Follow-up after gastric electrical stimulation for gastroparesis.

BACKGROUND: Gastric electrical stimulation (GES) is used to treat medically refractory gastroparesis. However, there are few large series with outcomes beyond 12 months. This study reports surgical outcomes of GES for patients up to 8 years receiving treatment from a single institution. STUDY DESIGN: A prospective database was reviewed from 2003 to 2013 for patients undergoing GES. Baseline patient characteristics were recorded, including age, sex, cause of gastroparesis, gastric emptying, and Hgb A1C. Outcomes variables included nutrition supplementation, additional operations, 30-day morbidity, and mortality. Pre- and postoperative pain and function scores are analyzed over time using generalized estimating equations. Patient outcomes in terms of reoperation rates and types of operations are also reviewed. RESULTS: Seventy-nine patients underwent GES with a mean ± SD age of 43 ± 11 years and a BMI of 27 ± 8 kg/m(2). Symptom scores were available for 60 patients: 60 patients at baseline, 52 patients at 1 year, 14 patients during years 2 to 3, and 18 patients during years 4 to 8. Symptom scores decreased considerably in all categories. At 1-year follow-up, 44% and 31% of patients had at least a 25% reduction in symptom distress for functional and pain symptoms, respectively. Preoperatively, 9 patients required nutrition supplementation. After implantation, 34 (43%) patients underwent additional operations, with a mean of 2.15 operations per patient. Generator-related causes were the most common indication for reoperation, including battery exchanges and relocation. Other operations included 8 gastrectomies and 7 median arcuate ligament releases. Postoperatively, 4 patients required supplemental nutrition. There were no 30-day mortalities, but 11 patients died during the study period. CONCLUSIONS: Gastric electrical stimulation was significantly associated with reductions in both functional and pain-related symptoms of gastroparesis. Patients who undergo GES have a high likelihood of additional surgery.

A novel single agent for nutritional supplementation following Roux-en-Y gastric bypass.

BACKGROUND: Duodenal bypass and intestinal malabsorption from Roux-en-Y gastric bypass (RYGB) can exacerbate known nutritional deficiencies of morbidly obese patients and worsen symptoms. Preventatively, most bariatric patients use postoperative nutritional supplementation. This study evaluated Nuvista(®) (Nutricia North America, Rockville, MD) and its potential as an adequate single nutritional supplement. SUBJECTS AND METHODS: From October 2009 to June 2010, 25 patients enrolled in a prospective, consecutive pilot study. Each underwent laparoscopic RYGB. The study group consumed two packs of Nuvista daily. The control group received standard nutritional supplements. Both groups had the same postoperative diet. Laboratory and demographics were compared at baseline and 12 months. Statistical analysis included paired t test, and a value of P<.05 was significant. RESULTS: The study and control groups (16 and 9 patients, respectively) had statistically similar demographic profiles. Both groups had preoperative elevations of hemoglobin A1c (HbA1c) (6.2% and 6.2%, respectively), low-density lipoprotein (LDL) (108.2 mg/dL and 199.2 mg/dL, respectively), and high-density lipoprotein (HDL) (55.1 mg/dL and 48.0 mg/dL, respectively) and deficiencies in vitamin D with respective mean values of 20.6 ng/mL and 22.7 ng/mL (normal range, 30-100 ng/mL). Postoperatively, the study group had significant increases in phosphorus (P=.02), iron (P=.03), vitamin D (P=.05), zinc (P=.01), and HDL (P≤.01) and significant decreases in body mass index (BMI) (P≤.01), creatinine (P=.02), HbA1c (P=.01), triglycerides (P≤.01), and LDL (P≤.01). The control group had a significant increase in HDL (P=.01) and significant decreases in BMI (P≤.01), hemoglobin (P=.01), creatinine (P≤.01), albumin (P=.05), HbA1c (P=.05), zinc (P≤.01), triglycerides (P=.03), and LDL (P=.01). No change in mean parathyroid hormone value was seen. CONCLUSIONS: Nuvista can provide adequate supplementation to bariatric patients 12 months after RYGB. Lifelong biochemical follow-up is necessary to personalize the diet and nutritional supplementation to compensate for the pathophysiologic changes of the gastric bypass.

Preoperative liver reduction utilizing a novel nutritional supplement.

BACKGROUND: One of the most common reasons for conversion in bariatric surgery is hepatomegaly caused by inadequate exposure of the proximal stomach. This study utilizes a novel nutritional supplement with a calorie-restricted diet to reduce liver volume preoperatively. METHODS: A consecutive series of morbidly obese patients consumed a nutritional supplement called Nuvista(®) for 4 weeks preoperatively. Preoperatively, each patient completed baseline demographics, blood work, urine ketone analysis, ultrasonography of the left lateral segment, and multiple questionnaires. At the time of surgery, these studies were repeated. Data were analyzed using a paired t-test and bivariate analysis where appropriate. A P<.05 was considered significant. RESULTS: Four men and 17 women were recruited with a mean preoperative weight and body mass index of 122.7±15.9 kg and 44.5±3.9, respectively. Mean preoperative liver volume of the left lateral segment was 562.5±291.3 cm(3). After 4 weeks of Nuvista, the mean weight and body mass index decreased significantly to 118.9±15.5 kg and 43.1±3.4, respectively (P<.001). The mean liver volume of the left lateral segment was significantly reduced to 299.9±162.1 cm(3) (P<.001). Mean liver reduction was 43.4%±17.2% (13.6%-81.9%, P<.05). Urinary ketone scores did not show any evidence of starvation. No preoperative factors correlated with liver volume reduction. CONCLUSION: Utilizing Nuvista, as part of a preoperative 4-week calorie-restricted regimen, significantly reduced lateral segment liver volume by 43.4%. This preoperative regimen incorporates healthy behavioral changes that are necessary to sustain long-term weight loss.