Non-Hodgkin's lymphoma of the appendix and distal ileum. A rare case report.

Primary gastrointestinal (GI) tract lymphomas constitute 1%-4% of all GI malignancies. Primary lymphomas of appendix are even more rare and are seen in 0.015% of all appendicectomy specimens. Here, we report a rare case of non-Hodgkin's lymphoma tumours in the appendix and distal ileum in a non-immune compromised young male patient who presented with intermittent intussusception and pain in the right iliac fossa. A laparoscopic right hemicolectomy was performed and the patient recovered uneventfully. Adjuvant chemotherapy (CHOP) in the form of CHOP regimen has been further advised.

Complications after bariatric surgery: A multicentric study of 11,568 patients from Indian bariatric surgery outcomes reporting group.

BACKGROUND: Complications after bariatric surgery are not uncommon occurrences that influence the choice of operations both by patients and by surgeons. Complications may be classified as intra-operative, early (<30 days post-operatively) or late (beyond 30 days). The prevalence of complications is influenced by the sample size, surgeon's experience and length and percentage of follow-up. There are no multicentric reports of post-bariatric complications from India. OBJECTIVES: To examine the various complications after different bariatric operations that currently performed in India. MATERIALS AND METHODS: A scientific committee designed a questionnaire to examine the post-bariatric surgery complications during a fixed time period in India. Data requested included demographic data, co-morbidities, type of procedure, complications, investigations and management of complications. This questionnaire was sent to all centres where bariatric surgery is performed in India. Data collected were reviewed, were analysed and are presented. RESULTS: Twenty-four centres responded with a report on 11,568 bariatric procedures. These included 4776 (41.3%) sleeve gastrectomy (SG), 3187 (27.5%) one anastomosis gastric bypass (OAGB), 2993 (25.9%) Roux-en-Y gastric bypass (RYGB) and 612 (5.3%) other procedures. Total reported complications were 363 (3.13%). Post-operative bleeding (0.75%) and nutritional deficiency (0.75%) were the two most common complications. Leaks (P = 0.009) and gastro-oesophageal reflux disease (P = 0.019) were significantly higher in SG, marginal ulcers in OAGB (P = 0.000), intestinal obstruction in RYGB (P = 0.001) and nutritional complications in other procedures (P = 0.000). Overall, the percentage of complications was higher in 'other' procedures (6.05%, P = 0.000). There were 18 (0.16%) reported mortalities. CONCLUSIONS: The post-bariatric composite complication rate from the 24 participating centres in this study from India is at par with the published data. Aggressive post-bariatric follow-up is required to improve nutritional outcomes.

Impact of COVID-19 pandemic on bariatric surgery in India: An obesity and metabolic surgery society of India survey of 1307 patients.

BACKGROUND: Although safe practice guidelines were issued by the Obesity and Metabolic Surgery Society of India (OSSI) in the end of May 2020, surgeons have been in a dilemma about risk of subjecting patients to hospitalisation and bariatric surgery. This survey was conducted with the objective to evaluate the risk of coronavirus disease-19 (COVID-19) infection in peri- and post-operative period after bariatric and metabolic surgery (BMS). METHODS: A survey with OSSI members was conducted from 20 July 2020 to 31 August 2020 in accordance with EQUATOR guidelines. Google Form was circulated to all surgeon members through E-mail and WhatsAppTM. In the second phase, clinical details were captured from surgeons who reported positive cases. RESULTS: One thousand three hundred and seven BMS were reported from 1 January 2020 to 15 July 2020. Seventy-eight per cent were performed prior to 31 March 2020 and 276 were performed after 1 April 2020. Of these, 13 (0.99%) patients were reported positive for COVID-19 in the post-operative period. All suffered from a mild disease and there was no mortality. Eighty-seven positive cases were reported from patients who underwent BMS prior to 31 December 2019. Of these, 82.7% of patients had mild disease, 13.7% of patients had moderate symptoms and four patients succumbed to COVID-19. CONCLUSION: BMS may be considered as a safe treatment option for patients suffering from clinically severe obesity during the COVID-19 pandemic. Due care must be taken to protect patients and healthcare workers and all procedures must be conducted in line with the safe practice guidelines.

Perioperative Practices Concerning Sleeve Gastrectomy - a Survey of 863 Surgeons with a Cumulative Experience of 520,230 Procedures.

BACKGROUND: Sleeve Gastrectomy (SG) is the most commonly performed bariatric procedure worldwide. There is currently no scientific study aimed at understanding variations in practices concerning this procedure. The aim of this study was to study the global variations in perioperative practices concerning SG. METHODS: A 37-item questionnaire-based survey was conducted to capture the perioperative practices of the global community of bariatric surgeons. Data were analyzed using descriptive statistics. RESULTS: Response of 863 bariatric surgeons from 67 countries with a cumulative experience of 520,230 SGs were recorded. A total of 689 (80%) and 764 (89%) surgeons listed 13 absolute and relative contraindications, respectively. 65% (n = 559) surgeons perform routine preoperative endoscopy and 97% (n = 835) routinely use intraoperative orogastric tube for sizing the resection. A wide variation is observed in the diameter of the tube used. 73% (n = 627) surgeons start dividing the stomach at a distance of 3-5 cm from the pylorus, and 54% (n = 467) routinely use staple line reinforcement. Majority (65%, n = 565) of surgeons perform routine intraoperative leak test at the end of the procedure, while 25% (n = 218) surgeons perform a routine contrast study in the early postoperative period. Lifelong multivitamin/mineral, iron, vitamin D, calcium, and vitamin B12 supplementation is advocated by 66%, 29%, 40%, 38% and 44% surgeons, respectively. CONCLUSION: There is a considerable variation in the perioperative practices concerning SG. Data can help in identifying areas for future consensus building and more focussed studies.

Trends and progress of bariatric and metabolic surgery in India.

Bariatric and metabolic surgery are being performed in India for 2 decades. Aim of this paper is to evaluate the changing clinical trends over the last 5 years and to present the other aspects helmed by Obesity and Metabolic Surgery Society of India (OSSI) to aid the growth of research, education, data management and registry, quality control, insurance-related issues and policy change. OSSI conducts an annual survey to collect data pertaining to numbers of surgical procedures. With the approval of the executive committee, data collected from 2014 to 2018 were retrieved and analysed. 20,242 surgical procedures were performed in 2018 which is an 86.7% increase from 2014. Laparoscopic sleeve gastrectomy continued to remain the most popular procedure, it's percent share saw a steady decline from 68 to 48%. One anastomosis gastric bypass showed an unprecedented growth from 14 to 34%. Numbers of laparoscopic Roux en y gastric bypass remained constant at 15-16%. OSSI has also initiated a COE program along with training fellowships and focus on registry and inclusion in insurance coverage. National trends over the past 5 years in bariatric surgery have shown emergence of newer procedures like OAGB, although LSG continues to be the most popular procedure performed These trends give an insight on how the field is evolving and the implications for any distinctive requirements unique to this region These will lay out important directives for not only ensuring good treatment outcomes but also increasing awareness about the disease on the whole.

Obesity and Metabolic Surgery Society of India (OSSI) Recommendations for Bariatric and Metabolic Surgery Practice During the COVID-19 Pandemic.

Bariatric and metabolic surgery (BMS), the only effective option for patients with obesity with or without comorbidities, has been stopped temporarily due to the ongoing novel corona virus disease (COVID-19) pandemic. However, there has been a recent change in the governmental strategy of dealing with this virus from 'Stay at Home' to 'Stay Alert' in many countries including India. A host of health services including elective surgeries are being resumed. In view of the possibility of resumption of BMS in near future, Obesity and Metabolic Surgery Society of India (OSSI) constituted a committee of experienced surgeons to give recommendations about the requirements as well as precautions to be taken to restart BMS with emphasis on safe delivery and high-quality care.

Selection of Bypass vs Sleeve for the Management of Type-2 Diabetes in Severely Obese: Could Ethnicity Play a Role?

PURPOSE: Prospective data was evaluated to see whether bariatric procedure type made any difference to diabetes remission. METHODS: One hundred eighty-six consecutive patients of Indian ethnicity (M:F 89:97) with type 2 diabetes mellitus (T2DM) and HbA1c > 6.5 were assessed before and at 1 year following surgery. Age, BMI, C-peptide and duration of diabetes (ABCD - described by WJ Lee), insulin use, baseline HbA1c, and % weight loss were tested as modifiers. We present remission rates (HbA1c ≤ 6.0%) and between group remission odds ratio (OR) and adjusted OR after controlling for key modifiers. RESULTS: Patients selecting RYGB (n = 113) vs SG (n = 73) were older (50.7 vs 44.2 years), had a lower BMI (44.1 vs 46.7), lower C-peptide (3.5 vs 4.7 ng/ml), greater duration of diabetes (8 vs 3 years), and higher HbA1c (8.90 and 7.9%) respectively p < 0.05 for all (combined R2 = 0.38). Weight loss at 1 year was 27 and 30% for RYGB and SG respectively (p = 0.01). Remission at 1 year was achieved by 37% of patient selecting RYGB and 74% for the SG (OR = 0.21, 95% CI 0.11-0.41, p < 0.001). After adjusting for ABCD, the adjusted OR (AOR) still favored the SG (AOR = 0.32, 0.14-0.74, p = 0.01), and adjustment for HbA1c and weight loss (AOR 0.4, 0.17-0.95, p = 0.038) attenuated the effect. CONCLUSION: The analysis suggests SG may be superior to RYGB in this Indian population. Ethnicity may play a role in predicting the response to bariatric surgery and hence the choice of procedure. A randomized controlled trial is needed to clarify the relative benefit.

High-Percentage Pathological Findings in Obese Patients Suggest that Esophago-gastro-duodenoscopy Should Be Made Mandatory Prior to Bariatric Surgery.

ᅟ: Obesity is a global epidemic and will soon become the number one priority in healthcare management. Bariatric surgery causes a significant improvement in obesity and its related complications. Pre-operative esophago-gastro-duodenoscopy (EGD) is done by several bariatric surgical teams across the world but is still not mandatory. AIM: To study the percentage of symptomatic and asymptomatic pathological EGD findings in obese patients undergoing bariatric surgery and to analyze whether these findings influence the eventual choice of bariatric surgery. MATERIALS AND METHODS: All patients posted for bariatric surgery at our institute from January 2015 to March 2017 had a pre-operative EGD done by the same team of endoscopists. RESULTS: In this study, totally, 675 patients were assessed prior to routine bariatric surgery. 78.52% of all pre-operative patients had an abnormal EGD. The most common endoscopic abnormalities found were hiatus hernia (52.44%), gastritis (46.22%), presence of Helicobacter (H.) pylori (46.67%), reflux esophagitis (16.89%), Barrett's esophagus (1.78%), gastric erosions (13.19%), and polyps (7.41%). Fifty patients had upper gastrointestinal polyps: 41 in the stomach, 3 in the esophagus, and 6 in the duodenum, mostly benign hyperplastic or inflammatory polyps. Two patients had gastrointestinal stromal tumor (GIST), 6 leiomyoma, and 6 neuroendocrine tumors (NET). Of those with endoscopic evidence of gastroesophageal reflux disease (GERD), 70 (60.03%) of patients were asymptomatic. The pre-operative EGD findings resulted in a change of the planned surgical procedure in 67 (9.93%) patients. CONCLUSION: Our study suggests that a large percentage of patients undergoing bariatric surgery have pathologically significant endoscopic findings of which a significant number are asymptomatic; this can lead to a change in the planned bariatric procedure in a section of patients; hence, we believe that EGD should be made mandatory as a pre-operative investigation in all bariatric surgery patients.

Zinc Deficiency after Gastric Bypass for Morbid Obesity: a Systematic Review.

Up to 50% of patients have zinc deficiency before bariatric surgery. Roux-en-Y gastric bypass (RYGB) is the commonest bariatric procedure worldwide. It can further exacerbate zinc deficiency by reducing intake as well as absorption. The British Obesity and Metabolic Surgery Society, therefore, recommends that zinc level should be monitored routinely following gastric bypass. However, the American guidance does not recommend such monitoring for all RYGB patients and reserves it for patients with 'specific findings'. This review concludes that clinically relevant Zn deficiency is rare after RYGB. Routine monitoring of zinc levels is hence unnecessary for asymptomatic patients after RYGB and should be reserved for patients with skin lesions, hair loss, pica, dysgeusia, hypogonadism or erectile dysfunction in male patients, and unexplained iron deficiency anaemia.

Bariatric Nutrition Guidelines for the Indian Population.

BACKGROUND: Bariatric surgery numbers have seen a sharp rise in India in the last decade. A country known for its undernourished population has seen economic growth and with it, greater influence of western culture and foods. The obesity epidemic is on the rise here and India is one of the 10 most obese nations of the world being second only to China in the number of type 2 diabetes. Nutritionists in India often rely on recommendations and guidelines meant for the Caucasian population. Religious and cultural practices influence the dietary habits and patterns of the Indian population to a great extent; because of which the nutritional requirements are very different. This document was put together with an aim to provide nutritionists with recommendations on how to manage the Indian bariatric patient. METHODS: A bariatric nutrition round table meeting was initiated by the Centre for Obesity and Digestive Surgery (CODS) to bring together experts in the field of bariatric nutrition to review current data on nutritional deficiencies in the morbid obese and existing post-operative deficiencies and to formulate nutritional recommendations for bariatric/metabolic surgery specific to patients from India. RESULTS: Percentage of nutritional deficiencies and reasons for the same were identified among the Indian population and recommendations were made to suit this particular population. CONCLUSION: It is recommended that all patients undergo compulsory pre-operative nutritional counseling and nutritional investigations and that nutritional follow-up be continued lifelong. In addition, long-term implications like hypoglycemia, dumping syndrome, sugar cravings, and weight regain, need to be picked up and managed efficiently. Most importantly, post-operative supplementation is a must irrespective of type of surgery.

Laparoscopic revision of Roux-en-Y gastric bypass to sleeve gastrectomy: A ray of hope for failed Roux-en-Y gastric bypass.

INTRODUCTION: Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric operation across the world, but sometimes revision is necessary. Inadequate weight loss, weight regain, and complications such as dumping syndrome are common reasons for revision. We report the 1-year outcomes of five patients who underwent laparoscopic conversion of RYGB to sleeve gastrectomy during surgical revision. METHODS: Mean age was 38.8 ± 9.1 years. Mean BMI at primary surgery was 57.9 ± 8.1 kg/m(2) . Two patients were diabetic and sleep apneic. One was hypertensive. All patients underwent a RYGB as the primary weight loss procedure. Mean weight loss was 36.8 ± 8.6 kg (excess weight loss = 39.8 ± 14.9%) at 2 years. At the end of 5 years, these patients regained 10.9 ± 4.1 kg (31.5 ± 13.6% of excess weight loss). Primary indications for revision surgery were failure to lose weight, weight regain, and intractable dumping syndrome. Mean duration between primary and revision surgery was 6.2 ± 1.1 years. RYGB was converted to sleeve gastrectomy as a first stage in all cases. RESULTS: Mean duration of revision surgery was 120.0 ± 15.5 min. Mean blood loss was 70 ± 50 mL. One year after revision surgery, a mean weight loss of 21.5 ± 10.5 kg was achieved (mean excess weight loss = 35.8 ± 8.8%). Two patients with type 2 diabetes mellitus and the one with hypertension achieved remission. Dumping was resolved. There were no complications. CONCLUSION: Laparoscopic conversion of RYGB to sleeve gastrectomy as a first stage may be considered as an additional option in the armamentarium of revision procedures after RYGB.

Single-incision sleeve gastrectomy versus laparoscopic sleeve gastrectomy. A 2-year comparative analysis of 600 patients.

BACKGROUND: This is a 2-year study to evaluate the feasibility; outcomes in terms of postoperative pain, weight loss, and complication rates; and cosmesis of the single-incision sleeve gastrectomy versus the conventional multiport sleeve gastrectomy. METHODS: A prospective comparative analysis was done in 300 patients in each arm who underwent laparoscopic sleeve gastrectomy and single-incision sleeve gastrectomy from September 2009 till January 2012. Both groups were matched for age and BMI. Postoperative pain scoring was done using visual analogue scale. Outcomes in terms of pain score, scar satisfaction score, excess weight loss, resolution of co-morbidities, and complications were compared in both groups at the end of 6 months, 1 year, and 2 years. RESULTS: Female patients preferred to undergo single-incision sleeve gastrectomy. Operating time and intraoperative blood loss were comparable in both groups. Visual analogue scale (VAS) scoring revealed lesser postoperative pain in the single-incision group. Excess weight loss and resolution of co-morbidities were also comparable in both groups at 6 months, 1 year, and 2 years. Incisional hernia was seen in 3 patients (1%) in the single-incision group. Leak rate was comparable. Cosmetic satisfaction was superior in patients who underwent single-incision surgery. CONCLUSIONS: Surgical outcomes are comparable in both groups at the end of 2 years. The myth of high long-term incisional hernia rate after single-incision surgery has been dispelled. Single-incision surgery is less painful with better cosmesis. It has come of age and should no longer be considered as an experimental procedure.

Predictors of Remission of T2DM and Metabolic Effects after Laparoscopic Roux-en-y Gastric Bypass in Obese Indian Diabetics-a 5-Year Study.

BACKGROUND: Bariatric surgery has proven results for diabetes remission in obese diabetics. Despite this, a lot of ambiguity exists around patient selection. The objectives of this study are the following: (1) evaluation of results of laparoscopic Roux-en-y gastric bypass (LRYGB) in obese type 2 diabetic (T2DM) Indian patients at 5 years and (2) to define predictors of success after surgery. METHODS: This is a prospective observational study. One hundred six Indian patients underwent LRYGB from January 2004 to July 2009. Patients were evaluated for percent excess weight loss (%EWL) and remission of T2DM. Mean age 50.34 ± 9.08 years, mean waist circumference 129.8 ± 20.8 cm, mean weight 119.2 ± 23.6 kg, mean BMI 45.01 ± 7.9 kg/m(2), and mean duration of diabetes 8.2 ± 6.2 years. RESULTS: At 5 years, mean EWL% was 61.4 ± 20.3, mean weight regain of 8.6 ± 6.2 kg was seen in 63.6 %, mean glycosylated hemoglobin dropped from 8.7 ± 2.1 to 6.2 ± 01.3 %, mean triglycerides declined by 31 %, and serum high density lipoprotein rose by 18.4 %. Mean low-density lipoprotein levels declined by 6.8 %. Age, BMI, fasting C-peptide levels, duration of T2DM, and pre-op use of insulin emerged as significant predictors of success after surgery. One hundred percent remission was seen in patients with T2DM <5 years. CONCLUSIONS: LRYGB is safe and efficacious for long-term remission of T2DM (BMI ≥ 35 kg/m(2)). In a country with the second largest population of type 2 diabetics in the world, predictors of success after surgery can help in prioritizing patients who have a greater chance to benefit from metabolic surgery.

Management of gastro-colic fistula after laparoscopic sleeve gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric procedure performed in Asia. Staple-line leaks post LSG are notoriously difficult to treat. Here we report a case of a gastro-colic fistula after a post-LSG leak. While reperforming laparoscopy and/or stenting remain the mainstay of early leak management, chronic complications such as a gastro-colic fistula are rare and require a tailor-made approach. Stenting alone has a limited role in managing chronic fistulas after LSG.

Roux-en-Y gastric bypass stands the test of time: 5-year results in low body mass index (30-35 kg/m(2)) Indian patients with type 2 diabetes mellitus.

BACKGROUND: Our objective was to evaluate the long-term results of laparoscopic Roux-en-Y gastric bypass on excess weight loss, remission of the metabolic syndrome, and complications in Indian patients with uncontrolled type 2 diabetes mellitus (T2DM) with a body mass index of 30-35 kg/m(2). The setting was a corporate hospital in Mumbai, India. METHODS: The present prospective observational study was begun in January 2006. A total of 52 patients with uncontrolled T2DM and a body mass index of 30-35 kg/m(2) elected to undergo laparoscopic Roux-en-Y gastric bypass. The duration of T2DM was 3.5-14.5 years (median 8.4). Of the 52 patients, 61.5% had hypertension and 59.6% had dyslipidemia. Remission of T2DM and other components of the metabolic syndrome were assessed. All patients were followed up for 5 years. RESULTS: The median percentage of excess weight loss was 72.2% at 1 year and 67.8% at 5 years. Of the 52 patients, 84.6% had achieved euglycemia and 73.1% had achieved complete remission, 23.1% partial remission, and 3.84% no remission at 1 year. Weight regain occurred in 8 patients. They required antihypertensive drugs and statins, decreasing the complete remission rate to 57.7% and partial remission rate to 38.5% at 5 years. However, 96.2% improvement in metabolic status was found at the end of 5 years. CONCLUSION: Laparoscopic Roux-en-Y gastric bypass is a safe, efficacious, and cost-effective treatment for uncontrolled T2DM in patients with a body mass index of 30-35 kg/m(2). Early-onset T2DM, better weight loss, and greater C-peptide levels were predictors of success after surgery. The improvement after surgery in hyperglycemia, hypertension, and dyslipidemia could help in controlling the occurrence of micro- and macrovascular complications and decrease the morbidity and mortality associated with T2DM.

Hyperuricemia: a reality in the Indian obese.

Hyperuricemia is known to be associated with obesity and metabolic syndrome. The aims of this study were to evaluate the prevalence of hyperuricemia in the Indian obese population and to determine if a correlation exists between hyperuricemia, body mass index, waist circumference and components of metabolic syndrome. This was a retrospective observational study. Four hundred nine obese patients were included. Anthropometric parameters were recorded. Prevalence of type 2 diabetes mellitus (T2DM), hypertension and dyslipidemia were recorded. Uric acid levels were measured in all patients. Hyperuricemia was defined as serum uric acid levels greater than 6 mg/dl. The population studied had a median body mass index (BMI) of 44.14 kg/m(2) (range 28.1-88.2 kg/m(2)) and a median age of 41 years (range 18 to 75 years). Overall prevalence of hyperuricemia was 44.6 %. Thirty-four percent in the BMI range of 28-35 kg/m(2) and 47 % of patients with a BMI of >35 kg/m(2) had hyperuricemia. The incidence of hyperuricemia in males was 50 vs 21.7 % in females. Of patients in the hyperuricemia group, 47.3 % had hypertension as compared to 37 % in the normouricemic group. Dyslipidemia was seen in 7.3 % of hyperuricemic patients as compared to 5.8 % of the normouricemic subjects. The prevalence of T2DM was comparable in both the groups. The Indian obese population has a significant high prevalence of hyperuricemia; the incidence of hyperuricemia in male patients was greater than in female patients. Central obesity had no direct link to hyperuricemia. There was no significant correlation between the occurrence of T2DM and dyslipidemia and hyperuricemia. Hypertension was the only comorbidity seen to occur in conjunction with hyperuricemia.