Evaluation of the outcome of a proposed more physiological bypass surgery technique in morbid obesity: Long term 3 years follows up.

Background: Obesity is a chronic condition that affects millions globally; consequently, bariatric surgery is the key to this serious issue. Bariatric procedures are rapidly expanding in number and methods to address the recognized problems. So, it would make a sense for surgeons and patients if there is a more physiological bypass surgery technique in Morbid obesity. This study aims to evaluate the outcome proposed technique. Patients and methods: The present study is a retrospective analysis on 256 participants subjected to the proposed bypass procedure from December 1999 to January 2017, the participants were followed up for an interval of 3years. Results: The findings of the present study revealed a significant Excess Weight Loss (EWL). In addition, patients experienced decreased calcium, iron, vitamin B12, Hemoglobin, zinc, and Prothrombin Concentration. However, three to six months after surgery, they experienced a significant improvement until they reached normal levels without any supplement by the end of 12,18 months, with a three-year follow-up. Conclusion: This proposed Bypass Operation aims to adequate digestions as well as selective absorption without inducing any vital deficit. Most of study's population showed no elements inadequacies, although few percentages emerged during the interval of maximal weight reduction, and it were transient and minimal. No minerals or vitamins were needed.

Incidence and Risk Factors of Thyroid Malignancy in Patients with Toxic Nodular Goiter.

Background: Although hyperfunctioning thyroid disorders were thought to be protective against malignancy, some recent studies reported a high incidence of incidentally discovered cancer in patients with hyperfunctioning benign thyroid disorders. We performed this study to estimate the incidence and predictors of malignant thyroid disease in patients with toxic nodular goiter (TNG). Patients and Methods. The data of 98 patients diagnosed with TNG were reviewed (including toxic multinodular goiter SMNG and single toxic nodule STN). The collected data included patients age, gender, systemic comorbidities, family history of thyroid malignancy, previous neck radiation, type of disease (multinodular or single), size of the dominant nodule by the US, operative time, and detection of significant lymph nodes during operation. Based on the histopathological analysis, the cases were allocated into benign and malignant groups. Results: Malignancy was detected in 21 patients (21.43%). Although age distribution was comparable between the two groups, males showed a significant increase in association with malignancy. Medical comorbidities and family history of cancer did not differ between the two groups. However, TMNG showed a statistically higher prevalence in the malignant group. Operative data, including operative time and lymph node detection, were comparable between the two groups. On regression analysis, both male gender and TMNG were significant predictors of malignancy. Conclusion: The presence of thyroid hyperfunction is not a protective factor against malignancy, as malignancy was detected in about 1/5 of cases. Male gender and TMNG were significant risk factors of malignancy in such patients.

Lichtenstein versus transabdominal preperitoneal (TAPP) inguinal hernia repair for unilateral non recurrent hernia: A multicenter short term randomized comparative study of clinical outcomes.

Background: The repair of inguinal hernia is still one of the most prevalent surgical procedures done worldwide. Among all repair techniques, open Lichtenstein repair is the most globally conducted. In the past few decades, laparoscopic technique for inguinal hernia repair has increased technical demand. Trans-abdominal pre-peritoneal (TAPP) technique is the main approach, which is featured by less postoperative pain and early recovery. Objective: The current work is a short-term study to make a comparison between open Lichtenstein repair of inguinal hernia as well as laparoscopic trans-abdominal preperitoneal repair of inguinal hernia (TAPP) for unilateral non recurrent hernia regarding intraoperative, postoperative complications and hospital stay. Patients and methods: The present prospective randomized study recruited 100 male subjects from General Surgery Department of Al-Azhar University Hospitals and Ain Shams university hospitals suffering from oblique inguinal hernia (unilateral non recurrent hernia) with an age above 18 years and good overall health, who were randomized into two groups: Group A: 49 cases were subjected to laparoscopic trans-abdominal pre-peritoneal repair (TAPP). Group B: 51 cases were subjected to open Lichtenstein repair. Results: This study detected less post-operative pain day 0, day 1, day 7 and 1 month postoperatively. There was no significant difference at 6 months post-operatively. Conclusion: Finally, we concluded that TAPP repair for inguinal hernia (unilateral non recurrent hernia) safer with less early post-operative pain. Also, it has fewer complications, with a significantly longer operative time.

Improvement of Coronary Calcium Scores After Bariatric Surgery in People with Severe Obesity.

BACKGROUND: Obesity is an independent risk factor for cardiovascular diseases. Coronary artery calcium (CAC) is a direct measure of coronary atherosclerosis. The study investigated the effect of bariatric surgery on CAC scores in people with severe obesity subjected to laparoscopic sleeve gastrectomy (LSG). METHODS: This prospective study included 129 people with severe obesity in two groups; the LSG group (n=74) subjected to surgery and the diet group (n=55), managed by a diet regimen and lifestyle modification. Cardiovascular risk was assessed by Framingham risk score (FRS) and coronary calcium score (CCS) measured by computed tomography initially and after 3 years. RESULTS: The two groups had a comparable CAD risk before treatment according to FRS or CCS. After treatment, CCS improved significantly in the LSG group (p=0.008) but not in the diet group (p=0.149). There was no correlation between FRS and CCS (r=0.005, p=0.952). Treatment resulted in significant weight reduction and improved fasting blood glucose and lipid profile in the two groups. The change of weight, blood glucose, and HDL, and remission of diabetes mellitus (DM) were significantly higher in the LSG group compared to the diet group. CONCLUSION: LSG may reduce the risk of developing future cardiovascular comorbidities evidenced by reducing CAC scores. Significant weight reduction and improvement of cardiovascular risk factors may recommend LSG as a cardioprotective procedure in people with severe obesity.

Impact of laparoscopic sleeve gastrectomy on fibrosis stage in patients with child-A NASH-related cirrhosis.

PURPOSE: Bariatric surgery can improve non-alcoholic fatty liver disease (NAFLD). Yet data on the effect on fibrosis are insufficient and controversial. This work endeavored to evaluate the safety of laparoscopic sleeve gastrectomy (LSG) in cases that have compensated non-alcoholic steatohepatitis (NASH)-related cirrhosis and its impact on fibrosis stage. METHODS: The current prospective work involved 132 cases with Child-A NASH-related cirrhosis suffering from morbid obesity scheduled for LSG. They were subjected to preoperative assessment, wedge biopsy, and ultrasound-guided true-cut liver biopsy after 30 months. Patients were included if proved to have F4 fibrosis initially. The liver condition was assessed based on the NALFD Activity Score (NAS). The primary outcome measure was the impact of LSG on fibrosis stage and its relation to weight loss. RESULTS: The analysis included only 71 patients who completed the 30-month follow-up period. By the end of the follow-up interval, there was a substantial weight loss with a reasonable resolution of comorbidities. The median NAS decreased significantly from 6 (1-8) to 3 (0-6) after surgery. Fibrosis score regressed to F2 in 19 patients (26.8%) and F3 in 29 (40.8%). Patients with improved scores had a significantly higher amount of weight loss (p < 0.001). Improvement was more frequent in males (p = 0.007). By 30 months after treatment, 53.8% of cases with borderline NASH and 36.8% of those with probable NASH showed complete resolution, and 44.7% of patients with NASH showed improvement. Steatosis improved in 74.6% of patients (p < 0.001). CONCLUSION: In patients with NASH-related liver cirrhosis of Child class A, LSG may be a secure approach for the management of morbid obesity. It has a long-term benefit for both obesity and liver condition with significant improvement of steatosis, steatohepatitis, and fibrosis.

Effect of Bariatric Surgery on the Cardiovascular System in Obese Cases with Pulmonary Hypertension.

INTRODUCTION AND AIM: Recently, the incidence of obesity has been rising exponentially. Clinical studies have demonstrated that different subtypes of pulmonary hypertension (PH) are linked to obesity. The current work mainly aims to assess the impact of laparoscopic sleeve gastrectomy (LSG) on PH in a cohort of obese cases. PATIENTS AND METHODS: The present prospective work included 37 obese cases with PH for whom LSG was done. Only cases with PH and presurgical right ventricular systolic pressure (RVSP) ≥ 35 mmHg using Doppler echocardiogram were enrolled. Fifteen months later, patients were reassessed regarding new weight and BMI in addition to changes in RVSP. RESULTS: At the end of follow-up, the average BMI improved from 45.8 + 3.9 to 33.8 + 2.5 Kg/m2 (p value < 0.001). Improved right ventricular (RV) size compared to baseline echo was observed in 20 patients. RV size decreased from 2.68 + 0.44 cm to 2.34 + 0.36 cm (p value < 0.001). Notable decrease of PH to less than 30 mmHg occurred in 33 patients. Mean RVSP decreased from 39.62 + 2.1 to 31.81 + 3.1 mmHg (p value < 0.001). LSG significantly decreased the requirements for PH drugs and supplemental oxygen therapy. CONCLUSION: The current work suggests that LSG-induced weight loss may result in a considerable decrease in pulmonary pressures as well as RV size with a concurrent resolution of other metabolic comorbidities.

Long-term effects of one-anastomosis gastric bypass on liver histopathology in NAFLD cases: a prospective study.

PURPOSE: Weight reduction can effectively improve nonalcoholic fatty liver disease (NAFLD), which is a constant companion of severe obesity. This study aimed to determine the effect of one-anastomosis gastric bypass (OAGB) on pathological liver changes in severely obese cases with NAFLD. METHODS: The present prospective research comprised 67 subjects with morbid obesity scheduled for OAGB during the period from February 2015 to August 2018. Clinical, biological, and histologic data were evaluated pre and 15 months postoperatively. RESULTS: Fifteen months after surgery, a considerable reduction was noted in the grades of fat deposition, liver cell ballooning, and lobular inflammatory changes, in addition to the total NAS score. Fifteen months after surgery, nonalcoholic steatohepatitis (NASH) disappeared in 42% of the patients. A significant regression of fibrosis stage occurred after surgery in 79.1% of patients (p < 0.001). After surgery, patients had substantial reductions in aspartate aminotransferase, alanine aminotransferase, γ-glutamyltransferase, HbA1c, total cholesterol, and Low-density lipoprotein (p < 0.001, for all comparisons). Diabetes mellitus, hypertension, and dyslipidemia resolved in 54%, 59%, and 69% of the patients, respectively. CONCLUSION: OAGB resolved NASH from nearly 42% of patients and reduced the histological features of NAFLD 15 months after surgery. Bariatric procedures might be adopted as a therapeutic modality in severely obese cases with NAFLD after the failure of lifestyle modifications.

Effect of weight loss induced by laparoscopic sleeve gastrectomy on liver histology and serum adipokine levels.

BACKGROUND & AIM: Bariatric surgery is a valid treatment option for persons with non-alcoholic fatty liver disease. This study prospectively examined the impact of laparoscopic sleeve gastrectomy (LSG) on liver histopathology, and blood levels of adiponectin, leptin, resistin, and pre-B cell enhancing factor/Nampt/visfatin. PATIENTS & METHODS: In 81 patients with non-alcoholic fatty liver disease who underwent LSG, paired liver biopsies and blood specimens were obtained before and 18 months after LSG. Differences between preoperative and 18 months postoperative data were tested by paired Student's t-test or Wilcoxon rank test as appropriate. RESULTS: At follow up, there was a significant improvement in biochemical markers for glucose homeostasis, including fasting glucose, HbA1c, insulin levels, and homeostatic model assessment index. Postoperative liver function tests, namely serum alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyl transpeptidase level, showed a significant improvement compared to before weight loss. The number of patients who had definite, borderline, or no non-alcoholic steatohepatitis was 43 (53%), 27 (33%), and 11 (14%), respectively, at baseline, and 9 (11%), 32 (40%), and 40 (49%) at 18-month post-surgery follow up. A significant reduction in steatosis, liver fibrosis, lobular inflammation, and hepatocyte ballooning was observed in the postoperative biopsies (P < 0.001 each). In addition, at the follow-up assessment, there was a significant increase in serum adiponectin levels and significant decline in serum levels of leptin, resisitin, and pre-B cell enhancing factor/Nampt/visfatin. CONCLUSION: Weight loss after sleeve gastrectomy was associated with a significant improvement in several metabolic parameters, liver enzyme levels, liver histopathology, and changes in serum adipokine levels towards antidiabetic and anti-inflammatory profiles.

Long-term Impact of Mini-Gastric Bypass on Inflammatory Cytokines in Cohort of Morbidly Obese Patients: a Prospective Study.

PURPOSE: One anastomosis gastric bypass (OAGB) is a promising bariatric procedure. We performed this study to evaluate the changes in a group of inflammatory cytokines 12 months after OAGB. METHODS: A single-arm prospective study was conducted on obese patients who underwent OAGB. The serum levels of the following adipocytokines were monitored pre- and 12 months postoperatively: adiponectin, leptin, interleukin 6 (IL-6), interleukin 8 (IL-8) levels, tumor necrosis factor-alpha (TNF-α), serum amyloid A (SAA), high-sensitivity C-reactive protein (hs-CRP), and monocyte chemotactic protein 1 (MCP-1). RESULTS: A total of 62 patients were included with a mean age of 43.9 ± 6.8 years old. The serum adiponectin increased significantly from 7.64 ± 0.29 to 8.76 ± 0.42 µg/mL 12 months after the operation (p < 0.001). hs-CRP and IL-6 decreased significantly 12 months after the OAGB from 3323.35 ± 643.4 ng/mL and 3.72 ± 7.7 pg/mL to 1376.81 ± 609.4 ng/mL and 3.64 ± 6.9 pg/mL, respectively (p < 0.001). The MCP-1 showed significant increase in its level after OAGB as well (p = 0.014). In contrary, there were no significant changes in serum levels of IL-8 (p = 0.12) and TNF-α (p = 0.84) 12 months after the operation. The correlation analysis showed significant correlations between initial body mass index (BMI) with serum adiponectin, IL-8, and serum SAA. CONCLUSION: OAGB can significantly impact the inflammatory cytokine profile in obese patients with possible subsequent protection from obesity-related comorbidities such as insulin resistance, cardiovascular diseases, and certain cancers.

Long-Term Changes in Leptin, Chemerin, and Ghrelin Levels Following Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy.

AIM: Published reports showed conflicting results regarding the sustained alterations in leptin, chemerin, and ghrelin concenratios after metabolic surgery. Therefore, we performed the present work to contrast the alterations in leptin, chemerin, and ghrelin levels one year after Roux-en-Y gastric bypass (RYGB) versus laparoscopic sleeve gastrectomy (LSG). METHODS: The present research is a prospective, comparative one that followed 100 cases for whom RYGB or LSG was done. We assessed the serum values of adiposity-associated mediators, including adipokcytokines (leptin and active chemerin) and gastrointestinal hormones (total ghrelin). The primary outcome in the present study was the alterations in leptin, chemerin, and ghrelin values at 12 months after RYGB and LSG. RESULTS: The serum leptin level decreased significantly in the LSG group with a mean change of - 170.8 ± 29.4 ng/mL (p < 0.001). Similarly, the serum leptin concentration decreased significantly in the RYGB group, with a mean change of - 165.42 ± 53.4 (p < 0.001). In addition, the mean reduction in baseline chemerin levels 12 months after the operation was considerable in the LSG cohort (- 23.24 ± 9.5 ng/mL) and RYGB group (- 22.12 ± 15.9 ng/mL). The ghrelin values demonstrated a notable reduction in the LSG cohort (- 0.083 ± 0.11 pg/mL) and RYGB group (- 0.068 ± 0.097 pg/mL). However, the changes in the three hormones were not substantially different between both groups (p > 0.05). CONCLUSION: Both RYGB and LSG result in a considerable, comparable decrease in the postoperative serum concentrations of leptin, chemerin, and ghrelin.

Study of changes of obesity-related inflammatory cytokines after laparoscopic sleeve gastrectomy.

BACKGROUND: Chronic inflammation in adipose tissue may play a substantial role in the pathogenesis of obesity-related metabolic disorders. The present study aims to evaluate the changes in adipocytokines, bile acids, fibroblast growth factor 19 (FGF-19) and pro-inflammatory cytokines 6 months after laparoscopic sleeve gastrectomy (LSG). METHODS: This prospective study included 75 obese patients with body mass index >35 kg/m2 who underwent LSG. All patients were recruited preoperatively and followed up post-operatively at 6 months, with laboratory assessment of their cytokines including adiponectin, leptin, resistin, bile acid, interleukin (IL)-6, IL-8, tumour necrosis factor-α, monocyte chemotactic protein-1, high-sensitivity C-reactive protein, plasminogen activator inhibitor-1, serum amyloid-A and FGF-19. RESULTS: There were statistically highly significant changes regarding anthropometric parameters (weight, body mass index and waist-to-hip ratio), blood glucose and lipid profile as well as liver enzymes at 6 months post-sleeve gastrectomy. The present study showed that the levels of serum adiponectin and FGF-19 significantly increased at 6 months of follow-up after surgery (P < 0.001), while the levels of serum leptin, resistin, high-sensitivity C-reactive protein, plasminogen activator inhibitor-1 and serum amyloid-A significantly decreased at 6 months of follow-up after surgery (P < 0.001). There were no significant differences regarding serum bile acid, IL-6, IL-8, tumour necrosis factor-α and monocyte chemotactic protein-1. CONCLUSION: Weight loss after LSG is associated with significant improvement of the adipokine levels towards anti-diabetic and anti-inflammatory profiles. Future studies should use a larger sample size and longer follow-up periods.