Sleeve Gastrectomy and Anterior Fundoplication (D-SLEEVE) Prevents Gastroesophageal Reflux in Symptomatic GERD.

BACKGROUND: A worrying increase of gastroesophageal reflux disease (GERD) and Barrett esophagus has been reported after sleeve gastrectomy (SG). Recent reports on combined fundoplication and SG seem to accomplish initial favorable results. However, no study included manometry or pH monitoring to evaluate the impact of fundoplication in SG on esophageal physiology. METHOD: In this study, 32 consecutive bariatric patients with GERD and/or esophagitis had high-resolution impedance manometry (HRiM) and combined 24-h pH and multichannel intraluminal impedance (MII-pH) before and after laparoscopic sleeve gastrectomy associated to anterior fundoplication (D-SLEEVE). The following parameters were calculated at HRiM: lower esophageal sphincter pressure and relaxation, peristalsis, and mean total bolus transit time. The acid and non-acid GER episodes were assessed by MII-pH, symptom index association (SI), and symptom-association probability (SAP) were also analyzed. RESULTS: At a median follow-up of 14 months, HRiM showed an increased LES function, and MII-pH showed an excellent control of both acid exposure of the esophagus and number of reflux events. Bariatric outcomes (BMI and EWL%) were also comparable to regular SG (p = NS). CONCLUSION: D-SLEEVE is an effective restrictive procedure, which recreates a functional LES pressure able to control and/or prevent mild GERD at 1-year follow-up.

Remission of type 2 diabetes in patients undergoing biliointestinal bypass for morbid obesity: a new surgical treatment.

BACKGROUND: Nutrient interaction with the mid-gut may play a role in improving type 2 diabetes mellitus (T2D) after bariatric surgery. However, Roux-en-Y gastric bypass, biliopancreatic diversion, and sleeve gastrectomy include diversion of food from the duodenum and/or partial gastrectomy. Biliointestinal bypass (BIBP) was introduced to eliminate the major side effects of jejunoileal bypass. It does not involve any change to the anatomy of the stomach or the duodenum. A prospective evaluation of the role of BIBP in glycemic control has not been reported. OBJECTIVES: Longitudinal evaluation of T2D after BIBP. SETTING: University hospitals in Europe and Canada. METHOD: The effects of BIBP on metabolism and glycemia in 28 consecutive patients with T2D were evaluated over 2 years. RESULTS: Decreases (P<.001) in fasting glycemia, insulinemia, and homeostasis model assessment were observed 3 months after surgery, were improved after 1 year, and remained stable after 2 years. Glycosylated hemoglobin levels decreased at 3, 12, and 24 months after surgery (from 9.2±2.1 to 6.3±1.1 (P<.0001), 4.9±1.7 (P<.0001), and 4.8±1.1 (P<.0001), after 3, 12, and 24 months, respectively). Medical therapy was discontinued in 83% (20 of 24) of the patients; for the remaining 17% (4 of 24), therapy was reduced to oral hypoglycemic agents. CONCLUSION: BIBP had a favorable risk-benefit relationship and positive metabolic effects in the short term. How BIBP achieves optimal glycemic control and whether it improves ß-cell function and/or insulin sensitivity require further study.

Sleeve gastrectomy improves obstructive sleep apnea syndrome (OSAS): 5 year longitudinal study.

BACKGROUND: Obstructive sleep apnea syndrome (OSAS) is prevalent among morbidly obese patients. Evaluation of the specific effects of sleeve gastrectomy (SG) on upper airway function has not been reported. Given the possibility that some patients will not respond despite weight loss, no studies have investigated whether other mechanisms may be responsible for persistent OSAS after bariatric surgery. OBJECTIVES: To evaluate by subjective and objective assessment the impact of SG on upper respiratory physiology in the long-term. SETTING: University Hospital, Division of Bariatric and ENT Surgery, in Italy. METHODS: Thirty-six consecutive patients with OSAS who underwent laparoscopic SG were prospectively enrolled. The effect of SG on respiratory function and OSAS was followed for 5 years. RESULTS: All patients completed the 5-year follow-up. A significant (P<.001) improvement in modified Epworth Sleepiness Scale questionnaire (ESS) was obtained in 91.6% (33/36) of patients. The Apnea/Hypopnea index (AHI) improved in 80.6% (29/36) of patients after surgery (from 32.8 ± 1.7 to 5.8 ± 1.2 (P<.001), 4.9 ± 1.7). The remaining 19.4% (7/36) of patients with a positive ESS and/or AHI all had an associated respiratory resistance due to nasal obstructive diseases. CONCLUSION: SG improved OSAS overall, but patients who did not improve or only partially improved despite weight loss were found to have an associated nasal responsible pathology. How these patients will respond to nasal surgery and whether a 2-step procedure should be recommended for OSAS patients requires further study.

Esophageal papilloma: Flexible endoscopic ablation by radiofrequency.

Squamous papilloma of the esophagus is a rare benign lesion of the esophagus. Radiofrequency ablation is an established endoscopic technique for the eradication of Barrett esophagus. No cases of endoscopic ablation of esophageal papilloma by radiofrequency ablation (RFA) have been reported. We report a case of esophageal papilloma successfully treated with a single session of radiofrequency ablation. Endoscopic ablation of the lesion was achieved by radiofrequency using a new catheter inserted through the working channel of endoscope. The esophageal ablated tissue was removed by a specifically designed cup. Complete ablation was confirmed at 3 mo by endoscopy with biopsies. This case supports feasibility and safety of as a new potential indication for Barrx(TM) RFA in patients with esophageal papilloma.

Sleeve gastrectomy and development of "de novo" gastroesophageal reflux.

BACKGROUND: Sleeve gastrectomy (SG) is currently gaining popularity due to an excellent efficacy combined to minimal anatomic changes. However, some concerns have been raised on increased risk of postoperative gastroesophageal reflux disease (GERD) due to gastric fundus removal, section of the sling muscular fibers of gastroesophageal junction, reduced antral pump function, and gastric volume. We undertook the current study to evaluate by means of high-resolution impedance manometry (HRiM) and combined 24-h pH and multichannel intraluminal impedance (MII-pH) the impact of SG on esophageal physiology. METHODS: In this study, 25 consecutive patients had HRiM and MII-pH before and after laparoscopic SG. The following parameters were calculated at HRiM: lower esophageal sphincter (LES) pressure and relaxation, peristalsis, number of complete esophageal bolus transit, and mean total bolus transit time. The acid and non-acid GER episodes were assessed by MII-pH with the patient in both upright and recumbent positions. RESULTS: At a median follow-up of 13 months, HRiM showed an unchanged LES function, increased ineffective peristalsis, and incomplete bolus transit. MII-pH showed an increase of both acid exposure of the esophagus and number of non-acid reflux events in postprandial periods. CONCLUSIONS: Laparoscopic SG is an effective restrictive procedure that creates delayed esophageal emptying without impairing LES function. A correctly fashioned sleeve does not induce de novo GERD. Retrograde movements and increased acid exposure are probably due to stasis and postprandial regurgitation.

Effect of bariatric surgery on left ventricular geometry and function in severe obesity.

OBJECTIVE: Weight loss improves cardiac abnormalities associated with severe obesity. We evaluated the impact of weight loss following laparoscopic gastric bypass (LGBP) on left ventricular (LV) geometry and function in obese patients. METHODS: Twenty-six patients with severe obesity (41 ± 8 years, 50% women) underwent Doppler echocardiograms before and after LGBP, to measure LV geometry, excess of LV mass relative to hemodynamic load and systolic and diastolic function. RESULTS: Pre-operatively, 85% of patients exhibited LVH, and 62% hypertension and metabolic syndrome, reflecting high cardiometabolic risk. After 8 ± 4 months of follow-up, the average weight loss was 19 ± 8%. Weight loss was significantly associated with improved metabolic parameters and reduced heart rate (-9 bpm), systolic (-11 mmHg) and diastolic (-6 mmHg) blood pressure (all p < 0.02). After surgery, there was significant reduction in relative wall thickness (0.43 ± 0.07 versus 0.39 ± 0.06), LV mass index (63 ± 14 g/m(2.7) versus 49 ± 10 g/m(2.7)) and excess of LV mass in relation to hemodynamic load (all p < 0.004). LVH remained in 54% of patients, hypertension in 23% and metabolic syndrome in 27%. Ejection fraction and Doppler indices of diastolic function did not change significantly, even after adjusting for changes in heart rate. All favorable changes in LV geometry and function were also confirmed in the subgroup with <9 month follow-up (median), whereas no further improvement could be detected in patients with longer follow-up. CONCLUSIONS: In patient with severe obesity, LV geometry and systolic function improved rapidly after LGBP, without evidence of further improvement during prolonged follow-up.

Impact of total fundoplication on esophageal transit: analysis by combined multichannel intraluminal impedance and manometry.

BACKGROUND: Laparoscopic total fundoplication is considered the most effective surgical option for gastroesophageal reflux (GER) disease. Some authors assume that total fundoplication may expose the patient to delayed transit of the swallowed bolus and increased risk of dysphagia, particularly when peristaltic dysfunction is present. We undertook this study to evaluate by means of combined multichannel intraluminal impedance and esophageal manometry (MII-EM) the impact of fundoplication on esophageal physiology. An objective measurement of the influence of the total wrap on bolus transit may be helpful in refining the optimal antireflux wrap (ie, partial vs. total). METHODS: In this study, 25 consecutive patients who underwent laparoscopic Nissen-Rossetti fundoplication had MII-EM and combined 24-hour pH and multichannel intraluminal impedance (MII-pH) before and after the surgical procedure. All patients completed preoperative and postoperative symptom questionnaires. The following were calculated for liquid and viscous deglutition lower esophageal sphincter pressure and relaxation, distal esophageal amplitude, the number of complete esophageal bolus transits and the mean total bolus transit time. The acid and nonacid GER episodes were calculated by MII-pH with the patient in both upright and recumbent positions. RESULTS: The postoperative MII-EM showed an increased lower esophageal sphincter pressure (P < 0.05), whereas lower esophageal sphincter relaxation and distal esophageal amplitude did not change after surgery (P = NS). Complete esophageal bolus transits and bolus transit time did not change for liquid swallows (P = NS), but was more rapid for viscous after surgery (P < 0.05). Twenty-four hour pH monitoring confirmed the postoperative reduction of both acid and nonacid reflux (P < 0.05). CONCLUSIONS: Laparoscopic Nissen-Rossetti is effective in controlling both acid and nonacid GER without impairment of esophageal function. Appropriate preoperative investigation, meticulous patient selection and correct surgical technique are extremely important in securing good results.

Metabolic surgery: the role of the gastrointestinal tract in diabetes mellitus.

Several conventional methods of bariatric surgery can induce long-term remission of type 2 diabetes mellitus (T2DM); novel gastrointestinal surgical procedures are reported to have similar effects. These procedures also dramatically improve other metabolic conditions, including hyperlipidemia and hypertension, in both obese and nonobese patients. Several studies have provided evidence that these metabolic effects are not simply the results of drastic weight loss and decreased caloric intake but might be attributable, in part, to endocrine changes resulting from surgical manipulation of the gastrointestinal tract. In this Review, we provide an overview of the clinical evidence that demonstrates the effects of such interventions-termed metabolic surgery-on T2DM and discuss the implications for future research. In light of the evidence presented here, we speculate that the gastrointestinal tract might have a role in the pathophysiology of T2DM and obesity.

"Metabolic" surgery for treatment of type 2 diabetes mellitus.

OBJECTIVE: To discuss the potential contribution of "metabolic" surgery in providing optimal management of patients with type 2 diabetes mellitus (T2DM). METHODS: A literature search was performed with use of PubMed, and the clinical experience of the authors was also considered. RESULTS: Bariatric-or, more appropriately, metabolic-surgical procedures have been shown to provide dramatic improvement in blood glucose levels, blood pressure, and lipid control in obese patients with T2DM. In these patients, metabolic surgery involves a low risk of short-term mortality and a significant long-term survival advantage, whereas the diagnosis of diabetes is associated with significant long-term mortality. Experimental studies in animals and clinical trials suggest that gastrointestinal bypass procedures can control diabetes and associated metabolic alterations by mechanisms independent of weight loss. As a result, the use of bariatric surgery and experimental gastrointestinal manipulations to treat T2DM is increasing, even among less obese patients. Although body mass index (BMI) currently is the most important factor for identifying candidates for bariatric surgery, evidence shows that a specific cutoff BMI value cannot accurately predict successful surgical outcomes. Furthermore, BMI appears limited in defining the risk profile for patients with T2DM. CONCLUSION: Current BMI-based criteria for performance of bariatric surgery are not adequate for determining eligibility for operative treatment in patients with diabetes. Large clinical trials, comparing bariatric surgery versus optimal medical care of patients with T2DM, should be given priority in order to define the role of surgery in the management of diabetes. Recognizing the need to work as a multidisciplinary team that includes endocrinologists and surgeons is an initial step in addressing the issues and opportunities that surgery offers to diabetes care and research.

Noninvasive evaluation of abdominal fat and liver changes following progressive weight loss in severely obese patients treated with laparoscopic gastric bypass.

BACKGROUND: Obesity is a chronic complex disease, consequence of an unbalance between energy intake and expenditure and of the interaction between predisposing genotype and facilitating environmental factors. The aim of the study was to evaluate body composition, abdominal fat, and metabolic changes in a group of severely obese patients before and after laparoscopic gastric bypass (LGBP) at standardized (10% and 25%) total weight loss. METHODS: Twenty-eight patients (14 M, 14 F; age 41.71 +/- 6.9 years; body mass index (BMI) 49.76 +/- 5.8 kg/m(2)) were treated with laparoscopic gastric bypass. All evaluations before surgery and after achieving ~10% and ~25% weight loss (WL). Body composition was assessed by bioimpedance analysis; resting metabolic rate (RMR) was measured by indirect calorimetry. RESULTS: Body weight, BMI, and waist circumference significantly decreased at 10% and 25% WL. We observed a significant reduction of both RMR (2,492 +/- 388 at entry vs. 2,098 +/- 346.6 at 10% WL vs. 2,035 +/- 312 kcal per 24 h at 25% WL, p = 0.001 vs. baseline) as well as of RMR corrected for fat-free mass (FFM; 35.7 +/- 6.7 vs. 34.9 +/- 9.0 at 10% WL vs. 33.5 +/- 5.4 at 25% WL kilocalorie per kilogram FFM x 24 h, p = 0.041 vs. baseline). Body composition analysis showed a relative increase in FFM and a reduction of fat mass at 25% WL. A significant reduction in blood glucose, insulin, homeostasis model assessment index was observed. Ultrasonography showed a marked decrease in the signs of hepatic steatosis. CONCLUSION: In conclusion, our study confirms that LGBP is a safe procedure in well-selected severely obese patients and has early favorable effects on both metabolic parameters and body composition. Longer-term observations are required for in-depth evaluation of body composition changes.

Laparoscopic reoperation with total fundoplication for failed Heller myotomy: is it a possible option? Personal experience and review of literature.

Laparoscopic Heller myotomy with antireflux procedure seems the procedure of choice in the treatment of patients with esophageal achalasia. Persistent or recurrent symptoms occur in 10% to 20% of patients. Few reports on reoperation after failed Heller myotomy have been published. No author has reported the realization of a total fundoplication in these patient groups. The aim of this study is to evaluate the efficacy of laparoscopic reoperation with the realization of a total fundoplication after failed Heller myotomy for esophageal achalasia. From 1992 to December 2007, 5 out of a series of 242 patients (2.1%), along with 2 patients operated elsewhere, underwent laparoscopic reintervention for failed Heller myotomy. Symptoms leading to reoperation included persistent dysphagia in 3 patients, recurrent dysphagia in another 3, and heartburn in 1 patient. Mean time from the first to the second operation was 49.7 months (range, 4-180 months). Always, the intervention was completed via a laparoscopic approach and a Nissen-Rossetti fundoplication was realized or left in place after a complete Heller myotomy. Mean operative time was 160 minutes (range, 60-245 minutes). Mean postoperative hospital stay was 3.1 +/- 1.5 days. No major morbidity or mortality occurred. At a mean follow-up of 16.1 months, reoperation must be considered successful in 5 out of 7 patients (71.4%). The dysphagia DeMeester score fell from 2.71 +/- 0.22 to 0.91 +/- 0.38 postoperatively. The regurgitation score changed from 2.45 +/- 0.34 to 0.68 +/- 0.23. Laparoscopic reoperation for failed Heller myotomy with the realization of a total fundoplication is safe and is associated with good long-term results if performed by an experienced surgeon in a center with a long tradition of esophageal surgery.

Prospective assessment of patient selection for antireflux surgery by combined multichannel intraluminal impedance pH monitoring.

INTRODUCTION: Selecting gastroesophageal reflux disease (GERD) patients for surgery on the basis of standard 24-h pH monitoring may be challenging, particularly if this investigation does not correlate with clinical symptoms. Combined multichannel intraluminal impedance pH monitoring (MII-pH) is able to physically detect each episode of intraesophageal bolus movements, enabling identification of either acid or non-acid reflux episodes and thus establish the association of the reflux with symptoms. MATERIALS AND METHODS: We prospectively assessed and reviewed data from 314 consecutive patients who underwent MII-pH for GERD not responsive or not compliant to proton pump inhibitor therapy. One hundred fifty-three patients with a minimum follow-up of 1 year constituted the study population. Clinical outcomes and satisfaction rate were collected in all patients who underwent laparoscopic Nissen-Rossetti fundoplication. Outcomes were reported for patients with normal and ineffective peristalsis and for patients with positive pH monitoring, negative pH monitoring and positive total number of reflux episodes at MII, and negative pH monitoring and normal number of reflux episodes at MII and a positive symptom index correlation with MII. RESULTS: The overall patient satisfaction rate was 98.3%. No differences were recorded in the clinical outcomes of the patients with preoperative normal and ineffective peristalsis. No differences in patients' satisfaction and clinical postoperative DeMeester symptom scoring system were noted between the groups as determined by MII-pH. CONCLUSION: MII-pH provides useful information for objective selection of patients to antireflux surgery. Nissen fundoplication provides excellent outcomes in patients with positive and negative pH and positive MII monitoring or Symptom Index association. More extensive studies are needed to definitively standardize the useful MII-pH parameters to select the patient to antireflux surgery.

Laparoscopic sleeve gastrectomy with duodeno-jejunal bypass: a new surgical procedure for weight control. Feasibility and safety study in a porcine model.

BACKGROUND: One limit of the Roux-en-Y gastric bypass (GBP) is the preclusion of exploring the bypassed stomach with conventional endoscopy and radiological studies. In this study, we explored the feasibility, safety, and weight progression of a new bariatric procedure that eliminates this inconvenience. METHODS: Eleven 40- to 50-kg Yorkshire pigs underwent laparoscopic sleeve gastrectomy and Roux-en-Y duodeno-jejunal bypass (SG-DJBP). Weight was monitored at postoperative days 15 and 30 and after 3 months; weight progression was compared with an identical group that underwent a sham procedure or GBP. At autopsy, surgical site was evaluated at microscopic and macroscopic level. RESULTS: Mean operating time was 66 +/- 5.76 min. All the survivors tolerated the procedure well, except one subject that experienced a gastric leak from the stapler line. The SG-DJBP had a had significantly slower weight gains than the sham group (P = 0.005). The absence of histological abnormalities in the duodenal wall was confirmed at autopsy. CONCLUSION: SG-DJBP is feasible and produces effects of weight progression comparable to those of GBP. Being a combination of previously standardized procedures, we are confident to propose this procedure as a bariatric alternative in humans. Long-term follow-up will be required to establish the efficacy on weight loss in humans.

Total fundoplication controls acid and nonacid reflux: evaluation by pre- and postoperative 24-h pH-multichannel intraluminal impedance.

BACKGROUND: Studies have demonstrated that Nissen fundoplication controls acid gastroesophageal reflux (GER). Combined 24-h pH and multichannel intraluminal impedance (MII-pH) allows detection of both acid and nonacid GER. Antireflux surgery is considered for any patient whose medical therapy is not efficient, particularly patients with nonacid gastroesophageal reflux disease (GERD). Nevertheless, fundoplication used to control nonacid reflux has not been reported to date. METHODS: In this study, 15 consecutive patients who underwent laparoscopic Nissen-Rossetti fundoplication had MII-pH both before and after the surgical procedure. The numbers of acid and nonacid GER episodes were calculated with the patient in both upright and recumbent positions. RESULTS: The 24-h pH monitoring confirmed the postoperative reduction of exposure to acid (p < 0.05). Postoperatively, the total, acid, and nonacid numbers of GER episodes were reduced (p < 0.05). CONCLUSION: According to the findings, MII-pH is feasible and well tolerated. It provides an objective means for evaluating the effectiveness of Nissen-Rossetti fundoplication in controlling both acid and nonacid GER.

Endoscopic cervical bariatric surgery: follow-up study in a porcine model.

BACKGROUND: The realisation of bariatric surgery has to date modified the digestive process solely through procedures within the abdominal cavity. However, endocrine surgeons have recently demonstrated the feasibility of a minimally invasive approach to the neck. In this study, we explored the feasibility, safety and weight progression of a bariatric procedure performed at the neck. METHODS: Eleven 40-50 kg Yorkshire pigs underwent endoscopic placement of an adjustable band to the cervical esophagus (ECB). Weight was monitored at postoperative days 15, 30, and after 7 weeks; weight progression was compared with an identical group of pigs who underwent a sham procedure. At autopsy, the surgical site was evaluated in a microscopic and macroscopic manner. RESULTS: Mean operating time was 66 +/- 5.76 min. All pigs tolerated the procedure well, except one subject that experienced food intolerance. The ECB group experienced significantly slower weight gain than the sham group (P = 0.005). Proper location of the band and absence of microscopic lesions at the esophageal wall were confirmed at autopsy and pathological examination. CONCLUSION: Bariatric surgery at the neck is feasible and produces effects on weight reduction. Further refinements and longer observation periods are required to propose this procedure as safe and effective alternative in humans.

[Laparoscopic total fundoplication is not an obstacle to oesophageal emptying after oesophago-gastric myotomy for the surgical treatment of achalasia]. / La fundoplicatio totale non ostacola lo svuotamento esofageo dopo miotomia esofago-gastrica estesa per il trattamento chirurgico dell'acalasia esofagea.

There are different surgical possibilities for the treatment of oesophageal achalasia ranging from a short extramucosal oesophagomyotomy to an extended esophago-gastric myotomy combined with a partial fundoplication to restore the main antireflux barrier. A total 360 degrees fundoplication is generally regarded as an obstacle to oesophageal emptying. The aim of this study was to evaluate the role and efficacy of total 360 degrees laparoscopic Nissen-Rossetti fundoplication after oesophago gastric myotomy in the treatment of oesophageal achalasia. From 1992 to January 2008, a total of 245 patients (112 males, 133 females), mean age 45.1 years (range: 12-79), were submitted to laparoscopic Nissen-Rossetti fundoplication after a Heller myotomy with endoscopic and manometric intraoperative monitoring. In 3 patients (1.2%), conversion to laparotomy was necessary. Mean operative time was 60 +/- 15 minutes. No mortality was observed. The overall morbidity rate was 1.6%. The mean postoperative hospital stay was 3.5 +/- 1.0 days (range: 1-12 days). A mean clinical follow-up of 100.2 +/- 7 months (range: 3-177) was possible for 228 patients (93.1%), and an excellent or good outcome was observed in 209 patients (91.7%) (DeMeester dysphagia score 0-1). No improvement in dysphagia was observed in 5 (2.2%) patients. Pathological gastro-oesophageal reflux was absent in all patients. Laparoscopic Nissen-Rossetti fundoplication after a Heller myotomy is a safe, effective treatment for oesophageal achalasia with excellent results in terms of dysphagia resolution, affording total protection from the onset of gastrooesophageal reflux.

Laparoscopic duodenal switch for pathologic duodenogastric reflux: initial experience.

Duodenogastric reflux (DGR) is barely responsive to medications and antireflux fundoplication is not able to control the gastric symptoms. Duodenal switch (DS) preserves the physiologic food transit while creating an effective Roux-en-Y diversion to duodenal juice. However, it never enjoyed great popularity, perhaps due to the invasiveness of the open approach. The paper reports our initial experience with laparoscopic DS. Preoperative assessment, surgical technique, and outcomes are described. Normalization of DGR was demonstrated by preoperative and postoperative 24-hour bilimetry and pH-multichannel intraluminal impedance. The procedure was completed under laparoscopy in all the cases with a mean operative time of 165 minutes. Mean blood loss was 200 mL. No patient required admission to the intensive care unit. Initial experience with laparoscopic DS encourages continued use of the minimally invasive approach. A meticulous preoperative evaluation is essential to place a correct indication.

Metabolic and nutritional status changes after 10% weight loss in severely obese patients treated with laparoscopic surgery vs integrated medical treatment.

BACKGROUND: Bariatric surgery is considered the most effective treatment for reducing excess body weight and maintaining weight loss (WL) in severely obese patients. There are limited data evaluating metabolic and body composition changes after different treatments in type III obese (body mass index [BMI] > 40 kg/m(2)). METHODS: Twenty patients (9 males, 11 females; 37.6 +/- 8 years; BMI = 50.1 +/- 8 kg/m(2)) treated with dietary therapy and lifestyle correction (group 1) have been compared with 20 matched patients (41.8 +/- 6 years; BMI = 50.4 +/- 6 kg/m(2)) treated with laparoscopic gastric bypass (LGBP; group 2). Patients have been evaluated before treatment and after >10% WL obtained on average 6 weeks after LGBP and 30 weeks after integrated medical treatment. Metabolic syndrome (MS) was evaluated using the Adult Treatment Panel III/America Heart Association (ATP III/AHA) criteria. Resting metabolic rate (RMR) and respiratory quotient (RQ) was assessed with indirect calorimetry; body composition with bioimpedance analysis. RESULTS: At entry, RMR/fat-free mass (FFM) was 34.2 +/- 7 kcal/24 h.kg in group 1 and 35.1 +/- 8 kcal/24 h.kg in group 2 and did not decrease in both groups after 10% WL (31.8 +/- 6 vs 34.0 +/- 6). Percent FFM and fat mass (FM) was 50.7 +/- 7% and 49.3 +/- 7% in group 1 and 52.1 +/- 6% and 47.9 +/- 6% in group 2, respectively (p = n.s.). After WL, body composition significantly changed only in group 1 (% FFM increased to 55.9 +/- 6 and % FM decreased to 44.1 +/- 6; p = 0.002). CONCLUSION: After >10% WL, MS prevalence decreases precociously in surgically treated patients; some improvements in body composition are observed in nonsurgically treated patients only. Further investigations are needed to evaluate long-term effects of bariatric surgery on body composition and RMR after stable WL.

Laparoscopic cardioplasty to avoid esophageal resection in patient not responsive to Heller myotomy.

Some achalasia patients do not ameliorate dysphagia after Heller myotomy. If stenosis does not respond to endoscopic dilatations and persists after a second extended myotomy, an esophageal resection is considered unavoidable. This article describes an original technique of treating this type of persistent stenosis with an esophageal stricturoplasty. The procedure was completed under laparoscopy. The postoperative course was uneventful. Resolution of all preoperative symptoms was achieved at the first year follow-up. Control of gastroesophageal reflux was documented by 24-hour pH-impedance. If confirmed by further cases, laparoscopic esophageal stricturoplasty could become a valid option for a conservative treatment of these patients.