Gastroparesis: an evidence-based review for the bariatric and foregut surgeon.

Gastroparesis is a gastric motility disorder characterized by delayed gastric emptying. It is a rare disease and difficult to treat effectively; management is a dilemma for gastroenterologists and surgeons alike. We conducted a systematic review of the literature to evaluate current diagnostic tools as well as treatment options. We describe key elements in the pathophysiology of the disease, in addition to current evidence on treatment alternatives, including nutritional considerations, medical and surgical options, and related outcomes.

Qualifying for bariatric surgery: is preoperative weight loss a reliable predictor of postoperative weight loss?

BACKGROUND: Over the last 20 years, bariatric surgery has emerged as a highly effective weight loss intervention that can also improve co-morbid medical conditions. However, some payors have required preoperative supervised diets and weight loss. OBJECTIVE: To determine if preoperative weight loss is the best predictor of postoperative weight loss. SETTING: Academic county hospital, United States. METHODS: A retrospective chart review of 218 patients. Patients who received psychological evaluation and bariatric surgery were followed up at 1 year. All preoperative patients were encouraged to lose weight; however, no specified amount of weight loss was required. Preoperative weight loss and postoperative weight loss in body mass index (BMI), percent excess weight loss, and percent total weight loss were measured. Bariatric outcome predictor variables evaluated included age, race, and sex; BMI change; measures of depression and anxiety; number of unhealthy eating types; and co-morbid medical conditions. A linear regression model and stepwise regression analyses were used to estimate contributions of independent variables to the 1-year weight loss. RESULTS: All patients had a mean 28% reduction in BMI (63.3% excess weight loss and 29.1% total weight loss) at 1 year postoperatively. As a single independent variable, preoperative weight loss was a significant predictor of 1-year change in postoperative BMI (P = .006). However, when age, race, and sex were added to the regression equation, the predictive value of preoperative weight loss became nonsignificant (P = .543). CONCLUSION: The present findings indicate that preoperative weight loss should not be considered in isolation when clearance for bariatric surgery is being evaluated.

Micronutrient deficiencies after laparoscopic gastric bypass: recommendations.

BACKGROUND: The aim of this study was to evaluate the changes of micronutrients in patients with morbid obesity after laparoscopic Roux-en-Y gastric bypass surgery (LRYGBP). METHODS: We retrospectively reviewed 121 patients diagnosed with morbid obesity who undertook LRYGBP and evaluated the serum iron (Fe), calcium (Ca), zinc (Zn), selenium (Se), vitamin A (VitA), 25-hydroxy vitamin D3 (VitD), vitamin B(12) (VitB(12)), and parathormone (PTH) measured at 6, 12, and 24 months after LRYGBP. RESULTS: During a follow-up period of 69 months (June 1999 to February 2005), a cohort of 121 patients, 40 men and 81 women, underwent LRYGBP, a mean age of 46 years (range 22-67). The mean body mass index (BMI) before LRYGBP was 47.00 +/- 7.15 kg/m(2) (range 30.65-76.60 kg/m(2)). After 6 months of the surgery, the mean BMI was 33.79 +/- 6.06 kg/m(2) (range 21.70-52.76 kg/m(2)). The mean BMI decreased (P < 0.001) 6 months after the surgery. Within the following 2 years, the serum Fe, Ca, Zn, Se, VitA, VitD, and VitB(12) had normalized. The serum Zn, Se, and VitA of some patients decreased but were nearly normal. In contrast, serum PTH remained continuously at a higher level than normal. CONCLUSIONS: This study confirms that LRYGBP is a reliable and safe weight loss method for the patients suffering from morbid obesity. After surgery, serum Ca, Zn, and Se metabolisms and PTH levels are altered in these patients. Therefore, multi-vitamin and mineral supplementation are strongly recommended in all patients after LRYGBP.

Endoscopic perineal approach to the presacral space: a feasibility study.

BACKGROUND: Currently, pathologies from the presacral space are explored primarily by using transabdominal approaches. Major complications may occur, including bowel and rectal perforation, or bleeding. To avoid and reduce these potentially severe risks, a new surgical approach to the presacral space, which permits exploration through the perineum with minimal invasive techniques, had already been developed and is now further elaborated in a cadaver and clinical study. STUDY DESIGN: A prospective study was performed using four cadavers with no history of pelvic or perineal disease. A minimally invasive exploration of the presacral retroperitoneum was performed to examine a potential new anatomical surgical space. After positioning the patients in the prone or supine position, a 1-cm vertical median incision was made in the ano-coccygeal ligament. Entry to the presacral space was first established through blunt-finger and balloon dissection. A 30 degrees 10-mm laparoscope was inserted through a 12-mm trocar, and two additional 5-mm trocars were inserted to avoid injury to the sciatic nerve. A clinical pilot study was performed on three patients using this technique. RESULTS: Under direct vision, a wide dissected cavity was observed, with the rectum and mesorectum retracted ventrally. Access and manipulation of posterior pelvic organs were simplified. Placing cadavers in the jack-knife position provided superior accessibility to the presacral space when compared with a supine position. Clear exposure of the sacrum, mesorectum, ureters and bladder, prostate region, iliac vessels (with its branches), and lymph nodes was achieved. CONCLUSION: Endoscopic perineal approach to the presacral space was considered.

Sleeve gastrectomy with wrapping using polytetrafluoroethylene to prevent gastric enlargement in a porcine model.

BACKGROUND: The safety and efficacy of laparoscopic sleeve gastrectomy followed by biliopancreatic diversion with duodenal switch for morbid obesity has been well established. We previously recommended 2-stage laparoscopic biliopancreatic diversion with duodenal switch for super-super obese patients. In the 2-stage version, these patients undergo laparoscopic sleeve gastrectomy as a first-stage procedure, followed by laparoscopic biliopancreatic diversion with duodenal switch as the second stage for more definitive treatment of their obesity. However, short-term weight regain may occur owing to gastric dilation after initial laparoscopic sleeve gastrectomy. The aim of this study was to prevent gastric dilation after sleeve gastrectomy. We designed a sleeve gastrectomy with wrapping using polytetrafluoroethylene dual mesh. METHODS: Eleven Yorkshire pigs weighing 20-25 kg underwent sleeve gastrectomy with wrapping using polytetrafluoroethylene dual mesh (wrapping group) or sleeve gastrectomy only (control group) to compare the weight loss. The animals were weighed weekly postoperatively. Necropsy was performed 8 weeks postoperatively to confirm the wrapping by pathologic report. RESULTS: Four pigs died because of staple line failure or strangulation; no perioperative complications occurred in the other pigs. The operative time for the control group was 198 +/- 60 minutes and for the wrapping group was 181 +/- 86 minutes (P = NS). The average weight of the removed stomach was 123.3 +/- 5.8 g in the control group and 140.3 +/- 69.9 g in the wrapping group (P = NS). The postoperative weight gain at 8 weeks was significantly slower in the wrapping group than in the control group (P <.0001). The pathologic necropsy report noted that the mesh was well attached to the stomach wall at 9 days postoperatively, with no unexpected deaths. CONCLUSION: Sleeve gastrectomy with wrapping using polytetrafluoroethylene dual mesh is feasible, and weight gain was reduced in the porcine model.

Effect of a polyethylene endoluminal duodeno-jejunal tube (EDJT) on weight gain: a feasibility study in a porcine model.

BACKGROUND: Decreased absorption of nutrients results in weight loss. Apart from a surgical bypass or restriction, or pharmacological manipulations, novel approaches include endoluminal devices placed inside the stomach or intestine which could be used to achieve weight loss. Our goal is to verify the technical feasibility of an Endoluminal Duodeno-Jejunal Tube (EDJT) in reducing weight gain in a living porcine model and its safety in a short to medium survival. METHODS: 8 45-kg Yorkshire pigs were used for this study. 4 pigs were used as controls, whereas 3 pigs had a 180-cm and 1 had a 360-cm EDJT implanted and fixed to the first part of the duodenum proximal to the ampulla of Vater with a solenoid circumferential suture by way of a duodenotomy. The EDJT is a 25-mm diameter and 0.05-mm thickness polyethylene tube. The intent was to avoid the mixing of food and biliopancreatic juice for its entire length. RESULTS: Each pig was evaluated daily for symptoms of distress and weighed weekly for 7 weeks. No major complications were observed. The percentage weight changes 7 weeks after surgery in the control group, 180-cm group, and 360-cm group were 22.5%, 6%, and -2.8%, respectively. The EDJT groups (180-cm, 360-cm) had significantly slower weight gains than the control group (P=0.005). CONCLUSION: Use of an EDJT is safe; no major complications, such as obstruction, intussusception, or pancreatitis occurred. The EDJT slowed weight gain dramatically in a porcine model when compared to the controls. A trend of reduced weight gain was obtained with a longer tube.