Thromboembolic Complications After Bariatric Surgery: Is the High Risk Real?

INTRODUCTION: Nowadays, a large number of bariatric surgery (BS) procedures are undertaken worldwide as surgery has become an efficient strategy to treat the obesity epidemic. The risk of venous thromboembolism (VTE) is increased in patients undergoing BS not only due to the intrinsic surgical risk but also because patients with obesity have a 2-3-fold higher risk of VTE. The optimal strategy for VTE prevention in BS setting, including optimal dose and thromboprophylaxis regimen, is still not fully clarified. The aim of this study was to report a bariatric high-volume center experience and to propose a practical thromboprophylaxis protocol for this population. METHODS: A single-center, observational, retrospective, and longitudinal study was conducted from January 2018 to December 2020, a total of 901 patients who underwent primary and revisional bariatric surgery were included. RESULTS: The overall frequency of VTE events was 0.44% (n=4), one patient had pulmonary embolism (PE) during index hospital admission; another patient had simultaneous deep venous thrombosis (DVT) and PE, two months after surgery; and two other patients had DVT, nine and 16 months after surgery. The median time for VTE was four months. The incidence of females was 75% (n=3) and the median age was 57 years. Only one female patient was using oral contraception. None had a previous history of thromboembolic events, chronic venous insufficiency, or other known diseases that could increase the VTE risk. CONCLUSION: Considering the outcomes reported by this experienced center with low rates of thromboembolic events, we suggest a thromboprophylaxis protocol that can be easily applied to the majority of bariatric patients.

Diffuse Peritonitis Caused by Splenic Abscess After Laparoscopic Sleeve Gastrectomy: A Case Report.

A splenic abscess (SA) following sleeve gastrectomy (SG) is a rare manifestation of a gastric leak (GL). The clinical findings include fever, abdominal pain, leukocytosis, and an elevated C-reactive protein. A computed tomography scan is diagnostic and can show signs of GL, or diffuse peritonitis. Treatment can either be non-operative (including large-spectrum antibiotics and percutaneous drainage) or surgical (including splenectomy). We present the case of a 41-year-old female patient with SA, with septic shock and diffuse peritonitis, successfully treated with a splenectomy three months post-SG.

Accuracy of prediction models for long-term type 2 diabetes remission after gastric bypass.

AIM: To evaluate the accuracy of DiaBetter, DiaRem, Ad-DiaRem and 5y-Ad-DiaRem scores' at predicting T2D remission 10 or more years after surgery. METHODS: Patients with obesity and T2D (n = 126) submitted to RYGB with 10 or more years of follow-up. It was a unicentric trial. Pre-operative anthropometric and clinical data was retrieved to calculate DiaRem, DiaBetter, Ad-DiaRem and 5y-Ad-DiaRem scores, while a hospital visit was conducted to assess current diabetes status. The area under the receiver operating characteristic (AUROC) curve was calculated as estimate of the scores' accuracy to predict long-term T2D remission. RESULTS: Among the entire cohort (n = 126), 70 subjects (55.6%) achieved and maintained T2D remission 10 or more years after RYGB. The 5y-Ad-DiaRem score was the one that depicted the highest discriminative power (AUROC = 0.838) to predict long-term T2D remission when compared to DiaBetter (AUROC = 0.735), DiaRem (AUROC = 0.721) and Ad-DiaRem (AUROC = 0.720). CONCLUSION: The score with highest accuracy to predict long-term T2D remission after RYGB surgery was the 5y-Ad-DiaRem. Yet, the available scores accuracy to predict T2D remission in the long term is still suboptimal, highlighting the unmet need for a better scoring system.

How Sustained is Roux-en-Y Gastric Bypass Long-term Efficacy? : Roux-en-Y Gastric Bypass efficacy.

PURPOSE: The rate of weight regain after Roux-en-Y Gastric Bypass (RYGB) can hamper the procedure long-term efficacy for obesity treatment and related comorbidities. To evaluate the rate of weight loss and comorbidity remission failure 10 years or more after RYGB surgery. MATERIALS AND METHODS: Retrospective observational cohort study. Patients submitted to RYGB for obesity treatment at a single centre with 10 years or more after surgery underwent a clinical reassessment. RESULTS: Among the subjects invited for clinical revaluation (n = 585), only those who performed RYGB and attended the hospital visit were included in the study (n = 281). The pre-operative mean body mass index (BMI) was 44.4 ± 6.1 kg/m2. Mean post-operative time was 12.2 ± 1.1 years. After surgery, mean BMI was significantly lower 33.4 ± 5.8 kg/m2 (p < 0.0001), 29.5% with a BMI < 30 kg/m2. Mean Total Weight Lost (%TWL) was 24.3 ± 11.4%, reaching a %TWL ≥ 20% in 70.1% with a mean %TWL of 30.0 ± 7.0%. Co-morbidities remission rate was 54.2% for type 2 diabetes, 34.1% for hypertension, 52.4% for hyperlipidemia and 50% for obstructive sleep apnea. Early complications rate was 13.2% and revision surgery occurred in 2.8% of patients. Four patients died of RYGB complications within the first 90 days after surgery. CONCLUSION: RYGB has a high rate of long-term successful weight loss and obesity-associated comorbidity improvement. Weight loss failure requiring revision surgery occurs in a small proportion of patients. Our data confirms the long-term effectiveness of RYGB as primary bariatric intervention.

Lung Nodule and Food Bolus Impaction: Can They Be Related?

Achalasia is a rare primary disorder of esophageal motility characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. This results in patient complaints of dysphagia to solids and liquids, regurgitation, chest pain, and weight loss. However, achalasia may also present with respiratory symptoms, such as aspiration pneumonia, due to remarkable regurgitation. In untreated patients and a long period of evolution, respiratory symptoms may even be the initial manifestation of achalasia. An endoscopic finding of retained food and saliva with a puckered gastroesophageal junction or barium swallow showing dilated esophagus with birds beaking in a symptomatic patient should prompt appropriate diagnostic and therapeutic strategies. We describe an atypical presentation of a rare disease in a young man with a history of symptoms caused by the late manifestation of achalasia.

Does Reconstruction Type After Gastric Resection Matters for Type 2 Diabetes Improvement?

BACKGROUND: Gastrointestinal (GI) surgery involving gastric resection and bypass of intestinal segments was reported to facilitate glucose control in obese patients with type 2 diabetes (T2D). AIM: Our aim was to assess whether the type of post-gastrectomy GI reconstruction also influences glucose control in T2D patients with BMI below 35 kg/m2 submitted to gastrointestinal surgery without bariatric intention. METHODS: A cohort of T2D Caucasian patients (n = 40) with upper GI malignancy (n = 33) or complicated reflux disease (n = 7) were submitted to either a gastrectomy plus Billroth II (BII) gastrojejunal anastomosis (n = 17), a gastrectomy plus Roux-en-Y gastrojejunostomy (RY) reconstruction (n = 18; subtotal gastrectomy n = 7 and total gastrectomy n = 11), or atypical gastrectomy without reconstruction (no-R) (n = 5). Patients were evaluated before and 2 years after surgery for body weight, Hb1Ac, need of glucose lowering drugs, and presence of diabetes. RESULTS: Body mass index (BMI) decreased after every surgical procedure when compared to baseline (- 0.9 ± 0.8 kg/m2 for BII vs - 4.3 ± 2.6 kg/m2 for RY vs - 4.6 ± 2.5 kg/m2 for no-R, p < 0.05), which was only significantly different after RY surgeries. Diabetes remission occurred in 5.9% of BII patients, in 27.8% of RY patients, and 0% of no-R patients, while in patients with persistent T2D, the needs for glucose-lowering drugs were significantly also decreased after RY (31.3% BII vs 66.7% RY vs 25% no-R, p = 0.03). CONCLUSIONS: T2D Caucasian patients undergoing post-gastrectomy GI reconstructions without a bariatric intention experience a significant improvement of T2D, in a magnitude that could be influenced by the technical procedure performed in favor of RY reconstruction. Thus, presence of T2D should be taken into consideration when deciding for the type of post-gastrectomy GI reconstruction.