Ten years of follow-up of bilio-intestinal bypass: is malabsorption necessary for long-term metabolic results?

BACKGROUND: Bilio-intestinal bypass (BIBP) is an uncommon bariatric procedure. In 1999, a prospective trial was started at our institution to evaluate the effectiveness of BIBP. Trial was interrupted in 2006 due to high rate of complications. The aim of the present paper was to retrospectively review 10-year outcomes of BIBP. METHODS: Retrospective review of bariatric database was performed to find patients that had undergone BIBP from 1999 to 2006. Data collected were as follows: age, gender, body weight, body mass index (BMI), percentage of excess weight loss (%EWL), remission from weight-related diseases, complications, and deaths at 1,3, 5, 7, and 10 years. Quality of life was evaluated using "BAROS" questionnaire. RESULTS: From May 1999 to September 2006, 86 patients underwent BIBP. The mean age was 34.9 ± 22.4 years, and the initial weight and BMI were 141.2 ± 40.4 kg and 49.8 ± 15.5 kg/m2, respectively. After 10 years, the mean %EWL and BMI were 72.6 ± 18.7 and 31.2 ± 5.6 kg/m2. Almost all patients had diarrhea after surgery. Bloating syndrome occurred in 24% of patients, 48% had nephrolithiasis, and 20.9% had cholelithiasis. Remission from diabetes and hypertension was obtained in 75% and 80% of patients. Mortality was 3.2% and reoperation rate was 14.5%. CONCLUSIONS: Malabsorption plays a determinant role to obtain a long-lasting treatment for obese patients. However, BIBP is not recommendable due to high rate of complications and metabolic disorders.

Rhabdomyolysis after sleeve gastrectomy: increase in muscle enzymes does not predict fatal outcome.

INTRODUCTION: Rhabdomyolysis (RML) is a clinical and biochemical syndrome caused by destruction of skeletal muscles and constitutes a complication of bariatric surgery, with an incidence near to 22%. It is accompanied by increase in serum of intracellular enzymes. Laboratory data as predictive of prognosis have been evaluated by some authors. We report a case of RML after a sleeve gastrectomy, with good prognosis despite a very extensive muscle damage and very high seric and urinary peaks of intracellular enzymes. CASE REPORT: We describe a 34-years-old super-obese male (body mass index, 54.3 kg/m2) who underwent to laparoscopic sleeve gastrectomy. After 24 h, patient complained of pain in gluteal region, oliguria, and high levels of creatine phosphokinase that reached to 58,395 IU/l. Acute renal failure related to RML was diagnosed. Dialysis was not necessary. Ambulatorial control of renal function after dimission did not reveal a permanent damage. CONCLUSION: RML is a biochemical syndrome recently associated with bariatric surgery. Early diagnosis is ever necessary. Laboratory data represent markers for diagnosis and prognostic indicator of renal failure. There is no clear relation between seric levels of intracellular enzymes and irreversible renal damage and RML-related mortality.

Role of bariatric surgery in early detection of renal cell carcinoma: report of two cases and review of the literature.

Obesity is considered a strong risk factor for renal cell carcinoma, the most common primary renal malignant neoplasm. An association between renal cell carcinoma and obesity has been reported in numerous trials. Several potential mechanisms may be responsible for the risk of renal cell carcinoma in obese subjects. We report the cases of two patients, submitted to bariatric malabsorbtive surgery, who presented a renal clear cell carcinoma several months after the operation. The diagnosis was made by routine postoperative ultrasound examination and confirmed by computed tomography in both cases. Both were treated surgically. Our approach after diagnosis of cancer consisted in evaluation of the patient's immunological, metabolic and nutritional status to establish whether it was a case of real malnutrition or an oncological risk condition. We judged that restoration of original gastrointestinal continuity was not necessary. In the literature, we found no evidence of an association between a cancer histotype and bariatric surgery. Confirming the association between renal cell carcinoma and morbid obesity, these case reports indicate the importance of imaging control, especially with non-invasive diagnostic studies, in high-risk cancer patients, such as obese patients, to detect lesions incidentally at an early stage. After a thorough review of the literature data, we consider bariatric patients a suitable group to be assessed for an early diagnosis of various types of cancer, detectable at preoperative or postoperative screening. Weight loss and continuous instrumental exams are conditions favourable to an early diagnosis. Guidelines regarding the management of oncological patients with a history of bariatric surgery are indispensable.

Prophylaxis of thromboembolism in bariatric surgery with parnaparin.

BACKGROUND: There are limited data on appropriate dosing of low-molecular-weight heparins (LMWHs) for venous thromboembolism (VTE) prophylaxis in bariatric surgery. The primary objective of this preliminary study was to evaluate the preoperative effects of increasing doses of the LMWH parnaparin on coagulation in severely obese patients undergoing bariatric surgery. METHODS: Severely obese patients (BMI > 50 kg/m(2)) were administered three increasing single doses of parnaparin (3200, 4250, and 6400 IU) on the three consecutive days leading up to biliointestinal bypass surgery. Activated partial thromboplastin time (APTT), anti-factor IIa and anti-factor Xa levels were measured 1 h before and 4 h after dosing. The highest dose (6400 IU/day) was continued from the day of surgery until day 30 (recovery period). Intermittent pneumatic compression and stockings were applied during surgery and the recovery period, respectively. Lower limb echoDoppler and phleboscintigraphy, and pulmonary scintigraphy were used for VTE detection. RESULTS: Ten patients (mean BMI 52.4 kg/m(2)) were recruited into this study. During the preoperative dosing phase, parnaparin dose-dependently prolonged APTT, with the 6400 IU dose significantly prolonging APTT versus the lower doses. Meanwhile, anti-factor Xa and anti-factor IIa activity was increased by the 4250 and 6400 IU doses. After surgery, one patient with heparin resistance experienced pulmonary embolization. No bleeding complications were observed. CONCLUSION: The dose-response data reported in this preliminary study suggest that parnaparin doses of 4250 and 6400 IU may provide effective prophylaxis for VTE in patients undergoing bariatric surgery. However, given the small number of patients, larger, well-controlled trials are required to confirm these findings.

Endoscopic management of intragastric penetrated adjustable gastric band for morbid obesity.

This report describes a case of successful endoscopic management of intragastric penetrated adjustable gastric band in a patient with morbid obesity. The favorable course of the case described here demonstrates that adjustable gastric bands in the process of migration need not be removed surgically in patients who are asymptomatic.

Serum in vivo and in vitro activity of single dose of ertapenem in surgical obese patients for prevention of SSIs.

BACKGROUND: Despite progress made in the control of post-operative infections, the incidence of surgical site infections (SSIs) is still high. An improper perioperative antibiotic use can expose patients to the risk of resistant microorganisms, and, in surgical obese patients, the drug dosage and infusion time are critical points. The aim of our study was to evaluate the effectiveness of ertapenem in the prophylaxis of SSIs in obese patients undergoing general or bariatric surgery. METHODS: A total of 63 obese patients, candidates for several surgical interventions, were enrolled and divided into two groups. Patients received antibiotic prophylaxis before surgery: the case group received venous infusion of ertapenem; the control group received standard prophylaxis. Serum samples were tested for antimicrobial activity against Gram-positive and Gram-negative bacteria. RESULTS: After single-dose ertapenem in obese patients, we registered in vitro activity of sera against the growth of non-extended beta lactamase (ESBL)-producing Escherichia coli, Proteus mirabilis, Citrobacter freundii, Enterobacter cloacae, and non-ESBL-producing Klebsiella pneumoniae. Moreover, methicillin-sensitive Staphylococcus aureus and Streptococcus viridans were also inhibited. We found in vivo efficacy according to clinical monitoring: at the weekly and monthly follow-ups, one patient in the case group and six patients in the control group presented superficial incisional SSIs. CONCLUSIONS: These preliminary results are suggestive of the efficacy of ertapenem in perioperative prophylaxis of SSIs in obese patients; however, they need to be confirmed by further investigations and more defined trials.

Laparoscopic gastric band migration: role of environmental factors in the experience of a single team in three operating rooms.

Stomach erosion after gastric banding represents one of its least studied complications, despite the fact that the modalities of presentation and treatment have been clarified in recent years. Associations between this complication and specific surgical factors related to the patient have not been reported. We evaluated the incidence of this complication in various operating environments, to identify a possible association with a specific risk factor. A total of 250 patients underwent gastric banding between 2006 and 2008 and were followed for at least 1 year of follow-up. The procedure was performed in three Centers by the same surgical team. Center A was selected for the learning curve, in the initial phase of the study. All surgeries were performed with standardized techniques. An annual endoscopic evaluation was performed during first 12 months. The data from the three Centers were evaluated comparatively, to assess the incidence of migration and compare sterilization and perioperative preparation techniques. Between May 2006 and December 2008, 140 patients operated on at Center A, 70 at Center B, and 50 at Center C were included. Twelve cases of intragastric migration were observed (4.8% of the entire cohort): two cases at Center A (1.4%) and 10 cases at Center C (25%; A vs. C and A vs. B, p < 0.05); no cases of erosions were observed in Center B of 50 patients (0%; reviewer 1, comment 1). From a retrospective observation, no significant difference in sterilization techniques was observed, while there were differences in perioperative preparation, although these are not objectifiable parameters.