Randomized clinical trial on closure versus non-closure of mesenteric defects during laparoscopic gastric bypass surgery.

BACKGROUND: Internal herniation is a well known and potentially life-threatening complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). The aim of this study was to evaluate the benefit and harm of closing the mesenteric defects with clips during LRYGB to prevent internal herniation. METHODS: This was a single-centre, single-blinded RCT. Patients eligible for LRYGB were randomized to surgery with or without closure of mesenteric defects with clips. The primary endpoint was the incidence of (intermittent) internal herniation after LRYGB with a minimum follow-up of 24 months. Secondary outcomes were duration of surgery, number of clips used, trocars and sutures used, postoperative pain measured by a visual analogue scale (VAS), and postoperative complications. RESULTS: Between 13 August 2012 and 18 May 2017, 401 patients were randomized to closure (201) or non-closure (200) of mesenteric defects. Median follow-up for both groups was 59 months (range 8-67 and 16-67 months in non-closure and closure groups respectively). The cumulated risk of internal herniation after 2 years was 8.0 per cent in the non-closure group compared with 4.5 per cent in the closure group (hazard ratio (HR) 1.81, 95 per cent c.i. 0.80 to 4.12; P = 0.231). At 5 years, rates were 15.5 and 6.5 per cent respectively (HR 2.52, 1.32 to 4.81; P = 0.005). Closure of mesenteric defects increased operating time by a median of 4 min (95 per cent c.i. 52 to 56 min for the non-closure group and 56 to 60 min for the closure group; P = 0.002). There was no difference in postoperative blood transfusion rates and VAS scores between the groups. CONCLUSION: Routine closure of the mesenteric defects in LRYGB with clips is associated with a lower rate of internal herniation. Registration number: NCT01595230 (http://www.clinicaltrials.gov).

Mitochondrial respiratory capacity remains stable despite a comprehensive and sustained increase in insulin sensitivity in obese patients undergoing gastric bypass surgery.

AIM: It has been proposed, but not yet demonstrated by convincing evidence in published articles, that insulin resistance and mitochondrial respiratory function are causally related physiological phenomena. Here, we tested the prediction that weight loss-induced increase in insulin sensitivity will correlate with a corresponding change in mitochondrial respiratory capacity over the same time period. METHODS: Insulin sensitivity was evaluated using the hyperinsulinaemic-euglycaemic clamp technique, and skeletal muscle mitochondrial respiratory capacity was evaluated by high-resolution respirometry in 26 patients with obesity. Each experiment was performed ~2 months and 1-2 weeks before, and ~4 and ~19 months after Roux-en-Y gastric bypass (RYGB) surgery. RESULTS: A substantial weight loss was observed in all patients, and insulin sensitivity increased in all patients over the 21-months time period of the study. In contrast, skeletal muscle mitochondrial respiratory capacity, intrinsic mitochondrial respiratory capacity and mitochondrial content remained unchanged over the same time period. CONCLUSION: Among obese patients with and without type 2 diabetes undergoing RYGB surgery, intrinsic mitochondrial respiratory capacity in skeletal muscle is not correlated with insulin sensitivity before or after the surgical intervention. Mitochondrial respiratory function may not be germane to the pathophysiology and/or aetiology of obesity and/or type 2 diabetes.

Reoperation risk following the first operation for internal herniation in patients with laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most commonly used surgical procedure in the treatment of morbid obesity in Denmark. Internal herniation (IH) and intermittent internal herniation (IIH) are probably the most common late complications in patients with LRYGB. The aim of this study was to investigate a possible increased risk of subsequent operations after an initial IH or IIH event. METHODS: This long-term follow-up study of patients who had surgery for an initial IH or IIH event in 2006-2011, based on the Danish National Patient Registry (NPR), was performed to 2013. During this period, mesenteric defects were not closed routinely during LRYGB. RESULTS: Data were retrieved from 12 221 patients with LRYGB from the NPR. A total of 383 patients had surgery for an initial IH or IIH event. Some 102 patients (26·6 (95 per cent c.i. 22·5 to 31·3) per cent) had a second operation. Twenty-seven (26·5 (18·9 to 35·8) per cent) of these 102 patients had a third operation, and five (19 (8 to 37) per cent) of the 27 had a fourth operation. Of the 383 patients diagnosed with an initial IH or IIH event, 72 (18·8 per cent) had a second IH/IIH event, 14 (3·7 per cent) had a third event, and three (0·8 per cent) a fourth event requiring surgery. CONCLUSION: Patients who have surgery for IH or IIH have a substantial risk of needing further operations.

[Biloma]. / Bilom.

Most cases of biloma are caused by liver trauma or surgical intervention. However, spontaneous cases have been reported. We present a patient with spontaneous biloma which may have developed secondary to stenosis of the common bile duct or infarction of the liver. The initial treatment was percutaneous drainage, followed by ERCP with papillotomy and stenting of the common bile duct. Despite this therapy symptoms recurred and the patient had to undergo resection of a liver segment. The treatment of biloma in general is discussed.

Electrophoretic analysis of basal body (centriole) proteins.

Purified basal bodies isolated from the chicken oviduct were analyzed by using several different electrophoretic techniques. For comparison, oviduct cilia proteins were also analyzed. Prominent among the basal body proteins were the tubulin subunits (representing approximately 20% of the protein) and a low molecular weight protein (approximately 17,400 daltons). In addition, major bands were present with molecular weights of approximately 180,000 and approximately 90,000. Electrophoretically purified basal body tubulin subunits had isoelectric points of 5.45 (alpha subunit) and 5.1 (beta subunit). In addition, these isoelectric focus gels contained at least four other proteins that had higher isoelectric points, which indicates that tubulin purified by one-dimensional electrophoresis contains other proteins. On the basis of several different electrophoretic techniques, it was found that basal body tubulin differed from cilia tubulin even though they both had similar isoelectric focusing points. Whereas basal bodies did not contain any proteins that corresponded to the cilia dynein ATPase, five different sets of proteins were common to both cilia and basal bodies. Basal bodies did not contain significant amounts of actin, myosin, or desmin.

Adenosine triphosphate induced change in light scattering of isolated basal bodies.

Suspensions of isolated basal bodies undergo a characteristic decrease in turbidity following their exposure to 10(-3) M ATP. Typically, turbidity changes range from 8% to 20%, depending on the preparation, with an average change of 12%. Nucleotides other than ATP did not cause a turbidity decrease. The reaction has a pH optimum of pH 8.5 and is inhibited by concentrations of divalent cations greater than 2 X 10(-3) M. These results indicate that ATP induces a conformational change in the basal body that may be related to its activity in the cell.