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BACKGROUND: Obesity and its related medical conditions are well-established contributors to the development of chronic kidney disease (CKD). Metabolic and bariatric surgery (MBS), including procedures such as sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), is a potential intervention for these individuals. However, the heightened risk of postoperative complications casts doubts on the suitability of MBS in this population. Our aim is to evaluate the long-term safety, anthropometric and renal outcomes of MBS in patients with CKD. METHODS: A retrospective review of patients who underwent primary laparoscopic MBS with a BMI ≥ 35 kg/m2 and a preoperative diagnosis of stage 2 to 5 CKD. Criteria for CKD diagnosis and staging were based on estimated glomerular filtration rate measurements in accordance with established guidelines. Anthropometric and renal outcomes were measured at 3-, 6-, 12-, 24- and 60-months postoperatively. RESULTS: A total of 302 patients (177 SG, 125 RYGB) were included. RYGB was preferred for patients with stage 3 CKD, while SG was more common in stages 4 and 5. At 5-year follow-up, percentage of total weight loss was higher in the RYGB cohort compared to SG (25.1% vs. 18.6%, p = 0.036). Despite SG patients having more advanced CKD, the incidence of late complications was significantly higher following RYGB, with 11 incidents (8.8%), compared to the SG cohort with only 4 cases (2.3%) (p = 0.014). In those with preoperative CKD stage 3, 76 patients (43.2%) improved to stage 2, with another 9 patients (5.1%) improving further to stage 1. Of all patients, 63 (20.8%) eventually received a successful renal transplant. CONCLUSIONS: MBS is an effective strategy for sustained weight loss in patients with CKD with acceptable complications rates. RYGB leads to a higher percentage of overall weight loss, albeit with an elevated likelihood of late surgical complications. Future studies are needed to determine the safety of MBS in this demographic.
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Cirurgia Bariátrica , Complicações Pós-Operatórias , Insuficiência Renal Crônica , Humanos , Feminino , Masculino , Estudos Retrospectivos , Pessoa de Meia-Idade , Adulto , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/fisiopatologia , Cirurgia Bariátrica/métodos , Cirurgia Bariátrica/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Redução de Peso , Resultado do Tratamento , Derivação Gástrica/efeitos adversos , Derivação Gástrica/métodos , Laparoscopia/métodos , Laparoscopia/efeitos adversos , Taxa de Filtração Glomerular , Obesidade Mórbida/cirurgia , Obesidade Mórbida/complicações , Gastrectomia/métodos , Gastrectomia/efeitos adversos , SeguimentosRESUMO
BACKGROUND: Small bowel obstruction is a major source of morbidity and mortality that carries a significant economic burden. Recurrent small bowel obstruction may be secondary to circumferential strictures (small bowel diaphragm disease), an under-recognized entity secondary to long-term nonsteroidal anti-inflammatory drug (NSAID) use. We aimed to describe the sensitivity of preoperative computed tomography (CT) enterography in patients with surgically treated small bowel diaphragm disease. METHODS: We retrospectively reviewed adult patients who underwent elective small bowel resection for small bowel obstruction performed by a single minimally invasive surgeon between 2010 and 2023. Patient history, radiographic, endoscopic, operative, and pathology reports were reviewed for reference to NSAID use, small bowel strictures, diaphragms, and enteropathy. Exclusion criteria were prior radiation, inflammatory bowel disease, malignancy, adhesive disease, and anastomotic strictures. RESULTS: A total of 225 patients were identified, 22 (10%) of whom met the inclusion criteria. The mean age was 60.7 years (range 29-78), with 15 women (68%). All patients underwent minimally invasive small bowel resection for obstruction with histopathologic evidence of stricture without evidence of transmural inflammation, granuloma, or dysplasia and confirmed NSAID use (n = 22, 100%). Anemia was present in 36% (n = 8). Preoperative CT or magnetic resonance (MR) enterography was performed in 18 patients (82%), of which stricturing was reported in 13 (72%). Intraoperatively, palpation identified strictures in all patients. CONCLUSION: NSAID-induced small bowel injury is an under-recognized condition that, in severe cases, can present as small bowel obstruction. Surgeons should consider diaphragm disease in patients with obstruction and NSAID use, in which preoperative CT or MR enterography may be useful but cannot rule out disease.
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Anti-Inflamatórios não Esteroides , Obstrução Intestinal , Intestino Delgado , Tomografia Computadorizada por Raios X , Humanos , Feminino , Obstrução Intestinal/etiologia , Obstrução Intestinal/diagnóstico por imagem , Obstrução Intestinal/induzido quimicamente , Masculino , Pessoa de Meia-Idade , Anti-Inflamatórios não Esteroides/efeitos adversos , Estudos Retrospectivos , Adulto , Idoso , Intestino Delgado/diagnóstico por imagem , Intestino Delgado/patologia , Constrição Patológica/induzido quimicamenteRESUMO
Metabolic and bariatric surgery (MBS) is the most effective and durable therapeutic intervention for patients with obesity. In recent years, laparoscopic sleeve gastrectomy (SG) has become the most commonly performed primary MBS procedure owing to its technical feasibility and excellent short-term outcomes. Despite these favorable results and perceived advantages, SG is associated with several unique complications. Complications such as a postoperative leak or bleeding have been more commonly observed and reported than others, and their management approaches are well described. However, other complications following SG are far less familiar to surgeons, which may delay recognition and result in poor patient outcomes. Of these complications, we describe splenic injuries; esophageal perforation; staple line malformations; stapling of intraluminal devices; phytobezoar formation; gastro-colic, gastro-pleural and gastro-bronchial fistula; pancreatic leak; and portomesenteric venous thrombosis. It is paramount for surgeons to be aware of these underreported issues and have the resources to learn how to recognize and manage them when they arise. This review aims to describe rare (i.e., reported incidence <1%) and underdescribed complications after SG, focusing on causes, clinical presentation, prevention strategies, and management.
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Postmortem studies show gastrointestinal tract involvement in as many as 70% of patients affected by disseminated histoplasmosis. Although gastrointestinal involvement is common in disseminated disease, the presentation of small intestinal perforation is exceedingly rare with few reported cases in the literature. Herein we present our institutional case series. The aim of the study is to describe small intestinal perforation in gastrointestinal histoplasmosis with attention to management and outcomes. This is a retrospective single-institution review of patients ≥ 18 years of age treated for small intestinal perforation due to gastrointestinal histoplasmosis. A prospectively maintained institutional database was searched from 2002 to 2022. Data obtained included demographics, comorbidities, treatment course, and outcomes. Five patients with a mean age of 54 years (range 25-72) were identified. Pertinent underlying comorbid conditions included Crohn's disease, psoriatic arthritis, rheumatoid arthritis, and solid organ transplantation. All patients were on chronic immunosuppressive medication(s) with the most common being tumor necrosis factors alpha inhibitors and corticosteroids. Four had a clinical diagnosis of perforation based on physical examination and imaging. All patients underwent segmental resection(s) of the small intestine and received medical treatment with intravenous amphotericin B and eventual transition to an oral antifungal. No patients experienced complications related to surgery. The limitations of the study include nonrandomized retrospective review, single-institution experience, and small patient sample size. Although rare, histoplasmosis should be considered in the differential of patients on chronic immunosuppressive therapy who present with gastrointestinal symptoms concerning perforation, especially from endemic areas. Small intestinal perforation due to gastrointestinal histoplasmosis can be successfully treated with resection and antifungal therapy.
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Antifúngicos , Histoplasmose , Perfuração Intestinal , Intestino Delgado , Humanos , Perfuração Intestinal/etiologia , Perfuração Intestinal/cirurgia , Pessoa de Meia-Idade , Adulto , Estudos Retrospectivos , Histoplasmose/complicações , Histoplasmose/diagnóstico , Masculino , Idoso , Feminino , Antifúngicos/uso terapêutico , Anfotericina B/uso terapêutico , Anfotericina B/administração & dosagem , Resultado do Tratamento , Imunossupressores/uso terapêuticoRESUMO
Metabolic and bariatric surgery (MBS) is the most effective therapeutic intervention for patients with obesity, with sleeve gastrectomy (SG) being the most commonly performed primary MBS procedure. Long-term studies have demonstrated that 15-20% of patients require revisional bariatric surgery (RBS) due to weight-related issues or surgical complications. Despite the gold standard being laparoscopic revision, there are other available approaches such as open or robotic-assisted. An extensive literature review was performed for articles from their inception to February 2024. A descriptive review of MBS procedures (SG, Roux-en-Y gastric bypass (RYGB), single anastomosis duodeno-ileostomy (SADI) and biliopancreatic diversion-duodenal switch (BPD-DS)) was carried out to report and compare outcomes between primary and revisional bariatric surgery. A similar review was conducted to compare outcomes of revisional approaches (open, laparoscopic, robotic). RYGB remains the dominant RBS with a similar safety profile compared to revisional SADI and BPD-DS. In terms of the RBS surgical approach, all three options showed comparable short and long-term outcomes, with robotic RBS being associated with longer operative time and variable length of stay. Additional long-term studies are required to further validate our conclusions.
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BACKGROUND: Roux-en-Y gastric bypass (RYGB) has demonstrated excellent glycemic control and type 2 diabetes mellitus (T2DM) remission for patients with obesity and T2DM. Duration of T2DM is a consistent negative predictor of remission after RYGB. However, the exact timing to offer surgical intervention during the course of the disease is not well elucidated. MATERIAL AND METHODS: We performed a retrospective cohort study between 2008-2020 to establish the exact association between duration of T2DM and remission after RYGB. We divided our cohort into quartiles of preoperative disease duration to quantify the change in remission rates for each year of delay between T2DM diagnosis and RYGB. We also compared the average time to remission and changes in glycemic control parameters. RESULTS: A total of 519 patients (67.2% female; age 53.4±10.7 y; BMI 46.6±8.4 kg/m2) with a follow-up period of 6.6±3.8 years were included. Remission was demonstrated in 51% of patients. Longer duration of T2DM was a significant negative predictor of remission with an estimated decrease in remission rates of 7% for each year of delay ([OR=0.931 (95% CI 0.892-0.971)]; P<0.001). Compared to patients with <3 years of T2DM, remission decreased by 37% for patients with 3-6 years, 64% for those with 7-12 years and 81% for patients with more than 12 years (P<0.001). Half of the patients reached T2DM remission after 0.5 and 1.1 years respectively for the first and second quartiles, while patients in the other quartiles never reached 50% remission. Lastly, we noted an overall improvement in all glycemic control parameters for all quartiles at last follow-up. CONCLUSION: Patients with a recent history of T2DM who undergo early RYGB experience significantly higher and earlier T2DM remission compared to patients with a prolonged history of preoperative T2DM, suggesting potential benefit of early surgical intervention to manage patients with obesity and T2DM.
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Reactivation ofHepatitis B virus (HBV) is not an uncommon condition. It is known to occur with immunosuppressive therapy. There are several viral infections that can trigger HBV reactivation, such as human immunodeficiency virus (HIV) infection. However, there is no reported case of HBV reactivation triggered by Epstein-Barr virus (EBV) infection in the literature. To our knowledge, we report the first case of reactivation of HBV secondary to acute Epstein-Barr virus (EBV) infection in the literature. A 47-year-old Caucasian male with a remote history of resolved acute Hepatitis B virus infection presented to our hospital with severe acute hepatitis, which manifested as epigastric pain, jaundice, dark urine, light-colored stools, hyperbilirubinemia, and transaminitis in the 1000s. Ultimately, the patient was diagnosed with reactivation of HBV triggered by acute EBV infection. After several days of supportive treatment, his hepatic function normalized. He was discharged with a scheduled follow-up at a hepatology clinic. In conclusion, EBV infection should be suspected as a trigger in cases with HBV reactivation, particularly when common etiologies are excluded.
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Obesity remains prevalent in the US. One potential treatment is vagus nerve stimulation (VNS), which activates the sensory afferents innervating the stomach that convey stomach volume and establish satiety. However, current VNS approaches and stimulus optimization could benefit from additional understanding of the underlying neural response to stomach distension. In this study, obesity-prone Sprague Dawley rats consumed a standard, high-carbohydrate, or high-fat diet for several months, leading to diet-induced obesity in the latter two groups. Under anesthesia, the neural activity in the vagus nerve was recorded with a penetrating microelectrode array while the stomach was distended with an implanted balloon. Vagal tone during distension was compared to baseline tone prior to distension. Responses were strongly correlated with stomach distension, but the sensitivity to distension was significantly lower in animals that had been fed the nonstandard diets. The results indicate that both high fat and high carbohydrate diets impair vagus activity.
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Carboidratos/efeitos adversos , Dieta Hiperlipídica/efeitos adversos , Obesidade/fisiopatologia , Nervo Vago/efeitos dos fármacos , Potenciais de Ação/efeitos dos fármacos , Anestesia , Animais , Peso Corporal/efeitos dos fármacos , Carboidratos/farmacologia , Modelos Animais de Doenças , Humanos , Obesidade/induzido quimicamente , Obesidade/metabolismo , Ratos , Estômago/inervação , Estômago/fisiopatologia , Nervo Vago/fisiopatologia , Estimulação do Nervo VagoRESUMO
Pancreatic cancer patients experience debilitating pain, which makes pain management an integral part of the treatment plan. Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-guided CPN) is an alternative palliative therapy for patients with pain due to pancreatic cancer. We report a patient who developed paralytic ileus after undergoing EUS-guided CPN. A 77-year-old male patient presented with nausea, vomiting, and abdominal pain of one-day duration. He was diagnosed with stage IV pancreatic adenocarcinoma three weeks prior to presentation for which he underwent EUS-guided CPN. He had a 30-pack-year smoking history and quit 31 years ago. He reported moderate alcohol use and denied illicit drug use. In the emergency department, vital signs demonstrated normal blood pressure, heart rate, respiratory rate, and temperature. Abdominal exam was significant for minimal epigastric tenderness without guarding or rebound. Complete blood count (CBC), basic metabolic panel (BMP), and liver function tests were unremarkable. Computed tomography (CT) scan of the abdomen showed significant gastric distension. Esophagogastroduodenoscopy (EGD) showed large amounts of fluids within the gastric fundus and body. Upper gastrointestinal series showed delayed gastric emptying of the contrast, but contrast was seen in the third part of the duodenum and jejunum. Push enteroscopy showed no obstruction or mucosal abnormalities in the third or fourth parts of the duodenum. Small bowel obstruction was ruled out, and the diagnosis of ileus was made. The patient received ondansetron and polyethylene glycol as needed, and his diet was advanced slowly. His symptoms improved over the course of a few days, and he experienced a return of normal bowel activity. He eventually tolerated a regular diet and was discharged home in a stable condition. Although EUS-guided CPN is a safe procedure, the procedure resulted in an unexpected ileus that has rarely been reported in the literature. Future studies with large sample sizes are recommended to capture the occurrence of the rare side effects of EUS-guided CPN.