Roux-en-Y Gastric Bypass as a Treatment for Barrett's Esophagus after Sleeve Gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) is the most frequently performed bariatric procedure today. While an increasing number of long-term studies report the occurrence of Barrett's esophagus (BE) after SG, its treatment has not been studied, yet. OBJECTIVES: The aim of this study was to evaluate Roux-en-Y gastric bypass (RYGB) as treatment for BE and reflux after SG. SETTING: University hospital setting, Austria METHODS: This multi-center study includes all patients (n = 10) that were converted to RYGB due to BE after SG in Austria. The mean interval between SG and RYGB was 42.7 months. The follow-up after RYGB in this study was 33.4 months. Gastroscopy, 24 h pH-metry, and manometry were performed and patients were asked to complete the BAROS and GIQLI questionnaires. RESULTS: Weight and BMI at the time of SG was 120.8 kg and 45.1 kg/m2. Eight patients (80.0%) went into remission of BE after the conversion to RYGB. Two patients had RYGB combined with hiatoplasty. The mean acid exposure time in 24 h decreased from 36.8 to 3.8% and the mean DeMeester score from 110.0 to 16.3. Patients scored 5.1 on average in the BAROS after conversion from SG to RYGB which denotes a very good outcome. CONCLUSIONS: RYGB is an effective therapy for patients with BE and reflux after SG. Its outcomes in the current study were BE remission in the majority of cases as well as a decrease in reflux activity. Further studies with larger cohorts are necessary to confirm these findings.

Blunting of adaptive thermogenesis as a potential additional mechanism to promote weight loss after gastric bypass.

BACKGROUND: Adaptive thermogenesis (AT) is described as a change in resting metabolic rate (RMR) that is greater than would be predicted from changes in lean body mass (LBM) and fat mass (FM) alone during periods of energy imbalance. Whereas an AT-related downregulation of RMR has been implicated in suboptimal weight loss and weight regain after nonsurgical weight loss, defense against AT may underpin the durable weight loss after laparoscopic Roux-en-Y gastric bypass (LRYGB) and other bariatric surgeries. However, methodological differences across the few studies that have evaluated postoperative AT limit interpretation as to the effects of these procedures on RMR. OBJECTIVE: To quantify AT 6 months after LRYGB and laparoscopic adjustable gastric banding (LAGB). SETTING: The study was conducted in a large university hospital in the United States. METHODS: Changes in body composition and RMR were assessed in 13 severely obese adults 6 months after LRYGB (n = 8) and LAGB (n = 5). AT was calculated as the difference between measured RMR and RMR predicted from LBM, FM, age, and sex before and after surgery. RESULTS: RMR significantly decreased after LRYGB (-270±96 kcal/d, P<.01) but not after LAGB. Despite significantly greater reductions in weight, FM, and LBM with LRYGB than LAGB, AT responses after LRYGB (15±110 kcal/d, P = .7) and LAGB (42±97 kcal/d, P = .4) were similar (P = .7). CONCLUSION: Despite significant weight and body composition changes, AT was minimal after LRYGB. A blunting of AT may be an additional mechanism that favors sustainable weight loss with LRYGB.

Spotlight on esophageal perforation: A multinational study using the Pittsburgh esophageal perforation severity scoring system.

OBJECTIVE: The Pittsburgh group has suggested a perforation severity score (PSS) for better decision making in the management of esophageal perforation. Our study aim was to determine whether the PSS can be used to stratify patients with esophageal perforation into distinct subgroups with differential outcomes in an independent study population. METHODS: In a retrospective study cases of esophageal perforation were collected (study-period, 1990-2014). The PSS was analyzed using logistic regression as a continuous variable and stratified into low, intermediate, and high score groups. RESULTS: Data for 288 patients (mean age, 59.9 years) presenting with esophageal perforation (during the period 1990-2014) were abstracted. Etiology was spontaneous (Boerhaave; n = 119), iatrogenic (instrumentation; n = 85), and traumatic perforation (n = 84). Forty-three patients had coexisting esophageal cancer. The mean PSS was 5.82, and was significantly higher in patients with fatal outcome (n = 57; 19.8%; mean PSS, 9.79 vs 4.84; P < .001). Mean PSS was also significantly higher in patients receiving operative management (n = 200; 69%; mean PSS, 6.44 vs 4.40; P < .001). Using the Pittsburgh strata, patients were assigned to low PSS (≤2; n = 63), intermediate PSS (3-5; n = 86), and high PSS (>5; n = 120) groups. Perforation-related morbidity, length of stay, frequency of operative treatment, and mortality increased with increasing PSS strata. Patients with high PSS were 3.37 times more likely to have operative management compared with low PSS. CONCLUSIONS: The Pittsburgh PSS reliably reflects the seriousness of esophageal perforation and stratifies patients into low-, intermediate-, and high-risk groups with differential morbidity and mortality outcomes.

Thermogenic changes after gastric bypass, adjustable gastric banding or diet alone.

BACKGROUND: The mechanisms by which bariatric surgery achieves weight loss (WL) are under scrutiny. We assessed changes in resting energy expenditure (REE) after gastric bypass (RYGB) and gastric banding (AGB) to determine if changes in REE are associated with WL and type of surgery. METHODS: Three groups of morbidly obese patients were studied: RYGB (n = 12), AGB (n = 8), and a control group that underwent caloric restriction alone (Diet, n = 10). Studies were performed at baseline and after 14 days in all groups and 6 months after RYGB and AGB. REE (kcal/day) was measured by indirect calorimetry and adjusted for body weight (Wt-REE), and lean body mass by dual-energy X-ray absorptiometry (LBM-REE). RESULTS: At baseline, REE did not differ significantly among groups (RYGB = 2,114 ± 337, AGB = 1,837 ± 154, Diet = 2,091 ± 363 kcal/day, P = .13). After 14 days, the groups had similar percent excess WL (%EWL). Neither Wt-REE nor LBM-REE changed significantly in any group. After 6 months %EWL was 49 ± 10% after RYGB and 21 ± 11% after AGB (P < .01); RYGB patients had greater increase in the percent of weight that was LBM (RYGB = 7.9 ± 3.0 vs. AGB = 1.6 ± 1.5%, P < .01). Wt-REE increased significantly only after RYGB (+2.58 ± 1.51 kcal/kg/day, P < .01). There was a significant correlation between changes in Wt-REE and %EWL (r = 0.670, P = .003). CONCLUSION: The increase in Wt-REE may be a factor supporting WL after RYGB.

Changes in post-prandial glucose and pancreatic hormones, and steady-state insulin and free fatty acids after gastric bypass surgery.

BACKGROUND: Changes in the multiple mechanisms that regulate glucose metabolism after gastric bypass (RYGB) are still being unveiled. The objective of this study was to compare the changes of glucose and pancreatic hormones [C-peptide, glucagon, and pancreatic polypeptide (PP)] during a meal tolerance test (MTT) and steady-state insulin and free fatty acid (FFA) concentrations during euglycemic-hyperinsulinemic clamp 14 days and 6 months after RYGB in morbidly obese nondiabetic patients. METHODS: Two groups were studied at baseline and at 14 days: the RYGB followed by caloric restriction group (RYGB, n = 12) and the equivalent caloric restriction alone group (Diet, n = 10), to control for energy intake and weight loss. The RYGB group was studied again at 6 months to assess the changes after substantial weight loss. During MTT, the early and overall changes in glucose and pancreatic hormone concentrations were determined, and during the clamp, steady-state insulin and FFA concentrations were assessed. RESULTS: After 14 days, RYGB patients had enhanced postprandial glucose, C-peptide, and glucagon responses, and decreased postprandial PP concentrations. Steady-state insulin concentrations were decreased at 14 days only in RYGB patients, and FFA increased in both groups. Six months after RYGB and substantial weight loss, the decrease in insulin concentrations during clamp persisted, and there were further changes in postprandial glucose and glucagon responses. FFA concentrations during clamp were significantly lower at 6 months, relative to presurgical values. CONCLUSIONS: In morbidly obese nondiabetic patients, RYGB produces early changes in postmeal glucose, C-peptide, glucagon, and PP responses, and it appears to enhance insulin clearance early after RYGB and improve insulin sensitivity in adipose tissue at 6 months postsurgery. The early changes cannot be explained by caloric restriction alone.

Endoscopic grading of the gastroesophageal flap valve is correlated with reflux activity and can predict the size of the esophageal hiatus in patients with gastroesophageal reflux disease.

BACKGROUND: Endoscopic grading of the gastroesophageal flap valve (GEFV) is simple, reproducible, and suggested to be a good predictor of reflux activity. This study aimed to investigate the potential correlation between grading of the GEFV and quality of life (QoL), gastroesophageal reflux disease (GERD) symptoms, esophageal manometry, multichannel intraluminal impedance monitoring (MII) data, and size of the hiatal defect. METHODS: The study included 43 patients with documented chronic GERD who underwent upper gastrointestinal endoscopy, esophageal manometry, and ambulatory MII monitoring before laparoscopic fundoplication. The GEFV was graded 1-4 using Hill's classification. QoL was evaluated using the Gastrointestinal Quality-of-Life Index (GIQLI), and gastrointestinal symptoms were documented using a standardized questionnaire. The size of the esophageal hiatus was measured during surgery by calculating the hiatal surface area (HSA). Analysis of the correlation between QoL, GERD symptoms, esophageal manometry, MII data, HSA size, and GEFV grading was performed. Statistical significance was set at a p value of 0.05. RESULTS: A significant positive correlation was found between increased GEFV grade and DeMeester score, total number of acid reflux events, number of reflux events in the supine position, and number of reflux events in the upright position. Additionally, a significant positive correlation was found between HSA size and GEFV grading. No significant influence from intensity of GERD symptoms, QoL, and the GEFV grading was found. The mean LES pressures were reduced with increased GEFV grade, but not significantly. CONCLUSIONS: The GEFV plays a major role in the pathophysiology of GERD. The results underscore the importance of reconstructing a valve in patients with GERD and an altered geometry of the gastroesophageal junction when they receive a laparoscopic or endoscopic intervention.

The impact of bariatric surgery on nonalcoholic steatohepatitis.

Nonalcoholic steatohepatitis (NASH) is a stage of nonalcoholic fatty liver disease (NAFLD), and in most patients, is associated with obesity and the metabolic syndrome. The current best treatment of NAFLD and NASH is weight reduction with the current options being life style modifications, with or without pharmaceuticals, and bariatric surgery. Bariatric surgery is an effective treatment option for individuals who are severely obese (body mass index ≥ 35 kg/m(2)), and provides for long-term weight loss and resolution of obesity-associated diseases in most patients. Regression and/or histologic improvement of NASH have been documented after bariatric surgery. We review the available literature reporting on the impact of the various bariatric surgery techniques on NASH.

Better weight loss, resolution of diabetes, and quality of life for laparoscopic gastric bypass vs banding: results of a 2-cohort pair-matched study.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic gastric banding (LB) are the 2 most common operations used to treat morbid obesity, but few controlled comparative studies have reported perioperative and long-term outcomes. DESIGN: Two-cohort pair-matched study. SETTING: Academic tertiary referral center. PATIENTS: One hundred consecutive morbidly obese patients treated with LB were pair-matched by sex, race, age, initial body mass index, and presence of type 2 diabetes mellitus with 100 patients who were treated with RYGB. MAIN OUTCOME MEASURES: Perioperative and postoperative complications, reoperations, and 1-year outcomes, including weight loss, type 2 diabetes resolution, and quality of life. RESULTS: The RYGB and LB groups had similar characteristics. One-year outcomes were available for 93 patients in the LB group and 92 in the RYGB group. The overall rate of complications was similar in both groups (11 patients in the LB group [12%] vs 14 in the RYGB group [15%]; P = .83), with a higher rate of early complications (≤ 30 days) after RYGB (11 patients [11%] vs 2 [2%] for LB; P = .01) and a higher rate of reoperations after LB (12 patients [13%] vs 2 for RYGB [2%]; P = .009). No deaths occurred. Excess weight loss (36% vs 64%; P < .01), resolution of diabetes (17 patients [50%] vs 26 [76%]; P = .04), and quality-of-life measures were better in the RYGB group. CONCLUSIONS: When performed in high-volume centers by expert surgeons, RYGB has a similar rate of overall complications and lower rate of reoperations than LB. With the benefit of greater weight loss, increased resolution of diabetes, and improved quality of life, RYGB, in these circumstances, has a better risk-benefit profile than LB.

Early and late abdominal bleeding after Roux-en-Y gastric bypass: sources and tailored therapeutic strategies.

Bleeding is a potentially serious complication after Roux-en-Y gastric bypass (RYGB). Preventive measures and therapeutic strategies have not been adequately defined. We reviewed data on 742 consecutive patients treated at the University of California San Francisco to identify cases of early and late bleeding (less or greater than 30 days after surgery) after RYGB. Bleeding was defined as symptoms or signs of bleeding, associated with blood transfusion. We recorded patient characteristics, details of the operative technique, diagnostic approach, therapeutic strategies, and outcomes. Twenty-six patients (3.5%) had postoperative bleeding, which mostly occurred in the first 30 days postoperatively (N=19). Hematocrit decreased significantly from preoperative values (-5.2 ± 3.1 without bleeding vs. -14.8 ± 4.7 with, p<0.01). Type 2 diabetes was more prevalent in patients who had bleeding (58% vs. 32%, p=0.03). No other patient characteristics or details of the operative technique were associated with different rates of bleeding. Therapeutic intervention other than transfusion was needed for seven patients with early bleeding (36.8%) and for all patients with late bleeding. Four patients with early bleeding required reoperation. Early bleeding source was intraluminal in four patients, intraperitoneal in five, and self-limited and of unknown location in ten. Late bleeding occurred on average at 62.6 months (range, 5 to 300 months) after index surgery, five patients required reoperation, and the source was always intraluminal. Bleeding after RYGB may be from various anatomic sites; details of the operative technique were not associated with different rates of bleeding, and therapy should be tailored to suspected location of bleeding.

A safe and reproducible anastomotic technique for minimally invasive Ivor Lewis oesophagectomy: the circular-stapled anastomosis with the trans-oral anvil.

OBJECTIVES: In expert hands, the intrathoracic oesophago-gastric anastamosis usually provides a low rate of strictures and leaks. However, anastomoses can be technically challenging and time consuming when minimally invasive techniques are used. We present our preliminary results of a standardised 25 mm/4.8mm circular-stapled anastomosis using a trans-orally placed anvil. MATERIALS AND METHODS: We evaluated a prospective cohort of 37 consecutive patients offered minimally invasive Ivor Lewis oesophagectomy at a tertiary referral centre. The oesophago-gastric anastomosis was created using a 25-mm anvil (Orvil, Autosuture, Norwalk, CT, USA) passed trans-orally, in a tilted position, and connected to a 90-cm long polyvinyl chloride delivery tube through an opening in the oesophageal stump. The anastomosis was completed by joining the anvil to a circular stapler (end-to-end anastomosis stapler (EEA XL) 25 mm with 4.8-mm staples, Autosuture, Norwalk, CT, USA) inserted into the gastric conduit. Primary outcomes were leak and stricture rates. RESULTS: Thirty-seven patients (mean age 65 years) with distal oesophageal adenocarcinoma (n=29), squamous cell cancer (n=5) or high-grade dysplasia in Barrett's oesophagus (n=3) underwent an Ivor Lewis oesophagectomy between October 2007 and August 2009. The abdominal portion was operated laparoscopically in 30 patients (81.1%). The thoracic portion was done using a muscle-sparing mini-thoracotomy in 23 patients (62.2%) and thoracoscopic techniques in 14 patients (37.8%). There were no intra-operative technical failures of the anastomosis or deaths. Five patients had strictures (13.5%) and all were successfully treated with endoscopic dilations. One patient had an anastomotic leak (2.7%) that was successfully treated by re-operation and endoscopic stenting of the anastomosis. DISCUSSION: The circular-stapled anastomosis with the trans-oral anvil allows for an efficient, safe and reproducible anastomosis. This straightforward technique is particularly suited to the completely minimally invasive Ivor Lewis oesophagectomy.

A controversy that has been tough to swallow: is the treatment of achalasia now digested?

Esophageal achalasia is a rare neurodegenerative disease of the esophagus and the lower esophageal sphincter that presents within a spectrum of disease severity related to progressive pathological changes, most commonly resulting in dysphagia. The pathophysiology of achalasia is still incompletely understood, but recent evidence suggests that degeneration of the postganglionic inhibitory nerves of the myenteric plexus could be due to an infectious or autoimmune mechanism, and nitric oxide is the neurotransmitter affected. Current treatment of achalasia is directed at palliation of symptoms. Therapies include pharmacological therapy, endoscopic injection of botulinum toxin, endoscopic dilation, and surgery. Until the late 1980s, endoscopic dilation was the first line of therapy. The advent of safe and effective minimally invasive surgical techniques in the early 1990s paved the way for the introduction of laparoscopic myotomy. This review will discuss the most up-to-date information regarding the pathophysiology, diagnosis, and treatment of achalasia, including a historical perspective. The laparoscopic Heller myotomy with partial fundoplication performed at an experienced center is currently the first line of therapy because it offers a low complication rate, the most durable symptom relief, and the lowest incidence of postoperative gastroesophageal reflux.

Improvement in peripheral glucose uptake after gastric bypass surgery is observed only after substantial weight loss has occurred and correlates with the magnitude of weight lost.

INTRODUCTION: Altered gut and pancreatic hormone secretion may bolster resolution of insulin resistance after Roux-en-Y gastric bypass (RYGB), but the independent effects of weight loss and hormonal secretion on peripheral glucose disposal are unknown. METHODS: Two groups of nondiabetic morbidly obese patients were studied: RYGB followed by standardized caloric restriction (RYGB, n = 12) or caloric restriction alone (diet, n = 10). Metabolic evaluations (euglycemic-hyperinsulinemic clamp, meal tolerance test) were done at baseline and 14 days (both groups) and 6 months after RYGB. RESULTS: At baseline, body composition, fasting insulin, and glucose and peripheral glucose disposal did not differ between groups. At 14 days, excess weight loss (EWL) was similar (RYGB, 12.7% vs. diet, 10.9%; p = 0.12), fasting insulin and glucose decreased to a similar extent, and RYGB subjects had altered postmeal patterns of gut and pancreatic hormone secretion. However, peripheral glucose uptake (M value) was unchanged in both groups. Six months after RYGB, EWL was 49.7%. The changes in fasting glucose and insulin levels and gut hormone secretion persisted. M values improved significantly, and changes in M values correlated with the % EWL (r = 0.68, p = 0.02). CONCLUSIONS: Improvement in peripheral glucose uptake following RYGB was observed only after substantial weight loss had occurred and correlated with the magnitude of weight lost.

Portomesenteric venous thrombosis after laparoscopic surgery: a systematic literature review.

BACKGROUND: Portomesenteric venous thrombosis (PVT) is an uncommon but potentially lethal condition reported after several laparoscopic procedures. Its presentation, treatment, and outcomes remain poorly understood, and possible etiologic factors include venous stasis from increased intra-abdominal pressure, intraoperative manipulation, or damage to the splanchnic endothelium and systemic thrombophilic states. DESIGN: Systematic literature review. SETTING: Academic research. SUBJECTS: We summarized the clinical presentation and outcomes of PVT after laparoscopic surgery other than splenectomy in 18 subjects and reviewed the treatment strategies. MAIN OUTCOME MEASURES: Systematic review of the literature on PVT after laparoscopic procedures other than splenectomy. RESULTS: Eighteen cases of PVT following laparoscopic procedures were identified after Roux-en-Y gastric bypass (n = 7), Nissen fundoplication (n = 5), partial colectomy (n = 3), cholecystectomy (n = 2), and appendectomy (n = 1). The mean patient age was 42 years (age range, 20-74 years). Systemic predispositions toward venous thrombosis were identified in 11 patients. Clinical symptoms consisted primarily of abdominal pain manifested, on average, 14 days (range, 3-42 days) after surgery. Thrombus location varied, but 8 patients had a combination of portal and superior mesenteric venous thrombosis. Sixteen patients were treated with anticoagulation therapy. Ten patients underwent major interventions, including exploratory laparotomy in 6 patients and thrombolytic therapy in 4 patients. Six patients had complications, and 2 patients died. CONCLUSIONS: Portomesenteric venous thrombosis following laparoscopic surgery usually manifests as nonspecific abdominal pain. Computed tomography can readily provide the diagnosis and demonstrate the extent of the disease. Treatment should be individualized based on the extent of thrombosis and the presence of bowel ischemia but should include anticoagulation therapy. Venous stasis from increased intra-abdominal pressure, intraoperative manipulation of splanchnic vasculature, and systemic thrombophilic states likely converges to produce this potentially lethal condition.

Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis.

BACKGROUND: Although rare, esophageal achalasia is the best described primary esophageal motility disorder. Commonly used treatments are endoscopic botulin toxin injection (EBTI), endoscopic balloon dilation (EBD), and surgical myotomy with or without a fundoplication; however, reported outcomes mostly come from cohort studies. OBJECTIVE: To summarize and compare the safety and efficacy of endoscopic and surgical treatments for esophageal achalasia. METHODS: A systematic electronic Medline literature search of articles on esophageal achalasia. Treatment options reviewed included EBTI, EBD, and surgical myotomy using open and minimally invasive techniques. Main outcome measures were frequency of symptom relief, prevalence of post-treatment gastroesophageal reflux (GER), and complications. Outcome probability was estimated using weighted averages of the sample prevalence in each study, with weights equal to the number of patients. Outcomes, within or across studies, were compared using meta-analysis and meta-regression, respectively. RESULTS: A total of 105 articles reporting on 7855 patients were selected, tabulated and reviewed. Symptom relief after EBD was better than after EBTI (68.2% vs. 40.6%; OR 3.4; 95% CI, 1.2-9.8; P = 0.02), and the need for additional therapy was greater for patients receiving EBTI (46.6% vs. 25%; OR, 2.6; 95% CI, 1.05-6.5; P = 0.04). Laparoscopic myotomy, when combined with an antireflux procedure, provided better symptom relief (90%) than all endoscopic and other surgical approaches and a low complication rate (6.3%). The incidence of postoperative GER was lower when a fundoplication was added to a laparoscopic myotomy (31.5% without a fundoplication vs. 8.8% with; OR, 6.3; 95% CI, 2.0-19.4; P = 0.003). CONCLUSIONS: EBD is superior to EBTI. Laparoscopic myotomy with fundoplication was the most effective surgical technique and can be considered the operative procedure of choice.

Factors associated with weight loss after gastric bypass.

BACKGROUND: Gastric bypass (GBP) is the most common operation performed in the United States for morbid obesity. However, weight loss is poor in 10% to 15% of patients. We sought to determine the independent factors associated with poor weight loss after GBP. DESIGN: Prospective cohort study. We examined demographic, operative, and follow-up data by means of multivariate analysis. Variables investigated were age, sex, race, marital and insurance status, initial weight and body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared), comorbidities (diabetes mellitus, hypertension, joint disease, sleep apnea, hyperlipidemia, and psychiatric disease), laparoscopic vs open surgery, gastric pouch area, gastrojejunostomy technique, and alimentary limb length. SETTING: University tertiary referral center. PATIENTS: All patients at our institution who underwent GBP from January 1, 2003, through July 30, 2006. MAIN OUTCOME MEASURES: Weight loss at 12 months defined as poor (< or =40% excess weight loss) or good (>40% excess weight loss). RESULTS: Follow-up data at 12 months were available for 310 of the 361 patients (85.9%) undergoing GBP during the study period. Mean preoperative BMI was 52 (range, 36-108). Mean BMI and excess weight loss at follow-up were 34 (range, 17-74) and 60% (range, 8%-117%), respectively. Thirty-eight patients (12.3%) had poor weight loss. Of the 4 variables associated with poor weight loss in the univariate analysis (greater initial weight, diabetes, open approach, and larger pouch size), only diabetes (odds ratio, 3.09; 95% confidence interval, 1.35-7.09 [P = .007]) and larger pouch size (odds ratio, 2.77;95% confidence interval, 1.81-4.22 [P <.001]) remained after the multivariate analysis. CONCLUSIONS: Gastric bypass results in substantial weight loss in most patients. Diabetes and larger pouch size are independently associated with poor weight loss after GBP.

Initial laparoscopic access using an optical trocar without pneumoperitoneum is safe and effective in the morbidly obese.

Obtaining access to the peritoneal cavity in laparoscopic surgery is more difficult in morbidly obese people. The aim of this study was to examine the safety and efficacy of accessing the peritoneal cavity using an optical, bladeless trocar without previous pneumoperitoneum in morbidly obese patients. The patients' characteristics and outcomes with consecutive and preferential use of an optical, bladeless, first trocar insertion without previous pneumoperitoneum in morbidly obese patients (body mass index > 35 kg/m2) was reviewed. A total of 208 morbidly obese patients were included. The trocar insertion technique was used in 196 patients. No bowel or major abdominal vessel injuries occurred. Ninety-eight patients (50%) had previous abdominal operations. Trocar-related injuries occurred in 3 patients: a superficial mesenteric laceration in 2 and a laceration of a greater omentum vessel in 1. The direct first trocar insertion technique provides safe entry into the peritoneal cavity in morbidly obese patients.

A clinical scoring system for predicting nonalcoholic steatohepatitis in morbidly obese patients.

UNLABELLED: Nonalcoholic steatohepatitis (NASH) is common in morbidly obese persons. Liver biopsy is diagnostic but technically challenging in such individuals. This study was undertaken to develop a clinically useful scoring system to predict the probability of NASH in morbidly obese persons, thus assisting in the decision to perform liver biopsy. Consecutive subjects undergoing bariatric surgery without evidence of other liver disease underwent intraoperative liver biopsy. The outcome was pathologic diagnosis of NASH. Predictors evaluated were demographic, clinical, and laboratory variables. A clinical scoring system was constructed by rounding the estimated regression coefficients for the independent predictors in a multivariate logistic model for the diagnosis of NASH. Of 200 subjects studied, 64 (32%) had NASH. Median body mass index was 48 kg/m(2) (interquartile range, 43-55). Multivariate analysis identified six predictive factors for NASH: the diagnosis of hypertension (odds ratio [OR], 2.4; 95% confidence interval [CI], 1-5.6), type 2 diabetes (OR, 2.6; 95% CI, 1.1-6.3), sleep apnea (OR, 4.0; 95% CI, 1.3-12.2), AST > 27 IU/L (OR, 2.9; 95% CI, 1.2-7.0), alanine aminotransferase (ALT) > 27 IU/L (OR, 3.3; 95% CI, 1.4-8.0), and non-Black race (OR, 8.4; 95% CI, 1.9-37.1). A NASH Clinical Scoring System for Morbid Obesity was derived to predict the probability of NASH in four categories (low, intermediate, high, and very high). CONCLUSION: The proposed clinical scoring can predict NASH in morbidly obese persons with sufficient accuracy to be considered for clinical use, identifying a very high-risk group in whom liver biopsy would be very likely to detect NASH, as well as a low-risk group in whom biopsy can be safely delayed or avoided.

Laparoscopic bariatric surgery improves candidacy in morbidly obese patients awaiting transplantation.

BACKGROUND: To evaluate, at a university tertiary referral center, the safety and efficacy of laparoscopic Roux-en-Y gastric bypass (LRYGB) in patients with end-stage renal disease (ESRD) and laparoscopic sleeve gastrectomy (LSG) in patients with cirrhosis or end-stage lung disease (ESLD); and to determine whether these procedures help patients become better candidates for transplantation. METHODS: A retrospective review was performed of selected patients with end-stage organ failure who were not eligible for transplantation because of morbid obesity who underwent LRYGB or LSG. The prospectively collected data included demographics, operative details, complications, percentage of excess weight loss, postoperative laboratory data, and status of transplant candidacy. RESULTS: Of the 15 patients, 7 with ESRD underwent LRYGB and 6 with cirrhosis and 2 with ESLD underwent LSG. Complications developed in 2 patients (both with cirrhosis); no patient died. The mean follow-up was 12.4 months, and the mean percentage of excess weight loss at > or =9 months was 61% (ESRD), 33% (cirrhosis), and 61.5% (ESLD). Obesity-associated co-morbidities improved or resolved in all patients. Serum albumin and other nutritional parameters at > or =9 months after surgery were similar to the preoperative levels in all 3 groups. At the most recent follow-up visit, 14 (93%) of 15 patients had reached our institution's body mass index limit for transplantation and were awaiting transplantation; 1 patient with ESLD underwent successful lung transplant. CONCLUSION: The results of this pilot study have provided preliminary evidence that LRYGB in patients with ESRD and LSG in patients with cirrhosis or ESLD is safe, well-tolerated, and improves their candidacy for transplantation.

The impact of roux limb length on weight loss after gastric bypass.

BACKGROUND: Extending the length of the Roux limb (RL) in gastric bypass (GBP) may improve weight loss in super obese patients (body mass index [BMI] > 50 kg/m(2)), but no consensus exists about the optimal length of the RL. We sought to determine the impact of RL length on weight loss in super obese patients 1 year after GBP. MATERIALS AND METHODS: One-year weight loss outcomes were analyzed in all super obese patients who underwent consecutive and primary laparoscopic or open GBP between January 2003 and June 2006. Patients were divided into two groups according to RL length (100 vs. 150 cm). The RL length was at the discretion of the attending surgeon. Baseline and follow-up data were collected prospectively. Multiple linear regression was used to adjust for potential confounders in the weight loss outcomes. RESULTS: Twelve-month follow-up data were available in 137 (85%) of 161 patients with a BMI >or= 50 who underwent GBP during the study period. An RL of 100 or 150 cm was used in 102 (74.5%) and 35 patients (25.5%), respectively. In multivariate analysis, patients with the 150-cm RL lost more weight (68.5 vs. 55.3 kg, p < 0.01), had a greater change in BMI (25 vs. 21 kg/m(2), p = 0.01), and had greater excess weight loss (64 vs. 53%, p < 0.01). CONCLUSION: A 150-cm RL provides better weight loss outcomes in super obese patients at 1-year follow-up.