric bypass (RYGB) surgery can resolve T2D within days of operation, indicating a weight-independent mechanism of glycemic control. We hypothesized that RYGB normalizes glucose homeostasis by restoring ß-cell structure and function. Male Zucker Diabetic Fatty (fa/fa; ZDF) rats were randomized to sham surgery (n = 16), RYGB surgery (n = 16), or pair feeding (n = 16). Age-matched lean (fa/+) rats (n = 8) were included as a secondary control. Postprandial metabolism was assessed by oral glucose tolerance testing before and 27 days after surgery. Fasting and postprandial plasma GLP-1 was determined by mixed meal tolerance testing. Fasting plasma glucagon was also measured. ß-cell function was determined in isolated islets by a glucose-stimulated insulin secretion assay. Insulin and glucagon positive areas were evaluated in pancreatic sections by immunohistochemistry. RYGB reduced body weight (P < 0.05) and improved glucose tolerance (P < 0.05) compared with sham surgery. RYGB reduced fasting glucose compared with both sham (P < 0.01) and pair-fed controls (P < 0.01). Postprandial GLP-1 (P < 0.05) was elevated after RYGB compared with sham surgery. RYGB islets stimulated with 20 mM glucose had higher insulin secretion than both sham and pair-fed controls (P < 0.01) and did not differ from lean controls. Insulin content was greater after RYGB compared with the sham (P < 0.05) and pair-fed (P < 0.05) controls. RYGB improves insulin secretion and pancreatic islet function, which may contribute to the remission of type 2 diabetes following bariatric surgery.NEW & NOTEWORTHY The onset and progression of type 2 diabetes (T2D) results from failure to secrete sufficient amounts of insulin to overcome peripheral insulin resistance. Here, we demonstrate that Roux-en-Y gastric bypass (RYGB) restores islet function and morphology compared to sham and pair-fed controls in ZDF rats. The improvements in islet function were largely attributable to enhanced insulin content and secretory function in response to glucose stimulation.

Gastric mucocele after conversion of open butterfly gastroplasty to Roux-En-Y gastric bypass - A case report with a review of the literature.

INTRODUCTION: There has been a significant increase in the prevalence of morbid obesity across the globe. Various non-surgical weight loss options have shown limited long-term efficacy, leading to the popularity of surgical treatment alternatives with long-term efficacy. PRESENTATION OF CASE: This case report describes the development of a gastric mucocele in a 51-year-old female patient. The patient initially underwent open butterfly gastroplasty in August 2016. Seven years later, she presented with severe symptoms of gastroesophageal reflux disease (GERD). After further diagnostic evaluations, laparoscopic Roux-en-Y bypass surgery was performed. However, the patient experienced complications including fever, abdominal pain, and fluid collection around the stomach. Conservative management initially helped, but persistent symptoms led to laparoscopic exploration, which revealed a distended remnant stomach forming a gastric mucocele. Severe adhesions hindered attempts to remove the remnant stomach, resulting in the need for gastro-gastric anastomosis. Following the surgery, the patient had no symptoms, could eat solid food, and was discharged in good condition. DISCUSSION: Although various non-surgical weight loss options such as diet modifications, lifestyle changes, and drug therapy have been used for weight loss, they have demonstrated limited long-term efficacy. Surgical treatment has demonstrated long-term efficacy in such patient groups. In recent years, there has been an increased popularity of Roux-en-Y gastric bypass (RYGBP) due to long-term weight loss. However, in some cases, complications have also been reported. CONCLUSION: This case emphasizes the challenges in managing complications from open butterfly gastroplasty and Roux-en-Y gastric bypass. Surgeons should be aware of the possibility of gastric mucocele development and consider appropriate management strategies.

Can diabetes be surgically cured? Long-term metabolic effects of bariatric surgery in obese patients with type 2 diabetes mellitus.

OBJECTIVE: Evaluate the long-term effects of bariatric surgery on type 2 diabetes (T2DM) remission and metabolic risk factors. BACKGROUND: Although the impressive antidiabetic effects of bariatric surgery have been shown in short- and medium-term studies, the durability of these effects is uncertain. Specifically, long-term remission rates following bariatric surgery are largely unknown. METHODS: Clinical outcomes of 217 patients with T2DM who underwent bariatric surgery between 2004 and 2007 and had at least 5-year follow-up were assessed. Complete remission was defined as glycated hemoglobin (A1C) less than 6% and fasting blood glucose (FBG) less than 100 mg/dL off diabetic medications. Changes in other metabolic comorbidities, including hypertension, dyslipidemia, and diabetic nephropathy, were assessed. RESULTS: At a median follow-up of 6 years (range: 5-9) after surgery (Roux-en-Y gastric bypass, n = 162; gastric banding, n = 32; sleeve gastrectomy, n = 23), a mean excess weight loss (EWL) of 55% was associated with mean reductions in A1C from 7.5% ± 1.5% to 6.5% ± 1.2% (P < 0.001) and FBG from 155.9 ± 59.5 mg/dL to 114.8 ± 40.2 mg/dL (P < 0.001). Long-term complete and partial remission rates were 24% and 26%, respectively, whereas 34% improved (>1% decrease in A1C without remission) from baseline and 16% remained unchanged. Shorter duration of T2DM (P < 0.001) and higher long-term EWL (P = 0.006) predicted long-term remission. Recurrence of T2DM after initial remission occurred in 19% and was associated with longer duration of T2DM (P = 0.03), less EWL (P = 0.02), and weight regain (P = 0.015). Long-term control rates of low high-density lipoprotein, high low-density lipoprotein, high triglyceridemia, and hypertension were 73%, 72%, 80%, and 62%, respectively. Diabetic nephropathy regressed (53%) or stabilized (47%). CONCLUSIONS: Bariatric surgery can induce a significant and sustainable remission and improvement of T2DM and other metabolic risk factors in severely obese patients. Surgical intervention within 5 years of diagnosis is associated with a high rate of long-term remission.

Post-laparoscopic sleeve gastrectomy with splenic abscess: Case report.

INTRODUCTION AND IMPORTANCE: One of the complications of laparoscopic sleeve gastrectomy (LSG) is a splenic abscess, considered a rare complication. As it is rare, it is a challenge to diagnose. CASE PRESENTATION: In this case, a 62-year-old male patient who underwent LSG returned after three weeks with abdominal pain and fever. CLINICAL DISCUSSION: leak, Infection, spleen infarction These seemed like common complications, such as leaking from the stapler line, but the CT findings indicated a splenic abscess. The primary explanation for such an abscess is unclear in our case as the other reported cases were with the hypothesis of the late leak. A different treatment approach, laparoscopic exploration with incision and drainage, is the preferred option for this patient. CONCLUSION: rare complications can be a challenge and how to manage them can be different from the standard to help the patient.

Delayed Presentation of Gastric Volvulus with Gastric Outlet Obstruction after Laparoscopic Sleeve Gastrectomy.

Background: Globally among bariatric procedures, SG popularity has grown significantly. New complications arise as a result of the rapid growth in the numbers of LSG. Once SG has been performed, the stomach is left with no fixations along the entire greater curvature, which may predispose to volvulus. Case Report. The 44-year-old patient had laparoscopic sleeve gastrectomy 2 years and 6 months before presentation in our emergent department complaining of episodic intolerance to oral intake for 3 months before presentation. Gastrografin swallow study showed gastric outlet obstruction. The patient was taken to the operation room for laparoscopic exploration, gastric untwisting. Conclusion: This case highlights a rare complication of SG which has been inconsistently addressed in the literature. Awareness of such complications would help surgeons to widen their differential diagnosis of postoperative sleeve gastrectomy early complications to manage them effectively. The video of the procedure showing the intraoperative finding can be accessed at.

Splenic abscess after laparoscopic sleeve gastrectomy. A rare complication-case report and literature review.

Laparoscopic sleeve gastrectomy is currently a stand-alone bariatric procedure with a low complication profile. A rare complication of leak following sleeve gastrectomy was reported in this study. Its rareness and nonspecific clinical presentation could make the diagnosis difficult and could be easily confused with leak and subdiaphragmatic abscess. A 22-year-old Saudi female with body mass index 41 underwent laparoscopic sleeve gastrectomy in 2017, presented 18 months later to emergency department complaining of fever and abdominal pain for 3 months prior to presentation. Computed tomography of abdomen revealed a large splenic abscess, upper gastrointestinal studies were unremarkable. Patient was taken for laparoscopic exploration with finding of splenic abscess and gastric fistula, splenectomy and clipping of fistula was performed. The management of splenic abscess remains controversial. Splenectomy and antibiotics have generally been the definitive treatment particularly with large multilobulated collection. Familiarity with the rare complications as splenic abscess will allow for a prompt diagnosis and treatment.

Effect of Surgical Weight Loss on Plantar Fasciitis and Health-Care Use.

BACKGROUND:: Plantar fasciitis (PF) is one of the most common causes of heel pain. Obesity is recognized as a major factor in PF development, possibly due to increased mechanical loading of the foot due to excess weight. The benefit of bariatric surgery is documented for other comorbidities but not for PF. METHODS:: A retrospective medical record review was performed for patients with PF identified from a prospectively maintained database of the Cleveland Clinic Bariatric and Metabolic Institute. Age, sex, surgery, excess weight loss, body mass index (BMI), and health-care use related to PF treatment were abstracted. Comparative analyses were stratified by surgery type. RESULTS:: Two hundred twenty-eight of 10,305 patients (2.2%) had a documented diagnosis of PF, of whom 163 underwent bariatric surgery and were included in the analysis. Eighty-five percent of patients were women, mean ± SD age was 52.2 ± 9.9 years, and mean ± SD preintervention BMI was 45 ± 7.7. Postoperatively, mean ± SD BMI and excess weight loss were 34.8 ± 7.8 and 51.0% ± 20.4%, respectively. One hundred forty-six patients (90%) achieved resolution of PF and related symptoms. The mean ± SD number of treatment modalities used for PF per patient preoperatively was 1.9 ± 1.0 ( P = .25). After surgery, the mean ± SD number of treatment modalities used per patient was reduced to 0.3 ± 0.1 ( P = .01). CONCLUSIONS:: We present new evidence suggesting that reductions in BMI after bariatric surgery may be associated with decreasing the number of visits for PF and may contribute to symptomatic improvement.

Effect of Roux-en-Y gastric bypass on liver mitochondrial dynamics in a rat model of obesity.

Bariatric surgery provides significant and durable improvements in glycemic control and hepatic steatosis, but the underlying mechanisms that drive improvements in these metabolic parameters remain to be fully elucidated. Recently, alterations in mitochondrial morphology have shown a direct link to nutrient adaptations in obesity. Here, we evaluate the effects of Roux-en-Y gastric bypass (RYGB) surgery on markers of liver mitochondrial dynamics in a diet-induced obesity Sprague-Dawley (SD) rat model. Livers were harvested from adult male SD rats 90-days after either Sham or RYGB surgery and continuous high-fat feeding. We assessed expression of mitochondrial proteins involved in fusion, fission, mitochondrial autophagy (mitophagy) and biogenesis, as well as differences in citrate synthase activity and markers of oxidative stress. Gene expression for mitochondrial fusion genes, mitofusin 1 (Mfn1; P < 0.05), mitofusin 2 (Mfn2; P < 0.01), and optic atrophy 1 (OPA1; P < 0.05) increased following RYGB surgery. Biogenesis regulators, peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC1α; P < 0.01) and nuclear respiratory factor 1 (Nrf1; P < 0.05), also increased in the RYGB group, as well as mitophagy marker, BCL-2 interacting protein 3 (Bnip3; P < 0.01). Protein expression for Mfn1 (P < 0.001), PGC1α (P < 0.05), BNIP3 (P < 0.0001), and mitochondrial complexes I-V (P < 0.01) was also increased by RYGB, and Mfn1 expression negatively correlated with body weight, insulin resistance, and fasting plasma insulin. In the RYGB group, citrate synthase activity was increased (P < 0.02) and reactive oxygen species (ROS) was decreased compared to the Sham control group (P < 0.05), although total antioxidant capacity was unchanged between groups. These data are the first to show an association between RYGB surgery and improved markers of liver mitochondrial dynamics. These observed improvements may be related to weight loss and reduced energetic demand on the liver, which could facilitate normalization of glucose homeostasis and protect against hepatic steatosis.

Achalasia After Bariatric Surgery.

BACKGROUND: Obesity is an epidemic on the rise. Increasing body mass index (BMI) has been associated with a number of comorbid diseases, including rarely reported motility disorders such as achalasia. Motility disorders are prevalent in obese patients, possibly more prevalent when compared to the nonobese population. Identification of motility disorders is important before bariatric surgery and may alter the planned type of procedure performed. Limited data exist regarding the development or existence of esophageal motility disorders after bariatric surgery. This study aims to characterize patients who have undergone bariatric surgery and subsequently developed or were diagnosed with achalasia. METHODS: Patients with a diagnosis of achalasia who previously underwent bariatric surgery were identified. Data collected included baseline demographics, perioperative parameters, and postoperative outcomes. Descriptive statistics were computed for all variables. RESULTS: Ten patients met the inclusion criteria. All patients had endoscopy and manometry confirming diagnosis of achalasia after previous bariatric surgery. Eight patients had undergone Roux-en-Y gastric bypass (RYGB), and two patients had vertical banded gastroplasty (VBG). Median length of time from bariatric surgery to diagnosis was 6 years. Two patients had undergone Botox(®) treatment, and five had gone through the scope esophageal dilations. All patients had a surgical intervention for achalasia, specifically Heller myotomy (HM) (n = 4 open, n = 4 laparoscopic) was performed in the eight RYGB patients, whereas near total gastrectomy and esophagectomy (n = 1), and transhiatal esophagectomy with a partial gastrectomy (n = 1), were performed in each of the patients who previously underwent VBG. These patients were considered to have end-stage achalasia. All patients showed significant decrease in BMI after bariatric surgery (11.1 ± 1.5 kg/m(2)). Six of the eight patients who underwent HM achieved resolution of achalasia symptoms at a mean time of 1.6 months and remained asymptomatic for the total follow-up of 36 months. One patient developed recurrent achalasia 2 years after HM and subsequently underwent a peroral endoscopic myotomy. One HM patient was lost to follow-up. The two patients who underwent esophagectomies were symptom free at 36 months. CONCLUSION: Although the incidence of achalasia in the bariatric population is unknown, it does coexist and should be treated when identified. Dysmotility is not uncommon and rarely is the workup completed to identify achalasia before bariatric surgery. Increasing our attention to identify motility diseases preoperatively and specifically raising awareness that achalasia can occur after bariatric surgery will result in better care for patients. Our results suggest achalasia can be effectively treated with surgical therapy after previous bariatric surgery.

Bariatric surgery outcomes in patients with systemic lupus erythematosus.

BACKGROUND: Obesity is common among systemic lupus erythematosus (SLE) patients. An increased perioperative risk after major surgery in SLE has been reported. The aim of this study was to describe postoperative outcomes among SLE patients undergoing bariatric surgery. METHODS: Charts were reviewed to identify patients with an active diagnosis of SLE before bariatric surgery. Demographic variables, perioperative data, and SLE-related parameters were extracted. RESULTS: Thirty-one morbidly obese patients who underwent bariatric surgery between 2005 and 2013 had a SLE diagnosis. Twenty-three patients had laparoscopic Roux-en-Y gastric bypass (RYGBP), 3 underwent laparoscopic revisional surgery for failed bariatric procedure, 3 had laparoscopic sleeve gastrectomy and 1 underwent laparoscopic adjustable gastric banding. Mean age, body mass index, and excess weight (kg) at baseline were 52.8±9.4 years, 44.3±9 kg/m(2), and 52.5±25.7 kg, respectively. Of these 31 patients, 24 (77.4%) were taking immunosuppressive medications at the time of surgery. Early major postoperative complications occurred in 4 patients (12.9%), with 3 requiring reoperation (9.6%). Multivariate analysis identified immunosuppressive therapy to be significantly associated with postoperative complications (P = .05). At a mean follow-up of 3 years, 13 patients (42%) showed reduction in the number of immunosuppressive medications and 6 (19.3%) were off steroids completely. After bariatric surgery, mean body mass index decreased to 34.2±8.2 kg/m(2) (P<.005) and excess weight loss was 51.2%± 33.4%. CONCLUSION: Results suggest that weight loss after bariatric surgery is associated with decreased SLE immunosuppression medication requirements; however, the risks are higher. Bariatric surgery in this patient population should be approached with caution.

Effect of Roux-en-Y Gastric Bypass on the NLRP3 Inflammasome in Adipose Tissue from Obese Rats.

OBJECTIVE: Obesity is associated with low-grade chronic inflammation. We hypothesized that Roux-en-Y gastric bypass (RYGB) surgery would reduce activation of the NLRP3 inflammasome in metabolically active adipose tissue (AT) of obese rats, and this change would be related to decreases in body weight and improved glycemic control. METHODS: Omental, mesenteric and subcutaneous fat depots were collected from Sprague-Dawley rats: Sham control and RYGB; 90-days after surgery. NLRP3, caspase-1, apoptosis-associated speck-like protein (ASC), IL-1ß, IL-18, IL-6 and MCP-1 gene and protein expression were quantified. Glucose metabolism was assessed by oral glucose tolerance test (OGTT). RESULTS: Compared to Sham surgery controls, RYGB surgery decreased IL-6, MCP-1, NLRP3, IL-18, caspase-1 and ASC in omental fat, and decreased IL-6, MCP1, IL-1ß, IL-18, caspase-1 and ASC gene expression in mesenteric fat. We observed differential gene expression between visceral and subcutaneous fat for IL-6 and IL-1ß, both being downregulated by RYGB in visceral, and upregulated in subcutaneous depots. These changes in gene expression were accompanied by a decrease in NLRP3, ASC, IL-18, caspase-1 and IL-1ß protein expression in omental tissue. We found a positive correlation between caspase-1, ASC, MCP-1, IL-18 and IL-6 gene expression following surgery and glucose AUC response in omental fat, while the change in glucose AUC response correlated with caspase-1 gene expression in subcutaneous fat. CONCLUSION: This study demonstrates that bariatric surgery reverses inflammation in visceral adipose tissue by suppressing NLRP3 inflammasome activation. These are the first data to implicate the NLRP3 inflammasome in diabetes remission after RYGB surgery.

The Role of the Multidisciplinary Conference in the Evaluation of Bariatric Surgery Candidates with a High-Risk Psychiatric Profile.

Background: Implementation of a multidisciplinary conference (MC) attended by medical, surgical, nutrition, bioethics, and psychology specialists may help identify treatment plans for bariatric surgery candidates with a high-risk psychiatric profile. Methods: Data were assessed for all bariatric candidates evaluated by the MC in an academic center between January 2009 and December 2010. Results: A total of 134 patients of 2798 patients assessed by four different psychologists were subsequently evaluated by the MC. The most frequent psychiatric diagnoses were mood disorders (n = 37, 27.6%), anxiety disorders (n = 24, 17.9%), and binge eating disorder (n = 19, 14.1%). More than one psychiatric diagnosis was observed in 95.6% of the cohort. Substance abuse issues were present in 25% patients. Fifteen patients (11.2%) were eventually cleared and underwent surgery, 35 (26.1%) left the program before completing their requirements, and 84 patients (62.7%) were still working toward their individualized goals in the program. For those who underwent surgery, mean preoperative management duration was 221 days (range, 111-366) with an average of 11 preoperative psychiatric visits (range, 9-15). Conclusions: Patients with a high-risk psychosocial profile seeking bariatric surgery require multiple visits and resources to determine their candidacy. The majority of these patients are either deemed ineligible for surgery or require prolonged preoperative evaluation.

Is Laparoscopic Bariatric Surgery a Safe Option in Extremely High-Risk Morbidly Obese Patients?

INTRODUCTION: Age, superobesity, and cardiopulmonary comorbidities define patients as high risk for bariatric surgery. We evaluated the outcomes following bariatric surgery in extremely high-risk patients. MATERIALS AND METHODS: Among 3240 patients who underwent laparoscopic bariatric surgery at a single academic center from January 2006 through June 2012, extremely high-risk patients were identified using the following criteria: age ≥ 65 years, body mass index (BMI) ≥ 50 kg/m(2), and presence of at least two of six cardiopulmonary comorbidities, including hypertension, ischemic heart disease, congestive heart failure, chronic obstructive pulmonary disease, obstructive sleep apnea, and history of venous thromboembolism. Perioperative and intermediate-term outcomes were assessed. RESULTS: Forty-four extremely high-risk patients underwent laparoscopic Roux-en-Y gastric bypass (n = 23), adjustable gastric banding (n = 11), or sleeve gastrectomy (n = 10). Patients had a mean age of 67.9 ± 2.7 years, a mean BMI of 54.8 ± 5.5 kg/m(2), and a median of two (range, two to five) cardiopulmonary comorbidities. There was no conversion to laparotomy. Thirteen (29.5%) 30-day postoperative complications occurred; only six were major complications. Thirty-day postoperative re-admission, re-operation, and mortality rates were 15.9%, 2.3%, and 0%, respectively. Within a mean follow-up time of 24.0 ± 18.4 months, late morbidity and mortality rates were 18.2% and 2.3%, respectively. The mean percentage total weight and excess weight losses after at least 1 year of follow-up were 26.7 ± 12.0% and 44.1 ± 20.6%, respectively. CONCLUSIONS: Laparoscopic bariatric surgery is safe and can be performed with acceptable perioperative outcomes in extremely high-risk patients. Advanced age, BMI, and severe cardiopulmonary comorbidities should not exclude patients from consideration for bariatric surgery.

Clinical experience with a port-free internal liver retractor in laparoscopic bariatric surgery.

BACKGROUND: As laparoscopic techniques and instrumentation advance, bariatric surgery has begun to be performed through smaller incisions and fewer ports. Since the visualization of the dorso-lateral portion of the left liver lobe is critical for most bariatric procedures, surgeons have developed various techniques for providing adequate liver retraction without compromising patient safety. Herein, we present our experience with a port-free internal liver retractor used for bariatric cases. METHODS: Endolift™ does not require an additional port or anchoring to an external device. After insertion through an existing 5-mm port by means of the applier, one of the two attached clips (one on either end) was anchored to the left crus of the diaphragm while the other was fixed to the peritoneum above the right liver lobe through or beneath the falciform ligament. At the end of the surgery, the device was easily removed by using the applier. RESULTS: We used this technique for 31 Roux-en-Y gastric bypasses and 2 single-incision sleeve gastrectomies. There were 24 females and 9 males with a mean age of 46 and mean body mass index 45.0 kg/m(2). The mean operative time was 136.5 min. The time required for the placement of the device was 1-3 min. The approach to the upper part of the stomach was satisfactory in all patients. No device-related complications were observed. CONCLUSIONS: The internal liver retractor is easy to handle and provides adequate retraction and exposure for bariatric cases. It also has potential benefits for single-incision and reduced port laparoscopic procedures.