Bariatric Surgery as a Bridge to Facilitate Renal Transplantation in Patients with End-Stage Renal Disease.

PURPOSE: Renal transplantation (RT) is not recommended above BMI 40 kg/m2 as post-operative risks (delayed graft function, wound complications) are increased. Bariatric surgery (BS) results in sustained long-term weight loss. However, renal failure (RF) patients are theoretically higher risk candidates. We aim to investigate the safety of BS in patients with RF and the effect of BS on access to renal transplantation. METHODS: We reviewed data from 31 patients with RF referred for BS between 2013 and 2021. We compared the outcomes of patients with RF who underwent BS to those who were referred but did not undergo BS. Controls matched for age/BMI/comorbidity (MC) but without RF were used for comparison. RESULTS: Of 31 patients referred, 19 proceeded with BS (68% female, median age 52 years, BMI 46.2 ± 4.9 kg/m2) and 12 did not (58% female, median age 58, mean BMI 41.5 ± 4.1). Excess body weight loss (EBWL) was 71.2% ± 20.2% at 2 years in RF patients versus 66.0% ± 28.0% in MC patients. In the operated group, 11/19 (58%) patients reached their treatment target (six transplanted, five placed on waiting list) versus 3/12 (25%) in unoperated patients (three transplanted). There was no difference in perioperative complications between RF and MC groups. Long-term, there were seven deaths amongst RF patients (two operated, five unoperated), none amongst the MC group. CONCLUSION: BS in patients with RF increased access to RT and was safe and effective. We therefore recommend consideration of BS in patients with obesity and RF in specialised units.

Closure of Gastrocutaneous Fistula Following Bariatric Surgery: a Systematic Review.

Gastrocutaneous fistula (GCF) is a devastating complication that can arise after bariatric and metabolic surgery (BMS). This systematic review examines the success rate of closure techniques of GCF. A systematic search was conducted across MEDLINE, Embase and Cochrane databases to identify studies which reported on closure techniques of GCF after BMS in adults. Thirty-three studies (n = 108 patients) were included. Seventeen different techniques were used to close GCF across all studies. The most popular were stents (n = 17), tissue sealants (n = 12) and over-the-scope clips (n = 11). Twenty-one studies used multiple techniques to attempt closure, including endoscopic vacuum therapy and revisional surgery. This systematic review demonstrates current practice focusing on endoscopic methods such as stents and over-the-scope clips, with relative success in closing GCF.

Depot- and diabetes-specific differences in norepinephrine-mediated adipose tissue angiogenesis, vascular tone, collagen deposition and morphology in obesity.

AIMS: Norepinephrine (NE) is a known regulator of adipose tissue (AT) metabolism, angiogenesis, vasoconstriction and fibrosis. This may be through autocrine/paracrine effects on local resistance vessel function and morphology. The aims of this study were to investigate, in human subcutaneous and omental adipose tissue (SAT and OAT): NE synthesis, angiogenesis, NE-mediated arteriolar vasoconstriction, the induction of collagen gene expression and its deposition in non-diabetic versus diabetic obese subjects. MATERIALS AND METHODS: SAT and OAT from obese patients were used to investigate tissue NE content, tyrosine hydroxylase (TH) density, angiogenesis including capillary density, angiogenic capacity and angiogenic gene expression, NE-mediated arteriolar vasoconstriction and collagen deposition. KEY FINDINGS: In the non-diabetic group, NE concentration, TH immunoreactivity, angiogenesis and maximal vasoconstriction were significantly higher in OAT compared to SAT (p < 0.05). However, arterioles from OAT showed lower NE sensitivity compared to SAT (10-8 M to 10-7.5 M, p < 0.05). A depot-specific difference in collagen deposition was also observed, being greater in OAT than SAT. In the diabetic group, no significant depot-specific differences were seen in NE synthesis, angiogenesis, vasoconstriction or collagen deposition. SAT arterioles showed significantly lower sensitivity to NE (10-8 M to 10-7.5 M, p < 0.05) compared to the non-diabetic group. SIGNIFICANCE: SAT depot in non-diabetic obese patients exhibited relatively low NE synthesis, angiogenesis, tissue fibrosis and high vasoreactivity, due to preserved NE sensitivity. The local NE synthesis in OAT and diabetes desensitizes NE-induced vasoconstriction, and may also explain the greater tissue angiogenesis and fibrosis in these depots.

Gastro-Colic Fistula After Sleeve Gastrectomy Leak: Our Experience with this Rare Complication.

BACKGROUND: Sleeve gastrectomy (SG) is one of the commonest bariatric procedure performed worldwide (Asian Journal of Endoscopic Surgery 7:314-6, 2014). Leaks reported in 1 to 7% of cases are difficult to manage after SG. Leaks can be graded into acute (within 7 days), early (within 1-6 weeks), late (after 6 weeks) and chronic (after 12 weeks) (Asian Journal of Endoscopic Surgery 7:314-6, 2014). Oesophageal stents can be used for acute leaks. Gastro-colic fistula (GCF) is a rare complication following a chronic leak after SG (Asian Journal of Endoscopic Surgery 7:314-6, 2014). We would like to share our experience of a rare and challenging case of GCF after SG leak. METHOD: Prospectively collected data in our tertiary bariatric centre was retrieved. RESULTS: A 31-year-old female with body mass index (BMI) of 46.2 kg/m2 with history of bipolar disorder had an uneventful SG. On sixth day post-operatively, she presented to other unit with lower chest pain and had a computed tomography (CT) scan which was normal. At 6-week follow-up (FU), she had lost 44% excess weight loss (EWL) and complained of epigastric pain and reflux. CT scan showed collection with active leak in SG. This was successfully treated with partially covered stent placement. Imaging confirmed control of leak. Ten days later, endoscopic removal of the stent was successfully done. At 6-month FU, she had 86% EWL. At 1-year FU, she had 102% EWL with complain of reflux despite being on proton pump inhibitor (PPI). There were no nutritional parameter concerns. There was no history of diarrhoea. CT scan showed GCF (Image 1). OGD confirmed the findings and the site was tattooed. Colonoscopy was equivocal, and no clear fistula visualised which would explain the lack of diarrhoea. Operation was planned with colorectal team after multidisciplinary team discussion. At laparoscopy (Video 1), GCF was identified between SG and splenic flexure at the site of the previous leak. Adhesinolysis was done with a combination of blunt, sharp and energy device and the gastric sleeve and the splenic flexure were mobilised. The fistulous tract was isolated, divided and excised with Endo GIA tristapler taking partial lumen of colon. Intra-operative oesophagogastroduodenoscopy (OGD) showed no leak and colonoscopy showed no leak or narrowing of the lumen and showed healthy tissue. Post-operative recovery was uneventful. She was closely monitored by the bariatric dietician throughout the journey. At 6-month FU, she regained weight under close supervision, had EWL of 88% and is doing well. CONCLUSION: SG leaks can add long-term morbidity. Stent can be used successfully to treat SG leak if used judiciously. There should be low threshold for investigating patients with EWL of > 100% for anatomical complications like stricture, fistula or kink in the gastric sleeve. We wanted to make the bariatric fraternity aware of a rare late (> 12 weeks) complication of gastro-colic fistula after successfully treated SG leak. Limited literature is published about this rare complication and its management which ranges from conservative management to stent placement to surgical intervention (Asian Journal of Endoscopic Surgery 7:314-6, 2014; Clinical Case Reports 6:1342-1346, 2008; Surgery for Obesity and Related Diseases 6:308-12, 2010). It can be dealt with successfully with minimally invasive technique by a multidisciplinary team in an experienced tertiary bariatric unit.

Primary Banded Sleeve Gastrectomy: a Systematic Review.

We aim to investigate any advantages of primary banded sleeve gastrectomy (BSG) over laparoscopic sleeve gastrectomy (LSG). A literature search was performed according to the PRISMA guidelines. There were 236 patients with the mean age of 45.4 years, BMI of 47.9 kg/m2, operating time of 96.8 min, and LOS of 5.25 days. The median follow-up (F/U) was 1 year with mean F/U of 78% patients. Mean %EWL was 77.4% at 12 months, the complication rate of 11.8%, reoperation rate of 5.5%, and the mortality rate of 0.85%. There are small numbers of published cases with primary BSG in literature. This review is unable to examine the benefits versus risks of BSG in the long term. We need randomized studies with long-term F/U to adequately evaluate this procedure.

Chronic elevation of systemic glucagon-like peptide-1 following surgical weight loss: association with nausea and vomiting and effects on adipokines.

We determined whether persistent nausea and vomiting (N/V) symptoms following Roux-en-Y gastric bypass surgery is due to elevated systemic glucagon-like peptide-1 (GLP-1) and leptin in female non-diabetic subjects. Subjects with N/V post-Roux-en-Y gastric bypass (RYGB) surgery had significantly elevated fasting GLP-1 levels compared to that with post-operative asymptomatic subjects and to morbidly obese, obese and lean subjects not undergoing surgery. Weight loss, glycaemia, insulin and post-prandial GLP-1 levels were similar in all post-operative subjects. Despite comparable BMI, leptin was significantly lower in symptomatic subjects. Furthermore, leptin secretion from subcutaneous adipose tissue was inhibited by GLP-1 (0.1-1.0 nM; n = 6). Persistent N/V following RYGB surgery is associated with elevated fasting GLP-1, but lower leptin levels. The latter may be a consequence of the direct GLP-1 inhibition of leptin secretion from adipose tissue.

Factors predicting the occurrence of a gastrojejunal anastomosis leak following gastric bypass.

INTRODUCTION: Occurrence of anastomotic leaks following Roux-en-Y gastric bypass (RYGB), arising principally from the gastro-jejunal anastomosis, is associated with significant morbidity and mortality. Their early detection and treatment is essential. However, a significant number of postoperative oral contrast studies fail to identify leaks, and a negative study providing false reassurance can lead to a delay in diagnosis and treatment. Physiological features including tachycardia, increased respiratory rate and pyrexia or elevations in C-reactive protein and white cell count are seen in patients with leaks. In this study we examine physiological and laboratory parameters in patients with and without anastomotic leaks following RYGB to try and improve the detection of leaks. AIM: To evaluate clinical signs and laboratory tests in determination of the development of gastrojejunal leaks after gastric bypass surgery. MATERIAL AND METHODS: The study examined 116 consecutive patients undergoing laparoscopic RYGB. Clinical signs and laboratory results were reviewed retrospectively. RESULTS: Four gastrojejunostomy leaks in our series were identified after RYGB surgery. All these patients were treated successfully. Leak patients' in-hospital stay was longer. Tachycardia among leak patients occurs from day 1 with 100% sensitivity and 87% specificity at a cut-off point of 90 bpm. A temperature difference appears on day 2 in leak patients. The CRP was higher on day 2 and 3 in leak patients. Higher intravenous fluid requirements were observed in patients with leaks. CONCLUSIONS: Gastrojejunal anastomosis leak is associated with longer in-hospital treatment. The earliest significant indicators of a leak are tachycardia and positive fluid balance. A temperature spike and CRP rise occur on day 2. Leak patients matched SIRS WBC count criteria on day 3.

Bariatric support line: a prospective study of support line activity.

In this prospective study, we examine the workload of the North London Obesity Surgery Service Bariatric telephone support line (BTSL) and its effects on service provision. Over a 3-month period (June to August 2008), a prospective record was kept of all calls, who they were from, whether the patient was presurgery or postsurgery, the type of procedure planned or undertaken, the nature of the enquiry, and the time taken to answer the query. Seventy-five (72%) calls were related to patients who were postsurgery and 29 (28%) presurgery. Patients scheduled for or having undergone Roux-en-Y gastric bypass accounted for 46 (44%) calls; 24 (23%) were preprocedure and 22 (21%) postprocedure. Patients scheduled for or having undergone gastric banding accounted for 56 (54%) calls; five (0.5%) were preprocedure and 51 (49%) postprocedure. Patients undergoing sleeve gastrectomy accounted for two (<1%) calls. Both calls were postprocedure. The reason for the support line enquiry was psychological support in 15 (14%) patients, questions postsurgery in 26 (25%), general enquiries in 27 (26%), and clinical enquiries in 36 (36%). This study of the BTSL has allowed us to identify areas of need within our bariatric population and improve the service we deliver. The changes we have made should lead to a better use of the team's time, greater patient compliance, and satisfaction as well as reduced complaints and litigation.

Emergency and elective laparoscopic repair of spigelian hernias: two case reports and a review of the literature.

Diagnosing spigelian hernias through physical examination can be particularly challenging. Increasingly, laparoscopy is being used to both confirm the diagnosis and carry out therapeutic repair. Here, we describe 2 cases of successful laparoscopic repair of spigelian hernias using an Endocatch assisted sutured technique. A review of the literature describing the role of laparoscopy in the management of spigelian hernia is also provided.

Laparoscopic insertion of a gastric band for weight gain following laparoscopic Roux-en-Y Gastric bypass: description of the technique.

BACKGROUND: A recently published prospective series has demonstrated that weight loss ceases 18 to 24 months following Laparoscopic Roux-en-Y gastric bypass (RYGB) and that, by 48 months, there is significant weight regain in 50% of patients. METHODS: We report the case of a 38-year-old male patient who developed significant weight regain 42 months following laparoscopic (RYGB) and underwent laparoscopic placement of a Swedish ajustable gastric band (SAGB) around the gastric pouch. RESULTS: In previous reports, the gastric band was placed around the upper part of the stomach. This paper provides the first report of the placement of a gastric band around the lower gastric pouch, just above the gastrojejunal anastomosis, in the management of weight regain following laparoscopic RYGB. Prior to revision surgery, the patient's weight was 95 kg [body mass index (BMI) 31 kg/m(2), excess weight loss 65%]. CONCLUSION: Four months following the procedure this had reduced to 82.1 kg (BMI 26 kg/m(2), excess weight loss 90%).