[Nutrition management in obese patients with type 2 diabetes mellitus after laparoscopic sleeve gastrectomy].

OBJECTIVE: To explore the value of nutrition management in obese patients with type 2 diabetes mellitus(T2DM) after laparoscopic sleeve gastrectomy(LSG). METHODS: Clinical data of 22 obese T2DM patients undergoing LSG from March 2013 to July 2015 in Fudan University Pudong Medical Center were collected. All the patients strictly followed the specialized instruction by nutritionists: diabetic and low calorie diet 3347.2 to 5020.8 kJ (800 to 1200 kcal) per day before the operation; low calorie liquid diet 2510.4 kJ(600 kcal) per day before operation for promoting gastric emptying; fasting diet before postoperative ventilation; clear liquid diet 1673.6 to 2510.4 kJ (400 to 600 kcal) per day after postoperative ventilation (liquid intake >2000 ml); low fat liquid diet 2928.8 to 3765.6 kJ (700 to 900 kcal) per day (protein 60 g per day at least, 2000 ml liquid) 2 weeks after the operation; semi-liquid diet 1 month after operation and gradually normal diet. All the 22 patients were followed up at 1 week, 1, 3, 6 months after operation on time. Changes of body weight, waist circumference, hip circumference, body mass index(BMI), blood glucose indexes induding fasting blood glucose(FBG), 2-hour postparandial blood glucose(PBG), fasting C-peptide, 2-hour postprandial C-peptide, fasting serum inculin(FINS), 2-hour postprandial inculin(INS), HbAlc, blood pressure and blood lipid indexes were observed and analyzed before and 1 week, 1, 3, 6 months after operation. RESULTS: The average age of 22 patients (10 men and 12 women) was 38.6 years (18 to 66 years). The duration of diabetes varied from 1 month to 15 years. Comorbidity included 12 patients of high blood pressure, 14 of fatty liver, 1 of coronary heart disease, 1 of gout, 1 of chronic thyroiditis and 1 of menstrual disorder. LSG was performed successfully in all the patients and no severe complications and transference to laparotomy occurred. As compared to pre-operation, at 6 months after operation, the average body weight decreased from (103.9±20.2) kg to (80.9±12.6) kg (t=6.294, P=0.000), waist circumference from (118.6±13.8) cm to (96.4±8.0) cm (t=6.331, P=0.000), hip circumference from (116.9±12.6) cm to (104.0±7.7) cm (t=3.854, P=0.000), BMI from (36.2±5.9) kg/m2 to (27.9±3.5) kg/m2 (t=5.630, P=0.000), showing a decreasing trend over time. There was no underweight patient after 6 months follow-up. As compared to pre-operation, at 6 months after operation, the average FBG reduced from (7.4±1.4) mmol/L to (6.0±0.9) mmol/L (t=3.172, P=0.003), 2 h PBG from (14.1±4.9) mmol/L to (7.5±2.2) mmol/L (t=7.026, P=0.000), FINS from (160.0±71.9) mIU/L to (43.8±20.8) mIU/L (t=7.259, P=0.000), 2-hour postprandial INS from (437.6±261.4) mIU/L to (140.5±104.6) mIU/L (t=5.858, P=0.000), fasting C-peptide from (1.1±0.6) µg/L to (0.7±0.3) µg/L (t=3.560, P=0.000), 2-hour postprandial C-peptide from (2.5±0.9) µg/L to (1.5±0.7) µg/L (t=3.865, P=0.000), HbAlc from (8.0±1.6)% to (5.9±0.6)% (t=5.953, P=0.000), showing a decreasing trend over time except FBG, 2h postprandial C-peptide and HbAlc(all P<0.05). FBG and 2-hour PBG of 16 patients returned to normal 3 months after the operation. Blood pressure and trigly ceride decreased obviously 6 months after operation compared to pre-operation with significant difference(P<0.05). At 6 months after operation, blood pressure of 8 comorbidity patients with high blood pressure became normal (8/12, 66.7%) and of 4 patients improved(4/12, 33.3%); B ultrasound examination revealed normal in 11 comorbidity patients with fatty liver(11/14,78.6%) and improvement in 3 patients (3/14,15.4%). Blood uric acid of the gout patient and the menstruation of the menstrual disorder patient returned to normal 3 months and 1 month after the operation respectively. CONCLUSION: As for obese patients with T2DM undergoing LSG, reasonable nutrition management is helpful to decrease body weight, and to obtain an ideal improvement of blood glucose and blood lipid levels.

[Interpretation of the International Joint Statement on Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes].

Along with the soaring prevalence of obesity and type 2 diabetes mellitus (T2DM) globally, metabolic and bariatric surgery (MBS) has been rapidly developing into a major surgical subspecialty. However, the indications, benefits and potential risks of MBS are still controversial so far. In September 2015, the 2nd Diabetes Surgery Summit (DSS-II() was successfully convened, and later on an international joint statement on metabolic surgery in the treatment algorithm for T2DM was released based upon the consensus reached in DSS-II(, aiming to serve as a new global clinical guideline. The DSS-II( joint statement was initiated and endorsed by 5 leading international diabetes organizations, including American Diabetes Association (ADA), International Diabetes Federation (IDF), Chinese Diabetes Society (CDS), Diabetes India, as well as Diabetes UK, and was developed by an expert committee comprised of 48 international authorities as voting delegates. Up to the date of publication, the DSS-II( statement has been officially endorsed by 45 international professional associations/societies, including 30 non-surgical and 15 surgical organizations. In this statement, the following six aspects were recommended to differentiate MBS from traditional bariatric surgery: 1)The primary goal of MBS is to treat T2DM and to reduce the risk of T2DM complications; 2) In addition to a 50% or more of excess weight loss and normalization of glycemia, outcomes of diabetes complications should also be considered as clinical endpoints of MBS; 3) For patient selection, body mass index (BMI), T2DM treatment, as well as long-term risks versus benefits, including its effects on cardiovascular events (CVD), should all be considered; 4) T2DM and its complications, as well as pancreatic function reserve should be assessed pre-operatively; 5) Major surgical options include laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG), laparoscopic adjustable gastric banding (LAGB), and bilio-pancreatic diversion with duodenal switch(BPD-DS). BPD-DS has the best outcome in T2DM remission followed by LRYGB, LSG and LAGB; 6) Glycemic variation should be intensively monitored, and if needed, managed following surgery. Clinical follow-up should be conducted at least once every six months within two years after surgery. For patients achieving complete remission from T2DM, diabetes complications should still be monitored within five years after surgery with the same frequency and protocols as pre-operatively.

Duodenal-jejunal bypass attenuates progressive failure of pancreatic islets in streptozotocin-induced diabetic rats.

BACKGROUND: Preservation of pancreatic beta cell function has been increasingly appealing in the treatment of type 2 diabetes. Evidence is still limited on how bariatric surgery affects pancreatic beta cell apoptosis. SETTING: University medical center. OBJECTIVE: The study aimed to investigate the effect of a major component of Roux-en-Y gastric bypass, duodenal-jejunal bypass, on protecting pancreatic beta cells from progressive loss. METHODS: Forty-five normal Sprague-Dawley rats were randomly assigned into 3 groups: duodenal-jejunal bypass (DJB) group (n = 16) and sham (S) group (n = 17), based upon the procedure received, and a control (C) group (n = 12) without any procedure performed, to eliminate potential traumatic effects from surgery. Ten days after surgery, streptozotocin (STZ, 45 mg/kg weight) was injected intraperitoneally into each animal, including the control animals, to selectively induce pancreatic beta cell apoptosis. Weight, food intake, plasma glucose level, and the results of an oral glucose tolerance test were measured before surgery, pre-STZ injection, and up to 4 weeks after STZ injection. Plasma insulin and glucagon-like peptide-1 levels were also assayed during oral glucose tolerance test. At the end, pancreatic tissues were sliced and stained for beta cell analysis. RESULTS: There were no significant differences in weight among all groups at any time points measured, despite rats in the S and C groups consuming more food than those in the DJB group as measured on day 10 (P<.05) and day 20 (P<.01) after STZ injection. Animals undergoing DJB did not experience symptoms typical of uncompensated diabetes, including hyperphagia and progressive weight loss. After STZ injection, fasting plasma glucose levels in the DJB group were significantly lower than those in the C and S groups (P<.001). When challenged by glucose load, DJB rats also had a better glycemic excursion (P<.01) and incretin response compared with C and S rats (P<.05). In addition, pancreatic beta cell size and mass was better preserved in DJB rats (P< .001). CONCLUSION: DJB is able to protect pancreatic beta cells from apoptosis, which leads to better glycemic control and delayed onset of diabetes. These results imply the necessity of including a DJB component when designing bariatric procedure to achieve a better long-term outcome.

[History and development trend of minimally invasive surgical treatment for obesity and diabetes in China].

Obesity and type 2 diabetes mellitus have already become one of the most serious society-facing problems. Since the first report in the 1950s, gastrointestinal surgery has greatly developed as the golden standard in obesity treatment. With the convincing research and evidence, it is found that gastrointestinal surgery not only can cause weight loss, but can relieve, even cure many metabolic diseases associated with obesity, especially for type 2 diabetes mellitus. The operational manners, including adjustable gastric banding, Roux-en-Y gastric bypass, mini gastric bypass, sleeve gastrectomy, etc., are proved to be safe and effective in treating obesity and type 2 diabetes mellitus, and all of these operations can be performed with laparoscopy. Currently, gastrointestinal surgeons are focusing on the operation treatment for type 2 diabetes mellitus, and more and more gastrointestinal operations are applied in many medical centers in China. However, there are a lot of details that need to be standardized. It is believed, with the evolution of surgical technique, standardization of diagnosis and treatment, and breakthrough in the basic research, the metabolic surgery will get more development in the future.

Effectiveness of laparoscopic sleeve gastrectomy for weight loss and obesity-associated co-morbidities: a 3-year outcome from Mainland Chinese patients.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is becoming a stand-alone bariatric surgery for obesity, but its effectiveness for Mainland Chinese patients remains unclear. OBJECTIVES: To evaluate the effectiveness and safety of LSG for Mainland Chinese patients SETTING: A tertiary hospital METHODS: Retrospective analysis of patients admitted for LSG between January 2011 and February 2012 was performed. Medium-term outcome measures were: total weight loss (%TWL), excess weight loss (%EWL), co-morbidities, improvement, and complications. RESULTS: Seventy patients (body mass index [BMI] 40.8±5.9 kg/m2) underwent LSG, comprising 40 women and 30 men. The most common co-morbidity was diabetes (n = 29, 41.4%). Lost to follow-up rate for weight loss was 15.7%, 31.4%, and 41% at 1, 2, and 3 years. The %TWL was 34.4±6.1, 34.7±6.2 and 33.7±7.1 at 1, 2, and 3 years. The %EWL increased to 77.1±13.0, 77.9±12.2 and 77.2±13.1 at 1, 2, and 3years. The proportions of patients having successful weight loss were 100% or 85% at 3 years according the definition of %TWL>10% or %EWL>50%. Approximately 79.3%, 51.7%, and 44.8% of patients completed follow-up for glycemic control at each time point, respectively. The proportions of patients with optimal glycemic control (fasting blood glucose [FBG]<5.6 mmol/L; hemoglobin A1C [HbA1C]<6.5%) were 47.9%, 60.0%, and 69.2% at 1, 2, and 3years. The weight loss and glycemic control effect may be greater in the high BMI group (≥40 kg/m2). Early and late complications occurred in 8.6% and 7.1% of patients during follow-up. CONCLUSIONS: LSG is effective in weight loss and glycemic control and is safe for Mainland Chinese obese patients, especially for patients with a BMI≥40 kg/m2.

Comparing the Effectiveness of Total Gastrectomy and Gastric Bypass on Glucose Metabolism in Diabetic Rats.

BACKGROUND: Bariatric surgeries have been widely used in obesity associated type II diabetes. However, the mechanisms of surgical treatments for type II diabetes in non-obese patients remain controversial. Our study aims to compare the effectiveness of various bariatric surgeries in a non-obese diabetic rat model. METHODS: Goto-Kakisaki (GK) rats were used to compare the outcome of total gastrectomy (TG), Roux-en-Y reconstruction after total gastrectomy (RYTG), and Roux-En-Y gastric bypass (RYGB). Body weight, food and water intake, and glucose level were monitored prior to and after surgery. Oral glucose tolerance tests (OGTT) were performed, and key metabolic hormones were measured at selected time points. RESULTS: Despite a significant reduction in body weight in TG and RYTG groups, their glucose metabolic rate was not improved. RYGB rats, with only moderate reduction in food intake and body weight, had significantly improved glucose metabolism. Insulin and ghrelin were significantly reduced in TG and RYTG groups, but remained unchanged in RYGB group. CONCLUSIONS: Our study demonstrated the effectiveness of RYGB surgery in treating type II diabetes in non-obese diabetic rats. These results suggest an important role of gastric system in regulating glucose homeostasis.

[Efficacy analysis of laparoscopic sleeve gastrectomy in treatment of obesity with type 2 diabetes mellitus].

OBJECTIVE: To investigate the efficacy and safety of laparoscopic sleeve gastrectomy(LSG) for the treatment of obesity with type 2 diabetes mellitus(T2DM). METHODS: Clinical data of 32 obesity patients with T2DM patients undergoing LSG from May 2010 to February 2012 in our department were retrospectively analyzed. Their body weight indexes (body weight, waist circumference, BMI, EWL), blood glucose indexes [glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG), insulin resistance index (HOMA-IR)], and blood lipid indexes [total cholesterol, triglyceride, low density lipoprotein cholesterol(LDL-C), high density lipoprotein cholesterol(HDL-C)] were measured 1, 3, 6, 12 months after operation and compared with preoperative levels. Improvement in complications was observed. RESULTS: All the patients completed operation under laparoscopy except 1 case because of abdominal cavity adhesion. The average operative time was (115.0±19.6) min, and the average blood loss (69.0±29.7) ml. No operative death, anastomotic leakage, or surgical site infection were found. The body weight, waist circumference and BMI at 1, 3, 6, and 12 months after surgery were significantly lower(all P<0.05) showing a decreasing trend over time. EWL showed significant increasing trend (P<0.05). During 12 months of follow-up, no over-low weight was observed. From 1 month after surgery, HbA1c, FPG and HOMA-IR decreased significantly (P<0.05). HbA1c and FPG maintained stable level at 12 and 6 months after operation respectively. FPG of 28 patients returned to normal 3 months after operation. Clinical complete remission rate of T2DM was 87.5%(28/32), and clinical partial remission rate was 12.5%(4/32) at the 12-month follow-up. Serum total cholesterol, triglyceride and LDL-C decreased obviously after surgery(P<0.05). CONCLUSION: LSG procedure is a safe and effective surgical method in treatment of obesity with T2DM.

[Perioperative managment of laparoscopic sleeve gastrectomy].

OBJECTIVE: To summarize the surgical technique and perioperative management of laparoscopic sleeve gastrectomy (LSG). METHODS: A total of 57 morbid obesity patients undergoing LSG surgery from May 2010 to December 2012 were enrolled in the study, whose clinical data in perioperative period were analyzed retrospectively. These patients had more than 1 year of follow-up. All the patients received preoperative preparation and postoperative management, and postoperative excess weight loss(EWL%) and improvement of preoperative complications was evaluated. RESULTS: All the cases completed the operation under laparoscopy, except 1 case because of the abdominal extensive adhesion. The average operation time was(102.0±15.2) min and the mean intraoperative blood loss (132.3±45.6) ml. Of 2 postoperative hemorrhage patients, 1 case received conservative treatment, and another one underwent laparoscopic exploration. The EWL% at 3 months, 6 months and 1 year after procedure was (54.9±13.8)%, (79.0±23.6)% and (106.9±25.1)% respectively. The preoperative complications were improved in some degree. There were no operative death, and anastomotic leak, anastomotic stenosis, or surgical site infection occurred. CONCLUSION: LSG is a safe and effective surgical technique, whose safety and efficacy may be increased by improving the perioperative management.

siRNA-participated chemotherapy: an efficient and specific therapeutic against gastric cancer.

PURPOSE: This study aims to investigate the role of siRNA silencing fibroblast growth factor receptor (FGFR) expression in promoting chemotherapy effect of gastric cancer and to explore its mechanism. METHODS: Human gastric cancer cells MGC80-3 were divided into four groups: control group, cisplatin group (2 µg/L), cisplatin (2 µg/L) + siRNA group and siRNA group. The expressions of FGFR in four groups were detected by immunofluorescence. The cell proliferation and apoptosis were detected by MTT assay and flow cytometry. The protein expression levels of vascular endothelial growth factor receptor (VEGFR), caspase-3 and Bax were detected by Western blot. Further, animal model of gastric cancer was established and divided into four groups as in vitro experiment. The expression of FGFR mRNA in tumor tissue was detected by the real-time fluorescence quantitative polymerase chain reaction. The size of tumor was measured to analyze the effects of treatment. Histopathological detections were performed by hematoxylin and eosin staining and immunohistochemistry. RESULTS: For in vitro experiment, significant decrease inFGFR expression, inhibition of proliferation and promotion of apoptosis were observed in siRNA-treated cells, so as cisplatin group. siRNA also resulted in the reduction of VEGFR and rise in apoptosis-related protein (caspase-3). As for the experiment in vivo, siRNA also suppressed the expression of FGFR and enhanced tumor shrink. Furthermore, the co-administration of siRNA and cisplatin revealed a more excellent antitumor effect than other therapies. CONCLUSIONS: siRNA can effectively suppress FGFR expression and cell proliferation, but promote apoptosis in vitro and also inhibit tumor growth and FGFR production in vivo. siRNA-participated chemotherapy may provide an efficient therapeutic approach to treat gastric cancer.

[Impacts of laparoscopic bariatric surgery on GLP-1 and Ghrelin level in patients with type 2 diabetes mellitus].

OBJECTIVES: To investigate the impacts of laparoscopic bariatric surgery on fasting glucagon-like peptide-1 (GLP-1) and Ghrelin level in patients with type 2 diabetes mellitus (T2DM), and the mechanism in surgical treatment of T2DM. METHODS: From March 2010 to August 2011, 44 patients with T2DM underwent laparoscopic bariatric, including laparoscopic Roux-en-Y gastric bypass (LRYGB, n = 14), laparoscopic mini-gastric bypass (LMGB, n = 11), laparoscopic sleeve gastrectomy (LSG, n = 9) and laparoscopic adjustable gastric banding (LAGB, n = 10). The curative effects, changes of metabolism and gastrointestinal hormones were analyzed respectively. RESULTS: Within 6 months after surgery, the clinical complete remission of T2DM was 11, 8, 6, 3 cases in LRYGB, LMGB, LSG, LAGB group respectively; the clinical partial remission was 3, 3, 2, 4 cases respectively. The inefficacy was 1, 3 patients in LSG and LAGB group respectively. The effects of surgery within 6 months postoperative among 4 groups were different (χ(2) = 8.162, P < 0.05). The levels of body mass index (F = 275.29) and homeostasis model assessment of insulin resistance (F = 40.09) of 4 groups were declined in 6 months postoperatively (P < 0.01). The extents of decrease were no significance among 4 groups. Compared to preoperative level, GLP-1 in LRYGB ((116 ± 33) vs. (66 ± 20) ng/L and LMGB group ((103 ± 22) vs. (65 ± 16) ng/L) was higher in the first month after surgery (F = 21.76 and 139.21, P < 0.05). The changes in LSG and LAGB group were no significance (P > 0.05). The level of Ghrelin in LRYGB, LMGB, LSG group at the first week after surgery were (208 ± 79), (275 ± 102) and (258 ± 91) ng/L respectively, and they were lower than preoperative (there were (398 ± 114), (439 ± 96) and (446 ± 105) ng/L, F = 55.08, 49.96 and 46.47, all P < 0.01). But the level of Ghrelin in LRYGB and LMGB groups rebounded in the first postoperative month. The postoperative level of Ghrelin was higher in LAGB group (F = 29.24, P = 0.001). CONCLUSIONS: There are difference efficacies and impacts on gastrointestinal hormones among different modes of bariatric surgery. The change of gastrointestinal hormones is plausible mechanism of T2DM remission after surgery.

[Long-term outcomes and cause of high rate of loss to follow-up after laparoscopic adjustable gastric banding in obese patients].

OBJECTIVE: To evaluate the long-term outcomes of weight loss and the cause of high rate of loss to follow-up after laparoscopic adjustable gastric banding (LAGB) in obese patients. METHODS: Clinical and follow-up data of 226 obese patients undergoing LAGB operation in the Changhai Hospital from June 2003 to June 2007 were analyzed retrospectively. RESULTS: A total of 125 patients were followed up for 3-7 years. Among these 125 cases, 115 (92.0%) presented weight loss after LAGB, 60 (48.0%) presented extra weight loss after LAGB. Another 105 cases (44.7%) were lost to follow-up. Most of patients who were loss to follow-up were younger (P<0.05). Gender, weight and BMI were not associated with the rate of loss to follow-up (all P>0.05). CONCLUSIONS: Laparoscopic adjustable gastric band surgery is a relatively simple and safe procedure among the bariatric surgery, but the follow-up protocol is complex and the rate of loss to follow-up is high. Postoperative follow-up should be emphasized.

Laparoscopic adjustable gastric banding: a report of 228 cases.

OBJECTIVE: To evaluate the surgical outcomes and complications after laparoscopic adjustable gastric banding (LAGB) in obese patients. METHODS: This retrospective study included 228 patients (73 males and 155 females, mean age, 32.5 ± 10.3 years) who underwent LAGB at the Changhai Hospital of the Second Military Medical University from June 2003 to June 2011. The body weight and postoperative complications were followed up. RESULTS: The pre-operative mean body mass index (BMI) was 39.5 ± 6.3 kg/m(2). Except in one case of inadequate exposure of the stomach, all laparoscopic procedures were successfully accomplished, with no conversion to open surgery. The mean operation time was 65.0 ± 20.3 min. The mean hospital stay was 2.7 ± 0.9 days. Early postoperative complications (<30 days) occurred in five cases (2.2%) and late complications (>30 days) occurred in 75 cases (32.9%), including 56 cases (24.6%) with band-associated complications. The percentage of excess weight loss (EWL%) at 1, 3 and 5 years was 40.5 ± 30.5%, 59.5 ± 41.5% and 58.9 ± 46.4%, respectively. The percentages of patients with EWL% >25%, >50% and >75% were, respectively, 60%, 33% and 0% at 1 year follow-up, 43%, 39%, and 16% at 3 years follow-up and 40%, 34% and 16% at 5 years follow-up. CONCLUSION Although LAGB has low peri-operative mortality and morbidity rates, it is associated with a high late complication rate and unsatisfactory weight loss. It may be optional, but not the first choice, for the treatment of obesity.

[Efficacy comparison between 2 methods of laparoscopic gastric bypass surgery in the treatment of type 2 diabetes mellitus].

OBJECTIVE: To investigate the outcomes after 2 methods of laparoscopic gastric bypass surgery for patients with type 2 diabetes mellitus(T2DM). METHODS: From December 2009 to June 2011, 21 patients with T2DM underwent laparoscopic gastric bypass surgery, including laparoscopic Roux-en-Y gastric bypass (LRYGB, n=11), and laparoscopic mini-gastric bypass (LMGB, n=10). Clinical data were analyzed retrospectively. RESULTS: The clinical complete remission rate of T2DM was 64%(7/11) in LRYGB group, and 60%(6/10) in LMGB group. The clinical partial remission rate of T2DM was 36%(4/11) in LRYGB group, and 40%(4/10) in the LMGB group. There was no significant difference between the two groups(both P>0.05). The levels of BMI, waist circumference, HOMA-IR and HbA1c within the postoperative 6 months were improved in each group (all P<0.05), but there was no significant difference between the two groups(all P>0.05). There were no conversion or perioperative deaths in both groups. Compared to LMGB, the LRYGB group had longer operative time[(147.0±35.9) min vs. (110.5±39.7) min, P=0.038] and postoperative hospital stay [(8.9±2.3) d vs. (7.1±1.4) d, P=0.046). One patient suffered from ileus in LRYGB group, one patient suffered from reflux esophagitis and one suffered chronic diarrhea in LMGB group. The incidence of postoperative complication was similar between the two groups(P>0.05). CONCLUSION: LRYGB and LMGB may result in satisfactory and safe effects for the treatment of T2DM, while the LMGB is simpler and associates with quicker recovery.

[Understanding of International Sleeve Gastroectomy Expert Panel Consensus Statement and our experience].

An international symposium on the standard surgical treatment of morbid obesity and type 2 diabetes mellitus was held in Florida, USA in March 2011. An expert panel from all over the world attended the meeting. The expert panelists discussed and established International Sleeve Gastroectomy Expert Panel Consensus Statement : best practice guidelines based on experience of more than 12,000 cases, which made a very commendable attempt in standardized surgical pathway of sleeve gastroectomy. Based on clinical experience over 10 years and the understanding of the consensus , this paper discusses the learning curve, preoperative preparation, indications/contraindications, surgical technique, management and prevention of complications, and post operative management.

[Outcomes after laparoscopic surgery for 219 patients with obesity].

OBJECTIVE: To evaluate the outcomes after laparoscopic gastrointestinal surgery for patients with obesity and type 2 diabetes mellitus(T2DM). METHODS: From June 2003 to June 2010, 219 patients underwent laparoscopic gastrointestinal surgery for obesity and T2DM, including laparoscopic adjustable gastric banding(LAGB, n=201), laparoscopic mini gastric bypass(LMGB, n=13), and laparoscopic sleeve gastrectomy(LSG, n=5). Clinical data were analyzed retrospectively. RESULTS: The mean body mass index(BMI) of patients who received LAGB was 37.9 kg/m(2), and decreased to 32.4 kg/m(2) at 6 months and to 29.7 kg/m(2) at 12 months. In 43 patients who had concurrent T2DM, 11(25.6%) showed clinical partial remission(CPR) and 16(37.2%) clinical complete remission (CCR). Postoperative complications occurred in 26 patients(12.9%). The mean BMI of patients undergoing LMGB was 34.7 kg/m(2), and decreased to 31.6 kg/m(2) at 6 months and 26.9 kg/m(2) at 12 months after surgery. Ten patients had T2DM before operation, of whom 2(20.0%) had CPR and 7(70.0%) CCR postoperatively. Postoperative complications occurred in 2 patients(15.4%). The mean BMI of patients who underwent LSG was 43.8 kg/m(2), and was reduced to 38.1 kg/m(2) at 6 months and 34.3 kg/m(2) at 12 months after operation. Three patients were diagnosed with T2DM before operation. One patient (33.3%) had CPR and 1(33.3%) reached CCR after operation. There was 1(20.0%) patient who developed complication. No perioperative death occurred. CONCLUSION: Laparoscopic gastrointestinal surgery may result in satisfactory weight loss and clinical remission of T2DM with few complications.

Initial experience from the transgastric endoscopic peritoneoscopy and biopsy: a stepwise approach from the laboratory to clinical application.

BACKGROUND AND AIM: Natural-orifice translumenal endoscopic surgery (NOTES) is a newly minimally invasive technique that gives access to the abdominal cavity via transgastric, transcolonic, transvaginal or transvesical routes. The aim of the present study was to evaluate the safety and feasibility of transgastric endoscopic peritoneoscopy and biopsy from laboratory to clinical application. METHODS: With the animals under general anesthesia, a sterile esophageal overtube was placed and a gastric antibiotic lavage was performed. Subsequently, a needle-knife and through-the-scope dilating balloon were used to make an anterior gastric wall incision through which a therapeutic gastroscope was advanced into the peritoneal cavity. After 2 weeks, another transgastric endoscopic exploration was performed in a different location of the stomach. The peritoneal cavity was examined before the gastric incision was closed. After 4 weeks of observation, necropsy was performed. In the clinical application, after gastric lavage, the first step was the creation of the gastrotomy under general anesthesia, sometime under direct vision of the laparoscopic scope. Then the endoscope can be maneuvered in the peritoneal cavity. And peritoneoscopy and biopsy were performed. Biopsies can be obtained from any suspicious areas using punch biopsy forceps. The gastrotomy was then closed with clips. The gastroscopy was examined after one week. RESULTS: Twenty-eight transgastric endoscopic peritoneoscopies and biopsies in pigs and a total of five transgastric human endoscopic peritoneoscopies and biopsies have been performed. All procedures were completed satisfactorily in the pig model and all patients. There were no intraoperative or postoperative complications. CONCLUSIONS: The advantages of peritoneoscopy and biopsy appeared to be enhanced by this approach. Patients had minor postoperative pain and minimal scarring. It is safe and feasible for us to use transgastric endoscopic peritoneoscopy and biopsy in humans.

A modified method of using laparoscopic compression anastomosis clip for gastrointestinal anastomosis.

The aim of this study was to validate a modified method of using a laparoscopic compression anastomosis clip (LapCAC) for gastrointestinal anastomosis in an animal experiment and two clinical cases. Anastomotic surgery of the upper digestive tract was performed on dogs using the conventional and modified methods for LapCAC. The animals were sacrificed postoperatively at different time points to obtain sections from the anastomotic site for pathologic study. Anastomotic outcomes of the two methods were also verified in two clinical cases. The animal experiments and the two clinical cases showed that no anastomotic leakage occurred with the modified method, and that the new method was simple, convenient and reliable as compared with the conventional method. The mean time of placing the anastomosis clip was shorter, and the mean numbers of operation attempts, secondary actions and sutures in the operating holes were reduced. The serosa at the anastomosis healed completely, the muscular layer and submucosal fibers proliferated well, and the anastomosis was covered with mucosa within two weeks after the operation. LapCAC offered a better surgical outcome when it was used according to the modified method, where anastomoses formed smoothly and completely within two weeks after the operation.

Extraluminal laparoscopic wedge resection of gastric submucosal tumors: a retrospective review of 84 cases.

BACKGROUND: Laparoscopic resection of gastric stromal tumors is being performed with increased frequency. This study aims to evaluate the feasibility and safety of the extraluminal laparoscopic gastric wedge resection (ELWR) technique. METHODS: Clinical data of 84 patients who underwent ELWR for gastric submucosal tumors between September 2000 and December 2007 were reviewed and analyzed retrospectively. The operation includes: localization of the tumor, dissection of the omentum, mobilization of the upper stomach and the upper pole of the spleen, exposure of esophago-cardiac junction (ECJ), and wedge resection of the upper part of gastric body and/or the gastric fundus with endoscopic gastrointestinal anastomosis (Endo GIA) stapler. RESULTS: All of the procedures were performed successfully, with mean operation time of 62.6 +/- 8.9 min and mean intraoperative blood loss of 86.2 +/- 8.1 ml. Through extraluminal laparoscopic wedge resection, complete R0 resection was achieved for all tumors. All surgical margins were negative microscopically. No lesions were missed, nor were there any significant postoperative complications or intraoperative conversions to open surgery. A total of 78.6% of the patients recovered their gastrointestinal functions and began to eat and ambulate within 36 h of the operation. The smallest surgical margins were 0.7-2.5 cm, with a mean distance of 1.4 +/- 0.5 cm. Of the 84 cases of gastric submucosal tumors, 29 cases were leiomyomas, 51 cases were various types of stromal tumors, and 4 other cases were neurofibromas. Mean follow-up duration was 51 +/- 4.3 months (overall follow-up rate 73.8%, 62/84 cases), during which no recurrences or metastases were found. CONCLUSION: ELWR is a safe, simple, and effective procedure for treating submucosal tumors in the upper part of the stomach. It can avoid intraperitoneal contamination, possible tumor spillage, and postoperative esophageal stenosis, and provides unlimited scope for gastric resection.

[A new technique for esophagojejunostomy or esophagogastrostomy after laparoscopic gastrectomy].

OBJECTIVE: To report the newly developed reconstruction technique after laparoscopic total gastrectomy: intracorporeal circular stapling esophagojejunostomy using the transorally inserted anvil (OrVil; Covidien), and evaluate its feasibility, safety, and clinical outcomes. METHODS: After LTG (3 patients with gastric carcinoma in the body) or LPG (2 patients with gastric carcinoma in the cardiac and fundus, respectively, and 1 with cardiac stromal tumor), the anvil was then inserted transorally into the esophagus by using the OrVil system. Double-stapling esophagojejunostomy or esophagogastrostomy with a circular stapler was performed intracorporeally. RESULTS: The operations were uneventful. The operative time was (183.3+/-25.8) min, and blood loss was (128.3+/-90.2) ml. Postoperative fluorography revealed no anastomotic leakage or stenosis. Patients resumed an oral liquid diet on postoperative day (4.0+/-1.1), and were discharged on day (9.0+/-2.6). Patients were followed at 28 days and no complications were reported. CONCLUSIONS: LTG with Roux-en-Y reconstruction or LPG with esophagogastrostomy using the OrVil system appear to be safe and reliable with satisfactory short-term outcomes.