Mid-term outcomes after single anastomosis sleeve ileal (SASI) bypass in treatment of morbid obesity.

BACKGROUND: According to several short-term studies, single-anastomosis sleeve ileal (SASI) bypass offers similar weight loss to Roux-en-Y Gastric Bypass (RYGB) with fewer complication and better comorbidity reduction/resolution. Long-term data on this operation is lacking in the literature. The purpose of this study was to analyze the outcomes of SASI bypass up to 4 years. METHODS: This study is a retrospective cohort analysis of 366 patients with morbid obesity who underwent primary SASI bypass from January 2018 to February 2022. RESULTS: The mean age and preoperative body mass index (BMI) were 41 years (range 22-71 years) and 43.9 ± 6.5 kg/m2, respectively. Follow-up was available for 229 patients at 1-year (89%), 112 patients at 2-year (75%), 61 patients at 3-year (75%), and 35 patients at 4-year (71%). The intraoperative, short-term, and long-term complication rates were 0%, 2.5%, 4.6%, respectively. After 4 years, mean percentage excess weight loss (%EWL) was 93.3% and total weight loss (%TWL) was 41.2%. Remission of comorbidities was 93% for type 2 diabetes mellitus, 73% for hypertension, 83% for hyperlipidemia, 79% for sleep apnea, and 25% for gastroesophageal reflux disease (GERD). Biliary gastritis and ulcers are seldom. Eight patients developed de novo GERD symptoms requiring proton pump inhibitor treatment. None of the patients in our study had hypoalbuminemia or malabsorption that did not respond to increased protein intake and vitamin or mineral supplementation. CONCLUSION: SASI bypass appears to be safe, and one of the most effective bariatric procedures regarding weight loss and obesity related comorbidities. The double-outlet created in this procedure seemingly minimizes nutritional complications.

Current Status of Metabolic/Bariatric Surgery in Type 1 Diabetes Mellitus: an Updated Systematic Review and Meta-analysis.

This systematic review and meta-analysis intend to evaluate the efficacy of metabolic/bariatric surgeries (MBS) in patients with type-1 diabetes mellitus. A systematic literature search and meta-analysis were performed in electronic databases up to July 2021. In total, 27 primary studies comprising 648 subjects were included in this systematic review and meta-analysis. Patients had a mean age of 38.0 ± 7.3 years. Preoperative mean BMI was 42.6 ± 4.7 kg/m2 and 29.4 ± 4.7 kg/m2 after surgery, respectively. Following bariatric surgeries in patients with type 1 diabetes mellitus, insulin (unit/day) decreased by a weighted mean difference (WMD) of - 10.59. Also, insulin (unit/kg/day) decreased by a WMD of - 0.2, and HbA1C decreased by a WMD of - 0.71, showing MBS acceptable and durable effects of bariatric surgical procedures.

Religious Fasting of Muslim Patients After Metabolic and Bariatric Surgery: a Modified Delphi Consensus.

BACKGROUND: Fasting during Ramadan is one of the five pillars of the Muslim faith. Despite the positive effects of fasting on health, there are no guidelines or clear recommendations regarding fasting after metabolic/bariatric surgery (MBS). The current study reports the result of a modified Delphi consensus among expert metabolic/bariatric surgeons with experience in managing patients who fast after MBS. METHODS: A committee of 61 well-known metabolic and bariatric surgeons from 24 countries was created to participate in the Delphi consensus. The committee voted on 45 statements regarding recommendations and controversies around fasting after MBS. An agreement/disagreement ≥ of 70.0% was regarded as consensus. RESULTS: The experts reached a consensus on 40 out of 45 statements after two rounds of voting. One hundred percent of the experts believed that fasting needs special nutritional support in patients who underwent MBS. The decision regarding fasting must be coordinated among the surgeon, the nutritionist and the patient. At any time after MBS, 96.7% advised stopping fasting in the presence of persistent symptoms of intolerance. Seventy percent of the experts recommended delaying fasting after MBS for 6 to 12 months after combined and malabsorptive procedures according to the patient's situation and surgeon's experience, and 90.1% felt that proton pump inhibitors should be continued in patients who start fasting less than 6 months after MBS. There was consensus that fasting may help in weight loss, improvement/remission of non-alcoholic fatty liver disease, dyslipidemia, hypertension and type 2 diabetes mellitus among 88.5%, 90.2%, 88.5%, 85.2% and 85.2% of experts, respectively. CONCLUSION: Experts voted and reached a consensus on 40 statements covering various aspects of fasting after MBS.

The mesenteric defects in laparoscopic Roux-en-Y gastric bypass: 5 years follow-up of non-closure versus closure using the stapler technique.

BACKGROUND: Internal hernia (IH) is a common complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). Little large-volume data exist on how to handle the mesenteric defects during LRYGB. This study evaluated long-term follow-up (5.5 years) of 2443 patients with primary closure of the mesenteric defects with a stapling device at LRYGB, in comparison with a non-closed group from the same centre. METHODS: All patients (N = 4013) undergoing LRYGB over a 10-year period (2005-2015) at a single institution were evaluated. The mesenteric defects were routinely closed starting June 2010. In total, 1570 non-closure patients and 2443 patients with stapled closure of the defects were prospectively entered and the results analysed. RESULTS: Closure of the mesenteric defects increased surgical time by 4 min and did not affect the 30-day complication rate. IH incidence was significantly lower (2.5%) in the closure group compared with 11.7% in the non-closure group, at 60 months. The relative risk reduction by closing the mesenteric defects was 4.09-fold (95% CI = 2.97-5.62) as calculated using a survival model. CONCLUSIONS: Internal hernia after LRYGB occurs frequently if mesenteric defects are left unclosed. Primary closure with a hernia-stapling device is safe and significantly reduces the risk of internal hernia.

Long-term effects of laparoscopic Roux-en-Y gastric bypass on metabolic syndrome in patients with morbid obesity.

BACKGROUND: Diseases associated with obesity such as type 2 diabetes (T2D), hypertension, and dyslipidemia are common and together are defined as metabolic syndrome (MetS). The aim of this study was to evaluate long-term effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) in morbidly obese patients with MetS. METHODS: This was a retrospective study of data from a prospective database in a single center from 2005 to 2013 including 3795 LRYGB operated obese patients. Metabolic syndrome was defined according to the International Diabetes Federation Consensus Definition of Metabolic Syndrome from 2006. RESULTS: In the study population, 79% of the patients were women, the preoperative median age was 42.4 years, and median body mass index (BMI, kg/m2) was 40.9. MetS was diagnosed in 60% of the patients (2275/3795), with increased frequency in men and in those with higher age, higher BMI, and greater waist circumference; 27.5% of patients had impaired glucose metabolism, 40% hypertension, and 30% dyslipidemia. Postoperative follow-up rate>5 years was 71% (595/839). We found that 86.2% had resolution of MetS. After 5-9 years, complete remission of T2D was achieved in 78%, hypertension in 51%, and dyslipidemia in 89%. Mean excess BMI loss was significantly lower for patients with MetS (73.1%) compared with patients without MetS (75.6%) (P<.01). Early complications (leakage or hemorrhage) occurred in 1.2% (48/3975) and internal hernia in 7.8% (310/3975). Presence of MetS did not increase complication rates. CONCLUSION: LRYGB in obese patients is associated with a significant and sustained reduction in excessive weight. In the present study, 86.2% of patients with MetS achieved complete remission and complication rates were low. Early bariatric surgery should be considered in patients with obesity and concurrent MetS.

Internal hernia after gastric bypass: a new and simplified technique for laparoscopic primary closure of the mesenteric defects.

BACKGROUND: Bowel obstruction due to internal hernia is a well-known complication of laparoscopic Roux-en-Y gastric bypass (LRGB). Increasing evidence supports primary closing of the mesenteric defects, but controversy continues about surgical technique of systematic closure. This paper reviews our experience with internal hernia after LRGB and describes a new method of preemptive closure of the mesenteric defects. MATERIAL AND METHODS: Two thousand four hundred seventy-two consecutive patients undergoing LRGB from September 2005 to June 2010 were entered into our prospective longitudinal database. The mesenteric defects were not closed. Patients entered a 5-year follow-up program, and all who subsequently presented with internal hernia were analyzed. A further 1,630 patients operated on in the last 12 months were subjected to our new technique of closing the defects; data were entered in our own database as well as in the Scandinavian quality registry. Follow-up time for these patients is limited. RESULTS: In the first group, 117 patients developed an internal hernia (4.7%) at a mean interval after LRGB of 13 (range, 4-43 months). Four patients needed bowel resections because of severe ischemia. There was one death associated with complication of the internal hernia. In the primary closure group, four patients early in the series had reoperations for kinking of the enteroanastomosis. There have been no mesenteric haematomas encountered. CONCLUSIONS: Internal hernia should be ruled out in patients with previous LRGB and abdominal pain. Our technique for primary closing of the mesenteric defects seems to be safe and is so far promising.

The sandwich design: a new method to close a high-output enterocutaneous fistula and an associated abdominal wall defect.

Fistulas draining through large abdominal wall defects are exceptionally difficult to treat and are associated with a very high mortality. This case report describes a new method for closure of these fistulas where prior conservative and surgical treatment had failed. Initial use of a vacuum-assisted closure (VAC) system optimized wound care and led to coverage of the exposed intestines with granulation tissue. The serratus muscle of a composite free latissimus dorsi-serratus flap was used to close the fistula, while the large abdominal wall defect was closed with the musculocutaneous latissimus dorsi flap. Temporary placement of a VAC system between the serratus muscle and the latissimus dorsi muscle immobilized the serratus to the fistula and counteracted changes in abdominal pressure. The layering of muscle, VAC system, and muscle resembles a sandwich. The advantage of the sandwich design is an extraperitoneal approach that provides tension-free closure of the fistula and abdominal wall, with well-vascularized tissue.

The pressure-volume loop revisited: Is the search for a cardiac contractility index a futile cycle?

UNLABELLED: Our previous studies indicate that left ventricular end-systolic pressure-volume relations (ESPVRs) or elastance (Ees) are not reduced in studies where expected reductions of contractility should be found (i.e., heart failure, stunning, and endotoxemia). The present study was done to assess whether this phenomenon is due to a particular load sensitivity of elastance, rendering this index inappropriate as a measurement of contractility in pathologic states in vivo. METHODS AND RESULTS: Analysis of previously generated data revealed an increased ESPVR in stunned hearts, in pigs made endotoxemic, and in hearts rapidly paced. After inducing acute heart failure by microembolization, the ESPVR was increased when assessed using linear relations but reduced when assessing ESPVR by a curvilinear algorithm. To further evaluate the effect of different load alterations on ESPVR, this relation was generated by (i) inferior vena caval occlusions (VCOs); (ii) gradually occluding the descending aorta (pressure interventions); and (iii) rapidly infusing blood (120 mL) into the left atrium (volume increments). The load protocol was applied in 5 pigs, before and after the left ventricle was stunned by 11 brief left main coronary artery occlusions/reperfusions (accumulated ischemia 20 min affecting 81% of the left ventricle). Correlation coefficients for left ventricular elastance ranged from 0.93 to 0.99 in all the 3 types of loading interventions. Despite significant reductions in stroke volume, stroke work, and dP/dtmax, VCO-calculated linear and curvilinear Ees increased 90 min after stunning (55% +/- 4% and 94% +/- 6%, respectively). Linear Ees during pressure interventions decreased 36% +/- 1%, whereas curvilinear Ees decreased 33% +/- 3%. During volume infusions, linear Ees decreased 27% +/- 2%. We achieved the same results after blocking the baroreceptor reflexes using hexamethonium. CONCLUSIONS: The Ees is particularly load dependent and will reflect load interventions more than the inotropic state of the cardiac muscle. A VCO-generated Ees increase could be an unmasking of a pronounced preload sensitivity in failing myocardium.

Nitric oxide synthase inhibition impairs myocardial efficiency and ventriculo-arterial matching in acute ischemic heart failure.

BACKGROUND AND AIMS: The effect of nitric oxide (NO) manipulation in acute heart failure has not been sufficiently investigated. Therefore, we assessed the impact of NO-synthase (NOS) inhibition on left ventricular (LV) function and energetics as well as overall hemodynamics, in a porcine model of acute ischemic LV failure. METHODS: Acute heart failure was induced by left coronary artery microembolization in fourteen anesthetized pigs. LV pressure-volume relationships and mechanical work (PVA) were assessed 30 min after stable heart failure, using pressure-conductance catheters. Myocardial oxygen consumption (MVO(2)) was determined from coronary flow and coronary arteriovenous oxygen difference. Microembolization led to a significant decrease in cardiac output, arterial pressure and LV systolic and diastolic performance. Animals were then randomized to a control group (n=7) or to receive 15 mg/kg N(omega)-Nitro-L-arginine-metyl ester (n=7), an inhibitor of NO synthase (NOS). RESULTS: Measurements 15 min later revealed that NOS inhibited animals had significantly reduced cardiac output (1.53+/-0.45 vs. 2.13+/-0.49 l/min, P=0.003) and stroke work (1054+/-461 vs. 1296+/-348 mmHg ml, P=0.03), and also displayed a significant increase in the slope of the MVO(2)-PVA relationship (2.57+/-0.53 vs. 1.92+/-0.15, P=0.008), i.e. an inefficient chemomechanical coupling. NOS inhibition did not alter contractility, diastolic function or arterial pressure, but afterload was significantly increased compared to controls (arterial elastance 6.03+/-1.48 vs. 2.74+/-0.34 mmHg/ml, P=0.009). CONCLUSION: Inhibition of NOS in experimental acute heart failure increased afterload without altering left ventricular systolic and diastolic function. Consequently, cardiac output was reduced. Furthermore, mechanoenergetic efficiency was severely impaired. NOS inhibition in acute heart failure and cardiogenic shock warrants further investigations.

Mechanoenergetic inefficiency in the septic left ventricle is due to enhanced oxygen requirements for excitation-contraction coupling.

OBJECTIVE: Myocardial oxygen consumption (MVO2) in the septic myocardium is increased despite reduced left ventricular mechanical work. We investigated the mechanism behind this energetic inefficiency in the septic myocardium. METHODS: To clarify whether energy consumption in basal metabolism or excitation-contraction (EC) coupling is elevated in the septic myocardium, we separated MVO2 used for these two processes. We assessed hemodynamics, left ventricular pressure-volume area, left ventricular MVO2, myocardial substrate metabolism and the inflammatory response in eight control pigs and in eight septic pigs receiving E. coli endotoxin. Using cardiopulmonary bypass (CPB), unloaded MVO2 was assessed before and after arrest of electromechanical activity using KCl infusions. RESULTS: Unloaded MVO2 was significantly higher in the septic group compared to the control group (65.7 +/- 12.9 vs. 43.3 +/- 15.1 J.min(-1).100 g LV(-1), p < 0.005), but basal MVO2 after 5 min KCl arrest was equal in the two groups. No difference in mechanical energy consumption or substrate metabolism was observed between groups. CONCLUSION: Basal MVO2 in the septic myocardium is not elevated, but an increased MVO2 for EC coupling is responsible for the energetic inefficiency.

Increased oxygen cost of contractility in the endotoxemic porcine left ventricle.

OBJECTIVE: Myocardial oxygen consumption (MVO) in the septic myocardium is comparatively high in relation to the sepsis-induced reduction in ventricular work. Our previous studies indicate that this energetic inefficiency is due to increased energy consumption in excitation-contraction (EC) coupling, i.e. myocardial calcium handling. DESIGN: To further confirm this observation, we assessed the oxygen cost of contractility in anesthetized pigs before and 2 h after induction of endotoxemia (1 microg/kg endotoxin infusion over 1 h, Escherichia coli toxin, n=6). Baroreceptor reflexes were blocked by hexamethonium. Contractility was increased by stepwise dopamine infusions at baseline and 2 h after induction of endotoxemia. Oxygen cost of contractility was assessed as the relationship between myocardial contractility (E or elastance) and non-mechanical oxygen consumption (unloaded MVO), a measure of energy consumption in EC coupling or calcium handling. RESULTS: Non-mechanical oxygen consumption (unloaded MVO) was higher after endotoxin infusions than at baseline (0.641 +/- 0.05 vs 0.383 +/- 0.07 J/beat/100 g, p < 0.05). The relationship between unloaded MVO and E, constructed by the dopamine response, was highly linear both at baseline and endotoxemia (r2 =0.76-0.99). However, endotoxin increased oxygen cost of contractility by approximately 45% (baseline 0.06 +/- 0.03 vs endotoxin 0.09 +/- 0.04 J ml/mmHg/beat/100 g). CONCLUSION: Acute endotoxemia increases oxygen cost of contractility, a measure of energy consumed in EC coupling or myocardial calcium handling.

Replacing potassium with nicorandil in cold St. Thomas' Hospital cardioplegia improves preservation of energetics and function in pig hearts.

BACKGROUND: To determine whether the adenosine triphosphate-sensitive potassium channel opener nicorandil, instead of potassium in cold crystalloid cardioplegia, may enhance cardioprotection, crystalloid cardioplegia with nicorandil, magnesium, and procaine was compared with standard crystalloid cardioplegia in terms of left ventricular performance and efficiency. METHODS: Sixteen pigs were randomly assigned to receive cold hyperkalemic crystalloid cardioplegia (n = 8) or nicorandil in cold saline (n = 8). Cold (4 degrees C) cardioplegic solutions were given antegradely and intermittently, with a cross-clamp time of 60 minutes. The preload recruitable stroke work relationship (PRSW), pressure-volume area (PVA), and myocardial oxygen consumption (MVO(2)) were calculated at baseline and at one and two hours following cross-clamp release, using combined pressure-volume conductance catheters, coronary flow probes, and O(2)-content differences. RESULTS: The left ventricular contractility expressed in PRSW was reduced to 58% (standard deviation [SD]: 20) of baseline in the crystalloid group and to 89% (SD: 20) in the nicorandil group two hours after cross-clamp release (p = 0.044). The slope of the MVO(2)-PVA relationship increased in the crystalloid group from 1.59 (SD: 0.22) before cardioplegia to 2.55 (SD: 0.73) afterwards, significantly more than in the nicorandil group, where the slope changed from 1.69 (SD: 0.30) to 1.95 (SD: 0.47) (p = 0.027). CONCLUSIONS: Nicorandil in a crystalloid cardioplegic solution was easily employed and contractility was significantly better than after standard hyperkalemic cardioplegia. The smaller shift of the slope in the MVO(2)-PVA relationship in the nicorandil group shows improved efficiency in oxygen to mechanical transfer compared with the crystalloid group.

E. Coli sepsis induces profound mechanoenergetic inefficiency in the porcine left ventricle.

Myocardial dysfunction is believed to be a central part of septic multiorgan manifestations. The aim of the present study was to assess whether E. coli sepsis in an in vivo model would induce a dysfunction in the relationship between mechanical work and energy consumption in the left ventricle (LV). Accordingly, we measured hemodynamics, left ventricular pressure-volume area (PVA), and myocardial oxygen consumption (MVo2) in deeply anesthetized pigs. Eight pigs received 2.0 +/- 0.5 x 10(9) E. coli bacteria intravenously, and seven served as controls. Compared with baseline and the control group, no alternations were observed in LV diastolic function or indices of contractility in the septic group. The MVo2-PVA relationship was highly linear in both groups (all r2 = 0.96-0.99). At 5 h, the y-axis intercept of the MVo2-PVA relationship (nonmechanical MVo2) had increased in the sepsis group by 70% compared with baseline (P = 0.004) and by 60% compared with the control group (P = 0.003). Contractile efficiency (the inverse of the MVo2-PVA slope) remained unchanged over time and between groups. The study demonstrates a profound increase in nonmechanical oxygen consumption during E. coli sepsis in the LV.

Vasodilation and mechanoenergetic inefficiency dominates the effect of the "Ca(2+)-sensitizer" MCI-154 in intact pigs.

OBJECTIVE: Ca(2+)-sensitizing agents hold potential as ideal cardiac inotropes, but effects in intact animals are scarcely described. We evaluated a pyridazinone derivative, MCI-154, for hemodynamic, inotropic, mechanoenergetic and oxidative metabolic effects. DESIGN: Intracavitary left ventricular (LV) pressure and conductance (volume) was assessed in open chest anesthetized pigs (n = 6). Contractile performance, pressure-volume area (PVA) and myocardial oxygen consumption (MVO(2)) were assessed. Myocardial substrate uptake and production of (14)CO(2 )(from glucose) and (3)H(2)O (from fatty acids) were monitored. MCI-154 administration: "low range": 0.1, 0.2, 0.3, 0.5 microg/kg/min and "high range": 0.75, 1.0, 2.0, 3.0 microg/kg/min. Parameters were compared with baseline and a time reference group (n = 7). RESULTS: MCI-154 induced a progressive dose-dependent decrease in systemic vascular resistance, with a concomitant increase in heart rate and cardiac output. Contractility increased only in the high-dose range, and mechanoenergetic efficiency was significantly reduced by drug infusion in all doses. CONCLUSION: The pyridazinone derivative MCI-154 has minimal inotropic action, induces a significant "oxygen waste", and decreases vascular resistance in intact pigs. A potent phosphodiesterase inhibitory effect may explain this, which suggests further drug refinement.