The effects of bariatric surgeries on nonalcoholic fatty liver disease.

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease and is associated with obesity. Bariatric surgery has been shown to be the most effective method for weight reduction. However, no conclusive data exists on the effects of weight reduction surgery on NAFLD. This study aimed to characterize liver histology, metabolic status, and liver function changes in patients who underwent bariatric surgery, before and after the weight-reduction procedure. This is a phase 1 report of a prospective cohort study of patients who underwent bariatric surgery. Biopsies were obtained at baseline (intraoperatively) and 3 months postoperatively. Clinical characteristics, biochemical profile, and histopathological data [steatosis, NAFLD activity score (NAS), hepatocyte ballooning, lobular inflammation, and degree of fibrosis] were obtained at each time point. Twenty-seven patients were included (9 men and 18 women), and the median age was 35 ± 8 years old. At baseline, 3 patients had dyslipidemia, 4 had diabetes, and 5 patients had hypertension, which did not change at follow-up. The average body mass index decreased from 44.6 ± 7.8 to 34.2 ± 6.3 kg/m2 at follow-up (P < 0.001). On histopathology, 12 of the 18 patients with preoperative steatosis (median score 2) had reduced steatosis scores postoperatively (P = 0.025); fibrosis (median score 1) was also reduced in 17 patients (P = 0.012), and NAS was decreased from 4 (3-5) to 2 (1-3) (P = 0.004). The changes in lobular inflammation and hepatocyte ballooning were not statistically significant on follow-up. The phase 1 results of this study described the histopathological changes following weight reduction surgery and suggested that hepatic steatosis, fibrosis, and NAFLD activity score were reduced 3 months after surgery. This clinical trial is financially supported by the National Plan for Science, Technology and Innovation Program grant number (11-MED1910-02).

Effect of sleeve gastrectomy on the levels of oral volatile sulfur compounds and halitosis-related bacteria.

Background: The association between sleeve gastrectomy and halitosis remains relatively unknown. Therefore, this study aimed to evaluate the effect of sleeve gastrectomy on halitosis and the oral bacterial species associated with halitosis in patients with obesity. Methods: This was a prospective longitudinal cohort study that examined patients before and after sleeve gastrectomy and followed the patients at three time intervals (1, 3, and 6 months) after sleeve gastrectomy. Clinical periodontal measurements (plaque index [PI], gingival index [GI], and probing depth [PD]) were obtained. In addition, plaque samples were collected for quantification of the periodontopathogenic bacteria: Porphyromonas gingivalis, Tannerella forsythia, Treponema denticola, and Fusobacterium nucleatum using real-time quantitative polymerase chain reaction (qPCR). In addition, breath samples were collected to analyze the concentration of volatile sulfur compounds (VSCs), namely hydrogen sulfide (H2S), methyl mercaptan (CH3SH), and dimethyl sulfide (CH3SCH3), via portable gas chromatography (Oral Chroma™). Results: Of the 43 patients initially included, 39 completed the study, with a mean age of 32.2 ± 10.4 years. For PI and GI repeated measurements one way analysis of variance showed a significant increase (p-value < 0.001 for both) one month after surgery, with mean values of 1.3 and 1.59, respectively, compared to the baseline. During the same period, the number of P. gingivalis increased, with a p-value = 0.04. Similarly, the levels of hydrogen sulfide (H2S) and methyl mercaptan (CH3SH) increased significantly in the first month after surgery (p-value = 0.02 and 0.01, respectively). Conclusion: This study demonstrated that sleeve gastrectomy may lead to increased halitosis one month post-surgery, attributed to elevated and P. gingivalis counts, contributing to the development of gingivitis in obese patients who underwent sleeve gastrectomy. This emphasizes the importance of including oral health professionals in the multidisciplinary team for the management of patients undergoing bariatric surgery.

The impact of moderate versus deep neuromuscular blockade on the recovery characteristics following laparoscopic sleeve gastrectomy: A randomized double blind clinical trial.

Background: Anesthesia with deep neuromuscular block for laparoscopic surgery may result in less postoperative pain with lower intra-abdominal pressure. However, the results in the existing literature are controversial. This study aimed to evaluate the effect of deep versus moderate neuromuscular block (NMB) on the postoperative recovery characteristics after laparoscopic sleeve gastrectomy (LSG) for weight loss surgery. Methods: This is parallel-group, randomized clinical trial. The study was conducted at a tertiary care center. Patients undergoing LSG were included. Patients were randomly assigned to either deep (post-tetanic count 1-2) or moderate (train-of-four 1-2) NMB group. The primary outcomes were numeric rating scale scores of the postoperative pain at rest and postoperative shoulder pain. The secondary outcomes were the length of hospital stay (LOS) and postoperative complications. The statistics were performed using StatsDirect statistical software (Version 2.7.9). Results: Two groups were identified: Group D (deep NMB), 29 patients, and Group M (moderate NMB), 28 patients. The BMI mean values for groups D and M were 44 and 45 kg/m2 respectively (P > 0.05). The mean durations of surgery for were 46.7 min and 44.1 min for groups M and D, respectively (P > 0.05). The mean train-of-four (TOF) counts were 0.3 and 0 for groups M and D, respectively (P < 0.05). The mean times from giving reversal agent to tracheal extubation (minutes) were 6.5 and 6.58 min for groups M and D, respectively (P > 0.05). In the recovery room, the means of pain scores were 3 and 4 for groups M and D, respectively (P > 0.05). Upon admission to the surgical ward, the median values of the pain score were non-significant (P > 0.05) (95% CI: 0.4-0.7). The opioid consumption in the recovery room was non-significant between both groups (P > 0.05) (95% CI: 0.3-0.6). Postoperative shoulder pain was non-significant between both groups (P > 0.05) (95% CI: 0.4-0.7). The median values of surgeon opinion of both groups were non-significant (P > 0.05). Regarding the LOS, the mean values of groups D and M were 1.20 and 1.21 days, respectively (P > 0.05). Conclusions: There was no significant difference between moderate and deep NMB techniques in terms of duration of the surgical procedure, postoperative pain, shoulder pain, and length of hospital stay. Further studies on a larger sample size are required to investigate the long-term recovery characteristics of patients with obesity undergoing LSG.

Reliability and validity study of the translated Arabic version of Moorehead-Ardelt Quality of Life Questionnaire II.

OBJECTIVES: To generate a translated Arabic adaptation of the revised Moorehead-Ardelt Quality of Life Questionnaire II (MA-II), then to assess its reliability and validity. METHODS: The MA-II was translated to Arabic by 3 independent translators. Next, a concise translation, developed from the 3 translations, was re-translated to English and was compared with the original questionnaire. Both the reliability and the validity of the Arabic MA-II were assessed in 144 patients struggling with obesity before and after bariatric procedures at Khalid University Hospital, Riyadh, Saudi Arabia. Apart from the demographic data, both the MA-II and the 36-item short-form health survey (SF-36) were used to collect health-related quality of life (HRQL) data. The test-retest method and Cronbach's alpha (α)were used to assess reliability and internal consistency. RESULTS: Test-retest reliability exhibited an intraclass correlation coefficient of 0.966. The internal consistency of the translated version was also high (α=0.812). A satisfactory correlation was demonstrated between the translated Arabic version and the 8 items of the SF-36. A significant negative correlation was also observed between the MA-II and body mass index (r= -0.5778, p<0.001). CONCLUSION: The robustness and sustainability of the translated Arabic version of the MA-II suggested that this disease-specific instrument is a reliable and valid tool for the measurement of HRQL in obease Arabic-speaking people.

Pre-incisional Laparoscopic Preperitoneal Local Anesthetic Technique in Laparoscopic Sleeve Gastrectomy.

Background: The increasing prevalence of obesity is a significant concern worldwide. Laparoscopic sleeve gastrectomy (LSG) is an effective and standard procedure for sustained weight loss. However, optimal pain control is essential for enhanced recovery after surgery. The aim of this randomized controlled study was to investigate the efficacy of a pre-incisional laparoscopic preperitoneal local anesthetic technique (PLPLAT) on recovery characteristics following LSG. Methods: A total of 120 obese patients scheduled to undergo LSG were randomized into the PLPLAT or placebo group (n = 60 patients in both groups). All patients received conventional intravenous or other analgesics postoperatively, as required. The primary outcome was the postoperative pain score. The secondary outcomes included morphine consumption, other analgesics, length of stay in the postanesthesia care unit (PACU), hemodynamic changes, postoperative nausea and vomiting (PONV), early mobilization, and length of hospital stay. Results: Pain scores in the PACU and at 12 hours after surgery in the ward were significantly lower in the PLPLAT group than in the placebo group (P < 0.05). The morphine consumption was significantly less in PLPLAT group with mean dosage of 2.95 mg (± 0.39) compared to 6.0 mg (± 0.4) in placebo group. PONV, mean arterial pressure, and PACU stay were significantly higher in the placebo group than in the PLPLAT group (P < 0.05). Conclusion: Intraoperative PLPLAT provide effective postoperative pain relief for patients undergoing LSG. The findings indicated the efficacy of PLPLAT in reducing postoperative pain, enhancing recovery, and facilitating early discharge.

Blood Group and Response to Bariatric Surgery in Morbidly Obese Patients: A Retrospective Study in Saudi Arabia.

OBJECTIVES: To explore the relationship between the blood group of patients and their response to bariatric surgery and to identify predictors of better outcomes. METHODS: This was a retrospective cross-sectional analysis of patients who underwent laparoscopic sleeve gastrectomy for morbid obesity between 2014 and 2020 at King Saud University Medical City in Riyadh, Saudi Arabia. RESULTS: This study included 1434 individuals. The mean change in BMI (pre- versus post-BMI) differed statistically significantly between blood groups (p ≤ 0.01). The greatest drop in body weight was seen in individuals with the AB-negative blood type (56.0 (21.4) kg), which corresponds to the greatest percentage of reduction from baseline (47.7% (14.8)). The mean BMI of the patients decreased by 34.7% (9.2) from a mean pre-operation BMI of 45.5 (8.4) kg/m2 to 29.7 (6.1) kg/m2 (p ≤ 0.001). After laparoscopic sleeve gastrectomy, male patients and those with the B-negative blood type are more likely to see a greater BMI reduction (pre-operation compared to post-operation) (p ≤ 0.05). CONCLUSIONS: For morbidly obese patients, laparoscopic sleeve gastrectomy demonstrated promising weight loss outcomes. Blood groups may be able to predict the success rate of bariatric surgery in morbidly obese patients.

Laparoscopic Ventral Hernia Repair with Poly-4-Hydroxybutyrate Absorbable Barrier Composite Mesh.

BACKGROUND: Repair of ventral and incisional hernias (VIHR) is a common procedure, newly introduced resorbable mesh biomaterials provide an attractive option to reduce the use of permanent synthetic mesh in hernia surgery and reduce its complications. However, data on the use of slowly resorbable mesh materials remains scarce, this study aims to evaluate the use of poly-4-hydroxybutyrate/absorbable barrier composite mesh (P4HB/ABCM) in laparoscopic repair of VIHR. METHODS: This is a retrospective study of a sequential cohort of patients undergoing laparoscopic VIHR utilizing a P4HB/ABCM mesh. Perioperative characteristics and clinical outcomes were collected. RESULTS: In total, 26 patients including 10 females and 7 males underwent laparoscopic VIHR using P4HB/ABCM. All surgeries were performed in a single institution by the same surgeon. The average patient age was 52.6, and the mean BMI was 35.5. All patients had a clean wound classification. The average defect size was 136.4 cm2. All patients were seen in clinic with a median follow-up of 28 months. We observed 4 wound seromas, and no wound infections or recurrences during the follow-up period. CONCLUSION: Results of laparoscopic VIHR with P4HB/ABCM are favorable and encourages further studies on the role of absorbable biosynthetic mesh materials in hernia surgery.

The Relationship Between Thyroid Function and Body Composition, Leptin, Adiponectin, and Insulin Sensitivity in Morbidly Obese Euthyroid Subjects Compared to Non-obese Subjects.

BACKGROUND/OBJECTIVES: Thyroid function tests (TFTs) changes in obese people have been studied with increasing interest, however, studies have been inconsistent hence it remains poorly understood. We compared the TFTs of morbidly obese euthyroid Saudi subjects with non-obese controls and then we examined the influence of leptin, adiponectin, and insulin resistance on TFTs. SUBJECTS/METHODS: Fifty-five euthyroid obese subjects attending bariatric surgery clinic and 52 non-obese age-and gender-matched controls were recruited. We measured body weight, BMI, body composition, thyroid-stimulating hormone (TSH), Free T4 (FT4), Free T3(FT3), thyroid antibodies, fasting leptin, adiponectin, and lipid profile. Insulin resistance was quantified by HOMA-IR. Data are presented as mean ± SEM. RESULTS: Mean BMI was 45.6 ± 1.5 and 23.2 ± 0.5 kg/m2, for the obese and non-obese controls, respectively, P value < 0.001. Mean TSH was 2.7 ± 0.18 mIU/L in obese subjects and 1.7 ± 0.13 mIU/L (0.27-4.2) in the non-obese controls, respectively, P value .014. Mean FT3 was 3.9 ± 0.1 pmol/L (3.1-6.8) in obese subjects compared to 5.0 ± 0.1 pmol/L in non-obese controls, respectively, P value 0.001, however, FT4 was similar in the 2 groups. In the whole group (N = 107), BMI correlated positively with TSH and negatively with FT3. Leptin correlated negatively with both FT4 and FT3 in the non-obese group only while none of the TFTs correlated with HOMA-IR or adiponectin in either group. Binary logistic regression showed that each 1 unit increase in TSH increased the odds of becoming obese by 12.7, P value 0.009, 95 C.I. (1.9-85.0). Conversely, each - unit increase in FT3 decreased the odds of becoming obese by 0.2, P value 0.023, 95% C.I. (0.05-0.80). CONCLUSIONS: We report a small increase in TSH and a small decrease in FT3 within the normal range in obese subjects compared to non-obese controls. We also report a positive correlation between TSH and BMI with increased odds ratio of becoming obese with the increase in TSH and decrease in FT3. These changes may be either causally related or adaptive to the obesity state. FT4 and FT3 seem to correlate with leptin (but not with adiponectin or HOMA-IR) in the non-obese controls only. Larger mechanistic studies are needed to further elucidate the interesting association between obesity and TFTs.

The Effect of Laparoscopic Sleeve Gastrectomy on Serum Thyroid-Stimulating Hormone Levels in Obese Patients with Overt and Subclinical Hypothyroidism: a 7-Year Retrospective Study.

BACKGROUND: Inconsistent results were reported by several studies that evaluated the effect of weight loss induced by bariatric surgery on thyroid function panel. This study is aimed at evaluating this effect on thyroid-stimulating hormone (TSH) and thyroid hormone replacement dosages in obese population with overt and subclinical hypothyroidism (SH). METHODS: A retrospective study was performed on all morbidly obese patients with previous diagnosis of overt and subclinical hypothyroidism who underwent laparoscopic sleeve gastrectomy from October 2009 to January 2017. The correlation between TSH and body mass index (BMI) and the effect of weight loss induced by bariatric surgery on TSH were investigated. RESULTS: The prevalence of overt and SH in morbidly obese patients was 10.8% and 7.2%, respectively. Thirty-six hypothyroid patients and 67 subclinically hypothyroid patients were included in the study. Hypothyroidism improved in 44.5% of patients and completely resolved in 22.2%, and 33.3% experienced no change. Ninety-one percent of SH patients completely resolved, 6% improved, but 3% worsened, with one patient developed hypothyroidism. Both groups achieved a significant decrease in postoperative BMI. A positively statistically significant association was found between BMI and TSH (p < 0.005). CONCLUSIONS: Our results favor the effect of laparoscopic sleeve gastrectomy in the obese population with overt and SH as shown by the majority of SH resolution and overt hypothyroidism improvement.

Characteristics of morbid obese patients with high-risk cardiac disease undergoing laparoscopic sleeve gastrectomy surgery.

INTRODUCTION: Bariatric surgery is an efficient and safe method of weight reduction among patients who have morbid obesity which cannot be treated by the conservative approach. Safety and feasibility of bariatric surgery among high-risk patients are understudied. Therefore, we aimed to report the patient-level characteristics and outcome among high-risk obese patients undergoing laparoscopic sleeve gastrectomy surgery in Saudi Arabia. METHODS: A retrospective analysis was performed among 13 morbidly obese (BMI >39 kg/m2) patients with high-risk cardiac disease, who were referred to Upper Gastro-Intestinal Surgery Clinic at King Khalid University Hospital, which is a center of excellence in bariatric surgery, for consideration for weight loss surgery. Retrospective data on preoperative weight, height, and BMI, operative details, perioperative complications, length of stay, and information on comorbidities and endocrinal disease were collected for analysis and reporting. RESULTS: A total of 13 patients were included in the analysis. Of the total, 61.5% were males with a mean age 40.38 (SD: 16.28) and a mean BMI 51.87 (SD: 7.69). The mean duration of surgery was 33.30 min (SD: 31.01), while the mean duration of anesthesia was 83.61 min (SD: 34.73). The mean length of stay was 6.76 days (SD: 3.89). Three patients required postoperative HDU admission with a mean length of stay of 1 day, while 5 patients required postoperative ICU admission with a length of stay ranging from 1 to 3 days. Within 30 days after discharge, only 1 patient required ER visit and none of the patients reported any postoperative morbidity and mortality. CONCLUSION: Through this study, we can conclude that laparoscopic sleeve gastrectomy surgery can be considered a safe procedure. However, further studies with a large sample size and a more robust methodology are needed to build upon the findings of this study.

Validating candidate biomarkers for different stages of non-alcoholic fatty liver disease.

Non-alcoholic fatty liver disease (NAFLD) is a common chronic condition caused by the accumulation of fat in the liver. NAFLD may range from simple steatosis to advanced cirrhosis, and affects more than 1 billion people around the world. To date, there has been no effective treatment for NAFLD. In this study, we evaluated the expression of 4 candidate NAFLD biomarkers to assess their possible applicability in the classification and treatment of the disease.Twenty-six obese subjects, who underwent bariatric surgery, were recruited and their liver biopsies obtained. Expression of 4 candidate biomarker genes, PNPLA3, COL1A1, PPP1R3B, and KLF6 were evaluated at gene and protein levels by RT-qPCR and enzyme-linked immunosorbent assay (ELISA), respectively.A significant increase in the levels of COL1A1 protein (P = .03) and PNPLA3 protein (P = .03) were observed in patients with fibrosis-stage NAFLD compared to that in patients with steatosis-stage NAFLD. However, no significant differences were found in abundance of PPP1R3B and KLF6 proteins or at the gene level for any of the candidate.This is the first study, to our knowledge, to report on the expression levels of candidate biomarker genes for NAFLD in the Saudi population. Although PNPLA3 and PPP1R3B had been previously suggested as biomarkers for steatosis and KLF6 as a possible marker for the fibrosis stage of NAFLD, our results did not support these findings. However, other studies that had linked PNPLA3 to fibrosis in advanced NAFLD supported our current finding of high PNPLA3 protein in patients with fibrosis. Additionally, our results support COL1A1 protein as a potential biomarker for the fibrosis stage of NAFLD, and indicate its use in the screening of patients with NAFLD. Further studies are required to validate the use of COL1A1 as a biomarker for advanced NAFLD in a larger cohort.

A Novel Use of Fully Absorbable PhasixTM Mesh for Laparoscopic Inguinal Hernia Repair.

BACKGROUND AND OBJECTIVES: An inguinal hernia is usually repaired with synthetic nonabsorbable mesh, resulting in collagen formation, chronic inflammation, and fibrosis, with significantly reduced hernia recurrence. However, chronic pain may affect the quality of life. Poly-4-hydroxybutyrate (P4HB) mesh was introduced to minimize complications, and starts to degrade in 12-18 months. This study assesses the consequences and results of patients undergoing transabdominal preperitoneal (TAPP) inguinal hernia repair using P4HB mesh (PhasixTM, C.R. Bard Inc., Murray Hill, NJ, USA). METHODS: We performed a pilot study of laparoscopic TAPP repair for inguinal hernias using P4HB mesh in 15 patients (14 male and one female) with an average age of 55.8 y, and an average body mass index of 27.4 kg/m2. We assessed the recurrence rate and patients' chronic pain for 30 months, with institutional review board approval (E-19-3735). The study was conducted from January 2016 to July 2017 in Medical City, King Saud University. We measured postoperative pain, reactions, mesh sensation, discomfort, and recurrence. RESULTS: In 15 patients, we encountered no recurrence or mesh sensation, except in one patient, who experienced mild chronic inguinal pain for one year, without activity restrictions. CONCLUSION: Laparoscopic TAPP inguinal hernia repair using P4HB mesh is safe for combined, direct (medial), and indirect (lateral) inguinal hernia, with no recurrence. P4HB absorbable mesh caused less chronic pain and discomfort. Longer follow-up, more patients and 15 patients repaired using synthetic mesh are necessary to assess the utility of P4HB for inguinal hernia repair globally.

Trends in bariatric surgery and incidentalomas at a single institution in Saudi Arabia: a retrospective study and literature review.

BACKGROUND: Data are lacking on trends in bariatric surgery and the frequency of incidental findings in Saudi Arabia. OBJECTIVE: Report on trends in bariatric surgery as well as our experience in incidental findings along with a literature review (mainly on gastrointestinal stromal tumor). DESIGN: Retrospective chart and literature review. SETTINGS: Academic tertiary care center. PATIENTS AND METHODS: We conducted a retrospective study at King Khalid University Hospital and analyzed the data collected from 2009 to 2019. We collected data on age, body mass index (BMI), H pylori infection, type of bariatric surgery performed, and type and location of incidental findings. MAIN OUTCOME MEASURES: Incidental findings during or after bariatric surgery (in pathology specimen). SAMPLE SIZE: 3052 bariatric surgeries, 46 patients with incidentalomas. RESULTS: The mean and standard deviation for the age of the 46 patients with incidentalomas was 42.1 (13.9) years and the mean (SD) preoperative BMI was 43.4 (6.4) kg/m2. Of 3052 bariatric surgeries performed, the most common type was sleeve gastrectomy (93.9%), followed by gastric bypass surgery (4.58%) and gastric banding (1.47%). The total frequency of incidentalomas was 1.5%; 10.8% of patients had gastrointestinal stromal tumors (GIST), with the stomach being the commonest site for incidental findings. Eighty percent of the patients with GIST were positive for H pylori (P=.01 vs negative patients). CONCLUSION: The number of incidentalomas and other findings were consistent with other reports. All these findings suggest that bariatric surgeons should take special care before, during, and after a laparoscopic operation in obese patients. LIMITATIONS: Since this is a single-center, retrospective study, we did not collect data on important variables such as gender, socioeconomic status of the patient, and family history of obesity, and we did not perform a preoperative esophagogastroduodenoscopy. CONFLICT OF INTEREST: None.

Inhibition of C-reactive protein in morbidly obese patients after laparoscopic sleeve gastrectomy.

BACKGROUND: Obesity is considered a low-grade chronic inflammatory condition as reflected by increased C-reactive protein (CRP) levels. Inflammation is emerging as a predictor of cardiovascular disease and it may be a precursor of the metabolic syndrome. Bariatric surgery is commonly performed as a treatment for morbid obesity offering significant reductions in premature myocardial infarction. Laparoscopic sleeve gastrectomy (LSG) is a relatively new bariatric procedure that is currently used as a definitive procedure for weight loss. The aim of this study is to assess the impact of sleeve gastrectomy on CRP levels. METHODS: This study is part of an ongoing, prospective, cohort study to evaluate LSG impact on iron indices. CRP levels were compared preoperatively and 6 months after surgery. Similarly, demographics including body mass index and excess weight were also compared at these same study points. Data were analyzed using Student paired t test and Pearson product moment correlation analysis. RESULTS: Twenty-nine morbidly obese patients were included. There was significant decrease in body mass index (BMI) between the preoperative and 6-month period (50.9 +/- 13.2 and 35.1 +/- 6.85, respectively; P < 0.001). Also CRP levels were statistically significantly lower at 6 months after surgery (preoperative 12.3 +/- 7.53 mg/L and postoperative 5.6 +/- 4.2 mg/L. P < 0.0001). The significant weight loss as reflected by change in BMI was correlated with the difference between preoperative and postoperative CRP levels. CONCLUSIONS: Massive weight loss in morbidly obese patients induced by LSG causes a significant decrease in CRP levels, which could reduce the risk of cardiovascular diseases in these patients.

Incidental Duodenal Pancreatic Heterotopia During Laparoscopic Sleeve Gastrectomy: A Case Report and Literature Review.

BACKGROUND Heterotopic pancreas is pancreatic tissue that presents outside the normal anatomical location. It is mostly discovered in the upper gastrointestinal tract (mostly the foregut). We report the first case report of incidentaloma of duodenal heterotopic pancreas in obese patients during laparoscopic sleeve gastrectomy. CASE REPORT A 15-year-old Saudi male obese patient was admitted electively for laparoscopic sleeve gastrectomy. Incidentally, during intraoperative procedure, a duodenal nodule was noted in the first part of the duodenum. A wedge resection of the mass was done after a standard laparoscopic sleeve gastrectomy was accomplished and it had an uneventful postoperative course. The histopathological examination showed heterotopic pancreas tissue. CONCLUSIONS Gastrointestinal stromal tumors are found to be the most common incidental pathology during bariatric surgery. The safety and efficacy of excision of similar lesions during laparoscopic sleeve gastrectomy needs to be further investigated.

The Effect of Gabapentin on Postoperative Pain, Morphine Sparing Effect and Preoperative Anxiety in Patients Going for Sleeve Gastrectomy Surgical Procedure.

OBJECTIVE: To determine the effectiveness of preoperative administration of gabapentin in reduction of acute postoperative pain, morphine consumption and preoperative anxiety and sedation in obese patients undergoing laparoscopic sleeve gastrectomy. STUDY DESIGN: Double-blinded randomised control trial. PLACE AND DURATION OF STUDY: King Khalid University Hospital, King Saud University Riyadh, Saudi Arabia, from July 2014 to January 2017. METHODOLOGY: Fifty patients undergoing sleeve gastrectomy were enrolled in the study. The subjects received either 1200 mg gabapentin or placebo 2 hours before surgery. The amount of morphine consumption and postoperative pain at 4, 8,12,16, 20 and 24 hours of surgery were measured. Preoperative anxiety and sedation were recorded at 2 hours interval after the drug administration. RESULTS: There was no significant difference in patient characteristics in both groups. 24 hours PCA morphine consumption was significantly lower in gabapentin group than in the placebo group, 15.08±4.55 vs. 27.80±2.51 (p=0.001). Preoperative VAS anxiety, pre- verses post-drug, was significantly lower in gabapentin group 5.80±1.11 vs. 3.52±1.00 (p=0.001) than in placebo group 6.08 1.28 vs. 6.28 1.24 (p=0.635). Preoperative sedation score was not different in both groups. CONCLUSION: Preoperative oral gabapentin was effective in reducing the postoperative pain, morphine consumption and preoperative anxiety in morbid obese patients undergone laparoscopic sleeve gastrectomy.

Identification of Bacterial and Fungal Pathogens in Patients with Post-Laparoscopic Sleeve Gastrectomy Leakage.

BACKGROUND: Post-laparoscopic sleeve gastrectomy (LSG) leak leads to serious complications, and death may occur. The microbial pattern should be established in order to plan empirical antimicrobial therapy. The intra-abdominal leaks post-LSG were cultured and reviewed. METHODS: Microbial cultures collected from all post-sleeve leakage cases managed at the King Khalid University Hospital (KKUH) from May 2011 until April 2016 were reviewed. RESULTS: A total of 31 patients with positive leak post-LSG were included. The mean presentation time was postoperative day 12. Computed tomography (CT) was done for all patients on presentation with CT-guided aspiration and drainage next day. Samples from the collection were aspirated first for culture then a pigtail drain was kept in place. The average time of drain removal was on the 75th postoperative day. A total of 28 patients (90.3%) had positive culture results. Candida species were the most common organism isolated from 19 patients (61.2%), among them, 10 (32.2%) were positive for Candida species only. Positive bacterial cultures were found in 18 patients (58%). Majority of which single bacterial pathogen isolate, only seven patients had two organisms, and four patients had three organisms. Klebsiella pneumoniae was the most frequent isolated bacteria [8 patients (44.4%)] followed by Streptococcus and Pseudomonas species. Candida albicans was the most common Candida species isolated, 13 patients (68.4%). CONCLUSION: Fungal microbes isolated from post-LSG leak collection are common and could be considered in the primary empirical therapy. The antibiotic choice for the leak should cover Klebsiella, Streptococcus, and Pseudomonas until definitive culture results are obtained.

Prevalence and Predictors of Gastroesophageal Reflux Disease After Laparoscopic Sleeve Gastrectomy.

BACKGROUND AND AIMS: Laparoscopic sleeve gastrectomy (LSG) might be associated with a new onset or worsening of gastroesophageal reflux disease (GERD). We aim to evaluate the prevalence of post-LSG GERD symptoms and its predictors. METHODS: We included patients who underwent primary LSG at a university hospital from 2009 to 2015. We used the GERD-Health-Related Quality of Life (GERD-HRQL) questionnaire and included questions regarding regurgitation to evaluate symptoms before and after LSG; each item was scored from 1 to 5 based on the symptom severity. RESULTS: A total of 213 patients (mean age, 36.08 ± 10.22 years; 48.36% were men) were included. The mean preoperative body mass index (BMI) was 47.84 kg/m2, mean percent total weight loss was 37.99% (95% CI, 36.64 to 39.34), mean percent excess weight loss was 84.14% (95% CI, 80.91 to 87.36), and the mean percent excess BMI loss was 84.17% (95% CI, 80.94 to 87.41). The mean heartburn score while standing increased (0.71 vs. 1.09, p < 0.01) as well as the score of heartburn requiring a diet change (0.67 vs. 1.16, p < 0.01) post-LSG. The scores for dysphagia, odynophagia, and regurgitation increased. New-onset heartburn was reported in 47.06% of our cohort. Those with high preoperative BMIs were less likely to develop new-onset or worsening symptoms of GERD (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.95-0.99). More severe heartburn symptoms while standing were associated with higher risks of developing or worsening GERD symptoms (OR, 1.22; 95% CI, 1.01-1.47). None of the other variables could predict the development or worsening of the GERD symptoms. CONCLUSION: Symptoms of heartburn and regurgitation are common after LSG; however, none of the variables preoperatively could strongly predict patients who would develop new onset or experience worsening of symptoms postoperatively.

Is body mass index ≥50 kg/m2 a predictor of higher morbidity for patients who have undergone laparoscopic sleeve gastrectomy?

BACKGROUND: Super-morbid obese (SMO) patients (body mass index [BMI] >50 kg/m2) carry a higher risk for bariatric surgery. Despite several studies addressing this patient group, the number of patients included tends to be relatively small. METHODS: We reviewed 708 patients who underwent laparoscopic sleeve gastrectomy between 2009 and 2015 and compared the outcome of SMO (BMI ≥50 kg/m2) patients with MO (BMI <50 kg/m2) patients. RESULTS: Of 708 patients, 217 were SMO and 491 were MO. Both groups had homogeneous baseline characteristics and comorbidities, except sleep apnea which was higher in SMO group. There was no significant difference for the duration of operation, length of stay, or recovery room time. The mean number of trocars was four for both groups. There were no conversions to open or documented intraoperative complications in either group. Postoperative complications occurred in 13 (6%) SMO patients (3 patients with leakage and 10 with bleeding). Postoperative complications occurred in 21 (4.3%) MO patients (11 patients with leakage and 10 with bleeding). No reoperation was done in both groups. There was no surgical mortality. CONCLUSION: We detected no significant difference in the duration of operation and intra- or postoperative complication between SMO and MO groups. The possibility of the safety of this procedure in SMO group can be adopted.

Gastrosplenic fistula in Hodgkin's lymphoma treated successfully by laparoscopic surgery and chemotherapy.

A gastrosplenic fistula is a rare complication of a gastric or splenic lesion. We report a case of Hodgkin's lymphoma nodular sclerosis involving the spleen that was complicated by spontaneous gastrosplenic fistula. The fistula was closed laparoscopically, and the patient underwent partial gastrectomy and gastric wall repair, followed by successful chemotherapy. This is also the first reported case in published literature where closure of gastrosplenic fistula and partial gastrectomy was carried out laparoscopically. We recommend that extensive open surgical procedures including total gastrectomy, splenectomy, and pancreatectomy may be avoided in the management of gastrosplenic fistula, and the patient could be managed by less radical, simple laparoscopic fistulectomy, with partial gastric resection. If the fistula is caused by a malignant process, the surgical repair should be followed by definitive treatment with chemotherapy and radiotherapy.