Does Roux-en-Y Gastric Bypass Really Cure Gastroesophageal Reflux Disease? Analysis of Objective Data.

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the treatment of choice for obesity with gastroesophageal reflux disease (GERD). There are few reports showing objective data based on esophageal function tests (EFTs). The aim of our study was to evaluate the influence of LRYGB on GERD. Methods: Candidates for laparoscopic sleeve gastrectomy (LSG) underwent preoperative esophageal manometry (EM) and 24-hour pH monitoring. Based on the negative influence of LSG on GERD, patients with abnormal pH were offered LRYGB. Those patients repeated EFTs, esophagogastroduodenoscopy, and symptom questionnaire 1 year after surgery. Results: Two hundred fifty LSG candidates underwent preoperative EFTs; 38% were redirected to LRYGB due to abnormal pH and 13 (18%) completed EFTs postoperatively. In ten women, age: 40 ± 7 years, body mass index: 41 ± 1 kg/m2. EM: lower esophageal sphincter (LES) length increased from 2.6 to 2.9 cm (P = not statistically significant [NS]), and LES pressure decreased from 15 to 14.2 mmHg (P = NS). Preoperatively, LES was normotensive in 12 (92%) patients and postoperatively in 11 (85%) (P = NS). DeMeester score decreased from 35.7 to 11 (P < .001). Postoperatively, 9 (69%) patients resolved their GERD, 3 (23%) improved, and 1 (8%) remained the same (P < .001). Symptoms decreased significantly after surgery. Two patients (15%) had Grade A esophagitis. One of them was able to resolve it, while the other 1 remained the same. Conclusions: Our preliminary data showed that after LRYGB, LES pressure remained the same and DeMeester score decreased, while 69% of patients resolved their GERD. Therefore, LRYGB seems to be an excellent option for obesity and GERD.

Obese Patients with Type 2 Diabetes: Outcomes After Laparoscopic Sleeve Gastrectomy.

Background: Bariatric surgery is superior to medical treatment for type 2 diabetes mellitus (T2DM) control in obese patients. Reports in the literature have been mainly based on Roux-en-Y gastric bypass (RYGB) or adjustable gastric band. The aim of this study was to analyze mid- and long-term metabolic results after laparoscopic sleeve gastrectomy (LSG). Methods: Obese patients with T2DM undergoing LSG were included in this study. Selection criteria for T2DM remission were: post-operatory fasting glucose (FG) level <100 mg/dL, and hemoglobin A1c (HbA1c) <6% without medication. Results: Between January 2009 and July 2016, 166 T2DM obese patients underwent LSG and completed ≥1 year follow-up. There were 101 women (60.8%; mean age 49.07 ± 12.8 years). Initial body mass index (BMI) was 46.44 ± 7.68 kg/m2. Mean time since T2DM diagnosis was 5.95 years (1-28). Preoperative HbA1c was 7.53% ± 0.97%. Before LSG, 75.3% (n = 125) were receiving oral hypoglycemic agents, and 13.25% (n = 22) insulin. Mean follow-up was 65 ± 10 months. Complete T2DM remission was achieved in 78.3%, 76.2%, and 71.4% at 1, 3, and ≥5 years respectively; in the long term, 7.2% attained partial remission, 10% improved, and 11.4% experienced recurrence of the disease. Remission rate was significantly lower in patients under insulin therapy preoperatively, and in patients with T2DM diagnosed ≥5 years before consultation (P = .0004 and .0001, respectively). Conclusions: At mid- and long-term follow-up, T2DM control was satisfactory after LSG. Preoperative insulin therapy and T2DM duration ≥5 years were predictors of less favorable outcomes.

Gastroesophageal reflux disease and morbid obesity: evaluation and treatment.

Gastroesophageal reflux disease (GERD) is markedly increased among the obese population being recognized as one of the many obesity-related comorbidities. This concept should raise awareness, making physicians investigate more profoundly about this disease in this kind of patients. Currently, bariatric surgery is considered the gold standard treatment for morbid obesity. However, not all the operations are appropriate for the treatment of GERD and not all the patients are willing to receive bariatric surgery for the treatment of GERD. Even though sleeve gastrectomy has emerged as a suitable treatment option for morbid obesity, it has been related to development of de novo GERD or worsening the pre-existing one. Conversely, results after Roux-en-Y gastric bypass have been encouraging in this aspect, and it seems to be the best option for patients who suffer both diseases. Therefore, the presence of GERD should not be ignored at the time of deciding which type of surgery will be offered to the patient.

Metabolic Effects of Bariatric Surgery.

The number of obese people in the world has risen significantly over the past three decades. Obesity is associated with severe health comorbidities and metabolic disorders such as diabetes, hypertension, dyslipidemia, and nonalcoholic fatty liver disease. Even with aggressive pharmacotherapy, obese patients will have substantial poor health outcomes. Bariatric surgery has been used more often during the last 10 years as it has been shown to be safe and effective in decreasing weight. The term "metabolic surgery" has recently emerged from the recognition that the effects of surgery on comorbidities extended beyond weight loss. Most patients suffering from metabolic disorders will obtain significant improvements after surgery.

Sleeve Gastrectomy after Renal Transplantation.

BACKGROUND: Obesity induces or accelerates diabetes (DBT), hypertension (HT), and dyslipidemia (DSL), which are the main causes of renal failure. Obesity exacerbates in patients after renal transplantation (RT), and it has been associated with increased mortality rate, postoperative complications, and graft loss. We hypothesize that bariatric surgery might have a positive effect on obese patients with history of previous RT. METHODS: This was a retrospective review from prospectively collected data. Patients with sleeve gastrectomy (SG) with history of RT were studied. Demographics, anthropometric data, effect on comorbidities, postoperative course, immunosuppressive treatment, reason for transplantation, kidney function, graft survival, and quality of life associated with SG in obese patients with previous RT were assessed using a survey. RESULTS: From January 1, 2012 to January 1, 2016, five kidney transplant patients were operated on; 80% were female, with an average preoperative BMI of 42.18 ± 8.5 kg/m2 (range 37-54). Related comorbidities: 100% of the patients had HT and DSL, whereas 40% had DBT and gout. The average time gap between RT and SG was 15 ± 8.4 years (range 3-22). Average operative time was 65 ± 12 min (range 60-85), and there were neither complications nor mortality. At 16.8 ± 14.5 months (range 5-46) of follow-up, BMI was 29.8 ± 7.3 kg/m2 (range 26-44). All patients with HT and DSL were able to decrease their medication, showing improvement in blood pressure levels and laboratory test values. Regarding DBT, insulin was discontinued in one case, limiting the treatment to the use of oral hypoglycemic agents only. In another case, insulin dosage was significantly reduced. Graft function and proteinuria level improved in 80% of patients. All patients experienced a significant improvement in their quality of life. CONCLUSION: In this specific group of high-risk patients, SG showed encouraging results in terms of weight loss and resolution/improvement of comorbidities, renal function, and quality of life.

Laparoscopic Sleeve Gastrectomy: Endoscopic Findings and Gastroesophageal Reflux Symptoms at 18-Month Follow-Up.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) has shown excellent results in terms of weight loss and resolution of comorbidities. Despite that, the effect of LSG on gastroesophageal reflux disease (GERD) is still a controversial topic. Our objective was to evaluate the presence of gastroesophageal reflux symptoms, erosive esophagitis (EE), and hiatal hernia (HH) in obese patients undergoing LSG. METHODS: Prospective observational study. LSG patients were studied before and at 18-month follow-up. Demographics, anthropometrics, status of comorbidities, perioperative data, GERD symptoms, and esophagogastroduodenoscopy (EGD) findings were evaluated. RESULTS: Between June 2012 and July 2014, 285 patients underwent LSG. Pre- and postoperative data were available in 109 patients; therefore, they were included in the study. There were 72 women (66%), age 40 ± 9 years. Preoperative body mass index (BMI) was 47.8 ± 16 kg/m2. At 18-month follow-up, body mass index and percentage excess weight loss were 29.3 ± 6 kg/m2 and 64% ± 9.4%, respectively. Resolution/improvement of comorbidities was as follows: diabetes 73%, hypertension 57.5%, and obstructive sleep apnea 89%. GERD symptoms increased from 33% to 44% (P = no statistical significance), EE from 20.1% (100% grade A) to 33.9% (74% grade A) (P < .001), and HH from 22% to 34.8% (P < .001). Postoperative findings on symptomatic patients were as follows: EE was found in 64.5%, HH in 23%, while 12.5% had normal EGD. There was a significant association between manifestation of GERD symptoms and the presence of EE on EGD (P < .05). Symptoms de novo were observed in 36.9% of patients, EE in 28.7%, and HH in 16.4%. Complication rate was 3.5%; there was no mortality. CONCLUSION: The prevalence of GERD symptoms, EE, and HH was increased after LSG. At 18-month follow-up, severity of esophagitis was mild, the majority of them being Grade A esophagitis. There was good correlation between manifestation of GERD symptoms and the presence of EE on EGD.

Incidental Finding of Gastrointestinal Stromal Tumors during Laparoscopic Sleeve Gastrectomy in Obese Patients.

INTRODUCTION: The frequency of incidental pathology found during laparoscopic bariatric surgery has been estimated to be 2%. Gastrointestinal stromal tumors (GISTs) are infrequent lesions and account for less than 1% of all digestive tract tumors. The reported incidence of this type of tumors during bariatric surgery is around 0.8%. The objective of this study was to evaluate incidence, characteristics, and evolution of incidentally found GISTs in patients undergoing laparoscopic sleeve gastrectomy (LSG) for the treatment of obesity. MATERIAL AND METHODS: A retrospective analysis from a prospectively collected database was conducted. Demographic data, clinical data, laboratory tests, preoperative esophagogastroduodenoscopy (EGD), postoperative pathology report from surgical specimen with tumor markers, and patient's outcomes were evaluated. RESULTS: From June 2006 to January 2014, 915 patients underwent LSG at our institution. Five (0.5%) patients were found to have incidental GIST. There were four (80%) women; average age was 59.6 ± 6.3 years (range 46-63). None of them had symptoms that served as orientation for preoperative diagnosis. EGD findings were non-suggestive of this pathology in any of these cases. Superficial chronic gastritis was the most common finding in the endoscopic biopsy (60%). All the tumors found in the surgical specimen were of low or very low risk of malignancy, with less than 5 mitoses per 50 fields, less than 2 cm in diameter, and disease-free surgical margins. Cluster of differentiation (CD) 117 and CD 34 were positive in 100% of the cases. None of the patients required adjuvant therapy after the surgery. At 5-year follow-up, all patients were asymptomatic and disease free. CONCLUSION: The incidence of unsuspected GIST in LSG specimens in our series was low and similar to what has been reported. The lack of symptoms and the preoperative EGD findings were not suggestive of this diagnosis in any case. The degree of tumor malignancy was low in all patients and LSG was the definitive treatment, without recurrence at 5-year follow-up.

Barrett's esophagus after Roux-en-Y gastric bypass: does regression occur?

INTRODUCTION: Barrett's esophagus (BE) is recognized as a premalignant lesion for esophageal adenocarcinoma. BE appears as a consequence of gastroesophageal reflux disease (GERD), which is increased among obese population. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the best treatment option for obesity combined with GERD. However, data on evolution of BE after LRYGB are scarce. METHODS AND PROCEDURES: Patients were studied with esophagogastroduodenoscopy (EGD) and gastric biopsy preoperatively. If BE was suspected, esophageal biopsy was performed. If BE was confirmed, LRYGB was indicated with yearly surveillance EGD with biopsies. LRYGB patients who had BE with at least 1-year follow-up were included. RESULTS: Between 10/07 and 1/16, 2144 patients underwent laparoscopic bariatric surgery at our institution. There were 1681 (78 %) LRYGB, 399 (19 %) laparoscopic sleeve gastrectomies, and 64 (3 %) revisions. Nineteen patients (0.9 %) had BE preoperatively, and they all underwent LRYGB; 11 of them (58 %) were eligible for this study. There were 6 women and 5 men, mean age 49 ± 11 years, initial BMI 44 ± 6 kg/m2. Mean follow-up was 41 ± 31 months; there were 9 short-segment BE (SSBE) and 2 long-segment BE (LSBE). On pre- and post-op EGD, BE length was 2.1 ± 1.6 and 1.2 ± 1.2 cm, respectively (p = NS). Post-op EGD was compatible with BE in all cases, although esophageal biopsy showed remission in 4 (36 %) cases: three short-segment BE (SSBE) and one long-segment BE (LSBE). One patient was indefinite for dysplasia and remained the same after the operation. CONCLUSION: Our preliminary data showed that LRYGB is a suitable treatment option for obese patients with BE, demonstrated by 36 % regression rate of this premalignant disease. Although BE persisted in the remaining patients, no progression to dysplasia was observed. A larger number of patients and longer follow-up are needed for more definitive conclusions.

Laparoscopic Repair of Giant Bochdalek Hernia in Adults.

INTRODUCTION: Bochdalek hernia is a congenital diaphragmatic defect that results from improper fusion of the septum transversum and the pleuroperitoneal folds. It rarely persists asymptomatic until adulthood. The reported incidence is as low as 0.17%. Surgical repair of the defect can be performed through the abdomen or through the chest, and in both cases open or through laparoscopy/thoracoscopy. CASE REPORT: We present 2 cases of fully laparoscopic repair of giant Bochdalek hernia in adults. In both cases we used a GORE® DUALMESH® and we had neither complications nor recurrence. It is worthy of mention that hernia sac was not found in any of the cases. This has been described as a distinct characteristic that confirms diagnosis. CONCLUSION: Bochdalek hernia in the adult is a rare entity that requires surgical treatment to avoid complications. CT scan of the abdomen and chest with oral and IV contrast is the gold standard for diagnosis.

Sweet Eating Habit: Does This Affect the Results After Sleeve Gastrectomy?

BACKGROUND: It is commonly believed that eating habits, specially the sweet eating habit, can predict results after bariatric surgery; for this reason, it is considered one of the selection criteria when deciding the surgical technique. However, there is not enough evidence of its impact on the results after sleeve gastrectomy (SG). OBJECTIVE: To evaluate the relationship between the sweet eating habit and weight loss after SG. DESIGN: Cross-sectional retrospective study. MATERIAL AND METHODS: Group A: nonobese subjects, and group B: patients who underwent SG and had ≥6 months follow-up. Demographics, anthropometrics, percentage excess weight loss (%EWL) at 6, 12, and 24 months, and eating habits before surgery were analyzed. Sweet eating consumption was classified as follows: mild, moderate, and severe. Uni- and bivariate logistic regression analysis according to each variable was performed. RESULTS: Between 2006 and 2011, 157 patients underwent SG at our institution; 36% were male, age 41 years old, and initial body mass index 46 kg/m(2). Mean %EWL at 6, 12, and 24 months was 66%, 77%, and 70%, respectively. Sweet eating consumption: Mild: 59%; Moderate: 38%; and Severe: 3%. No difference was found in sweet eating patterns among groups A and B; %EWL for mild, moderate, and severe sweet eaters at 6 months was 66 ± 16, 66 ± 14, and 65 ± 10, respectively (P = non-significant [NS]). The same analysis was made at 12 months: 76 ± 20, 79 ± 18, and 78 ± 11 (P = NS). At 24 months, only mild and moderate sweet eaters were available for comparison: 69 ± 23 and 73 ± 19, respectively (P = NS). CONCLUSION: Preliminary data suggested that preoperative sweet eating habit would not predict results after SG in terms of weight loss.

Relationship Between Tobacco Use and Weight Loss After Bariatric Surgery.

BACKGROUND: Smoking cessation had been typically associated with weight gain. So far, there are no reports documenting the relationship between weight loss after bariatric surgery and smoking habit. The objective of the study was to establish the relationship between weight loss and smoking habit in patients undergoing bariatric surgery and to analyze weight loss on severe smokers and on those patients who stopped smoking during the postoperative period. METHODS: All patients undergoing laparoscopic sleeve gastrectomy (LSG) with at least 2-year follow-up were included. Patients were divided into three groups: (A) smokers, (B) ex-smokers, and (C) non-smokers. Demographics and weight loss at 6, 12, and 24 months were analyzed. Smokers were subdivided for further analysis into the following: group A1: heavy smokers, group A2: non-heavy smokers, group A3: active smokers after surgery, and group A4: quitters after surgery. Chi-square test was used for statistics. RESULTS: One hundred eighty-four patients were included; group A: 62 patients, group B: 57 patients, and group C: 65 patients. Mean BMI was 34 ± 6, 31 ± 6, and 31 ± 6 kg/m2; mean %EWL was 63 ± 18, 76 ± 21, and 74 ± 22 % at 6, 12, and 24 months, respectively. The subgroup analysis showed the following composition: group A1: 19 patients, group A2: 43 patients, group A3: 42 patients, and group A4: 20 patients. Weight loss difference among groups and subgroups was statistically non-significant. CONCLUSIONS: Our study shows that weight loss evolution was independent from smoking habit. Neither smoking cessation during the postoperative period nor smoking severity could be related to weight loss after LSG.

Lecciones aprendidas luego de 175 nefroctomías robóticas mano-asistidas en donantes para trasplante renal / Robotic assisted laparoscopic nephrectomy: our experience

Antecedentes: Desde el advenimiento de la cirugía mínimamente invasiva, el número de trasplantes renales vivo-relacionados se ha incrementado considerablemente. La tecnología robótica ha emergido como una alternativa promisoria a las técnicas laparoscópicas. En este estudio presentamos nuestra experiencia en nefrectomías laparoscópicas asistidas por robot. Diseño: Estudio retrospectivo de datos recolectados prospectivamente. Método: Entre agosto de 2000 y diciembre del 2004 se realizaron 175 nefrectomías robóticas utilizando técnicas mano-asistida. Información relacionada con las complicaciones, estadía hospitalaria, pérdida sanguínea, tiempo de isquemia, tiempo operatorio y resultados fue recolectada prospectivamente. Resultados: La cohorte de los donantes se compuso de 88 varones y 87 mujeres. Edad media: 36 años (18-59 años). Complicaciones postoperatorias: neumonía (n=2), pancreatitis (n=1) e infección superficial de la herida (n=6). Cuatro pacientes se convirtieron a cirugía abierte. Promedio de estadía hospitalaria: 2 días (1 a 8 días). Pérdida sanguínea estimada: 68 centímetros cúbicos (10 a 1500 centímetros cúbicos). Tiempo medio de isquemia caliente: 98 segundos (50-200 seg). Tiempo operatorio promedio: 192 minutos (100-320 min) en los primeros 87 casos y 114 minutos (60-210 min) en los últimos 88 casos (p < 0,0001), con un promedio de 150 minutos. Los resultados fueron similares en los casos con anatomía vascular normal versus anatomía vascular anormal. Supervivencia de los pacientes y del implante a 1 año: 100 por ciento y 98 por ciento respectivamente. La creatinina promedio del receptor a 6 meses fue de 1,4 mg/dl. Conclusión: Con el apropiado entrenamiento y experiencia del equipo quirúrgico, la nefrectomía robótica mano-asistida (NRMA) puede ser realizada en una forma segura, rápida y precisa, con excelentes resultados para el donante y el receptor (AU)

Lecciones aprendidas luego de 175 nefroctomías robóticas mano-asistidas en donantes para trasplante renal / Robotic assisted laparoscopic nephrectomy: our experience

Antecedentes: Desde el advenimiento de la cirugía mínimamente invasiva, el número de trasplantes renales vivo-relacionados se ha incrementado considerablemente. La tecnología robótica ha emergido como una alternativa promisoria a las técnicas laparoscópicas. En este estudio presentamos nuestra experiencia en nefrectomías laparoscópicas asistidas por robot. Diseño: Estudio retrospectivo de datos recolectados prospectivamente. Método: Entre agosto de 2000 y diciembre del 2004 se realizaron 175 nefrectomías robóticas utilizando técnicas mano-asistida. Información relacionada con las complicaciones, estadía hospitalaria, pérdida sanguínea, tiempo de isquemia, tiempo operatorio y resultados fue recolectada prospectivamente. Resultados: La cohorte de los donantes se compuso de 88 varones y 87 mujeres. Edad media: 36 años (18-59 años). Complicaciones postoperatorias: neumonía (n=2), pancreatitis (n=1) e infección superficial de la herida (n=6). Cuatro pacientes se convirtieron a cirugía abierte. Promedio de estadía hospitalaria: 2 días (1 a 8 días). Pérdida sanguínea estimada: 68 centímetros cúbicos (10 a 1500 centímetros cúbicos). Tiempo medio de isquemia caliente: 98 segundos (50-200 seg). Tiempo operatorio promedio: 192 minutos (100-320 min) en los primeros 87 casos y 114 minutos (60-210 min) en los últimos 88 casos (p < 0,0001), con un promedio de 150 minutos. Los resultados fueron similares en los casos con anatomía vascular normal versus anatomía vascular anormal. Supervivencia de los pacientes y del implante a 1 año: 100 por ciento y 98 por ciento respectivamente. La creatinina promedio del receptor a 6 meses fue de 1,4 mg/dl. Conclusión: Con el apropiado entrenamiento y experiencia del equipo quirúrgico, la nefrectomía robótica mano-asistida (NRMA) puede ser realizada en una forma segura, rápida y precisa, con excelentes resultados para el donante y el receptor