Calorie restriction and not glucagon-like peptide-1 explains the acute improvement in glucose control after gastric bypass in Type 2 diabetes.

AIMS: To compare directly the impact of glucagon-like peptide-1 secretion on glucose metabolism in individuals with Type 2 diabetes listed for Roux-en-Y gastric bypass surgery, randomized to be studied before and 7 days after undergoing Roux-en-Y gastric bypass or after following a very-low-calorie diet. METHODS: A semi-solid meal test was used to investigate glucose, insulin and glucagon-like peptide-1 response. Insulin secretion in response to intravenous glucose and arginine stimulus was measured. Hepatic and pancreatic fat content was quantified using magnetic resonance imaging. RESULTS: The decrease in fat mass was almost identical in the Roux-en-Y gastric bypass and the very-low-calorie diet groups (3.0±0.3 and 3.0±0.7kg). The early rise in plasma glucose level and in acute insulin secretion were greater after Roux-en-Y gastric bypass than after a very-low-calorie diet; however, the early rise in glucagon-like peptide-1 was disproportionately greater (sevenfold) after Roux-en-Y gastric bypass than after a very-low-calorie diet. This did not translate into a greater improvement in fasting glucose level or area under the curve for glucose. The reduction in liver fat was greater after Roux-en-Y gastric bypass (29.8±3.7 vs 18.6±4.0%) and the relationships between weight loss and reduction in liver fat differed between the Roux-en-Y gastric bypass group and the very-low-calorie diet group. CONCLUSIONS: This study shows that gastroenterostomy increases the rate of nutrient absorption, bringing about a commensurately rapid rise in insulin level; however, there was no association with the large post-meal rise in glucagon-like peptide-1, and post-meal glucose homeostasis was similar in the Roux-en-Y gastric bypass and very-low-calorie diet groups. (Clinical trials registry number: ISRCTN11969319.).

Reversal of Type 2 diabetes after bariatric surgery is determined by the degree of achieved weight loss in both short- and long-duration diabetes.

AIM: To define the impact of duration of diabetes and extent of weight loss on the reversibility of Type 2 diabetes after bariatric surgery. METHODS: Complete data were collated from 89 individuals with Type 2 diabetes mellitus undergoing any bariatric surgical procedure in a specialist bariatric centre. People with a preoperative HbA1c < 43 mmol/mol (6.1%) were excluded. Diabetes duration was defined as: short, < 4 years; medium, 4-8 years; and long, > 8 years. RESULTS: An HbA1c of <43 mmol/mol (6.1%) was achieved by 62% of patients in the short-duration group and 26% of patients in the long-duration group. Normoglycaemia was rarely achieved in the long-duration group if weight loss was < 25 kg. In the whole cohort there was a clear relationship of greater weight loss with lower HbA1c levels (Rs = -0.53; P < 0.0001). CONCLUSIONS: The study shows that the degree of achieved weight loss is the major determinant of return to normal blood glucose levels after bariatric surgery. Normoglycaemia can be achieved in long-duration Type 2 diabetes, but a greater degree of weight loss is required than for short-duration diabetes.

Laparoscopic adjustable gastric band survival in a high-volume bariatric unit.

BACKGROUND: Although laparoscopic adjustable gastric bands (LAGBs) have been shown to be efficacious, their long-term usefulness has been questioned. This study examined the fate of LAGBs in a unit with over a decade of experience in their use. Patient factors related to the need for, and timing of, band removal were investigated. METHODS: A prospectively maintained database was used to identify all patients with a LAGB. Patient demographics, need for band removal and band survival were examined. Logistic regression modelling was done and Kaplan-Meier curves were calculated for band survival. RESULTS: Between 2000 and 2012, 674 bands were placed in 665 patients. Of these, 143 (21.2 per cent) were removed. There was no difference in rates of removal by sex (P = 0.910). The highest rates of removal were in patients aged less than 40 years (26.7 per cent), and those with a BMI greater than 60 kg/m2 (28.6 per cent). Earlier band removal was seen in younger patients (P = 0.002). Rates of removal increased linearly by earlier year of placement. Of bands placed 4 or more years previously, 35.0 per cent required removal. Eighty-three patients (58.0 per cent) who had a LAGB removed went on to have a further bariatric procedure (band to bypass, 66; band to sleeve, 17). CONCLUSION: Even in experienced hands LAGB does not appear to be a definitive solution. In a large number of patients there appears to be a finite 'band life', with the majority of patients requiring conversion to a further bariatric procedure.

Intra-gastric balloon therapy and weight reduction.

BACKGROUND: Intra-gastric (TBT) can achieve pre-operative weight loss in obese patients, and may make surgery safer and easier. We report our experience in weight reduction and outcome in morbidly obese patients. METHODS: Data were prospectively collected in 50 consecutive morbidly obese patients undergoing intra-gastric balloon therapy. All balloons were inserted and removed by one consultant operator and injected with 500-600 mls of methylene blue-stained saline. Patients were admitted after balloon insertion to control nausea and reflux symptoms. Analysis was performed on post-insertion data collated from the hospital obesity database and patient note review. RESULTS: The majority of patients (70%) were female. Prior to IBT, mean patient weight was 149.9 +/- 36.8 kg (male 184.7 +/- 38.1 kg, female 135 +/- 26.5 kg). At six months follow-up, mean weight of patients reduced to 133.5 +/- 34.3kg (male 166.8 +/- 33.3 kg, female 119.3 +/- 25.9 kg). The overall percentage of excess weight loss was 22% (male 17%, female 25%, p=NS). Mean patient body mass index (BMI) at balloon insertion was 52.8 (+/-8.2) kg/m2 (male 56.8, female 51.0), mean patient BMI reduced to 47 (+/-8.1) (males 51.4, females 45.1) at six months. Average BMI loss was 5.8 (male 5.4, female 6.0). CONCLUSION: IBT is an effective method of weight reduction in morbid obesity with an average excess weight loss of 22% in this series. The benefit of pre-operative weight loss in this patient group is likely to be significant, but has yet to be measured.

Haematological indices and haematinic levels after mini gastric bypass: a matched comparison with Roux-en-Y gastric bypass.

Many surgeons believe mini gastric bypass (MGB) is more likely to cause micronutrient malabsorption compared to Roux-en-Y gastric bypass (RYGB). Till date, there is no published study evaluating haematological indices and haematinic levels in patients undergoing MGB and comparing these with a matched cohort of RYGB. Two hundred patients who underwent MGB between October 2012 and October 2015 were matched to 200 patients who underwent RYGB for age, sex, body mass index and time of surgery. We then compared haemoglobin, mean corpuscular volume, iron, ferritin, vitamin B12 and folic acid levels preoperatively and at 6 monthly intervals after surgery until 2 years. The percentage total weight loss was significantly higher in the MGB group compared to the RYGB group at all time points. At 2 years, MGB and RYGB both led to an increase in anaemia rates but the difference was only significant for MGB group. Compared to RYGB, MGB patients were more likely to be anaemic at 2 years, although the difference was not significant statistically (16.6% vs. 12.7%; P value = 0.55). There was a trend for lower iron and folate levels in MGB group compared to RYGB group but the difference was statistically significant at some of the time periods only (significantly lower folate at 6 and 12 months and lower iron at 6 months in the MGB group). MGB leads to a significant increase in anaemia rates in a supplemented cohort. There is a trend towards lower iron and folate levels and higher anaemia rates in MGB group in comparison with RYGB. Larger studies with longer follow-up should evaluate results of MGB with a shorter biliopancreatic limb.

Patient experiences of adjusting to life in the first 2 years after bariatric surgery: a qualitative study.

There is currently little research into the experiences of those who have undergone bariatric surgery, or how surgery affects their lives and social interactions. Adopting a constructivist grounded theory methodological approach with a constant comparative analytical framework, semi-structured interviews were carried out with 18 participants (11 female, 7 male) who had undergone permanent bariatric surgical procedures 5-24 months prior to interview. Findings revealed that participants regarded social encounters after bariatric surgery as underpinned by risk. Their attitudes towards social situations guided their social interaction with others. Three profiles of attitudes towards risk were constructed: Risk Accepters, Risk Contenders and Risk Challengers. Profiles were based on participant-reported narratives of their experiences in the first two years after surgery. The social complexities which occurred as a consequence of bariatric surgery required adjustments to patients' lives. Participants reported that social aspects of bariatric surgery did not appear to be widely understood by those who have not undergone bariatric surgery. The three risk attitude profiles that emerged from our data offer an understanding of how patients adjust to life after surgery and can be used reflexively by healthcare professionals to support both patients pre- and post-operatively.

Mini Gastric Bypass: first report of 125 consecutive cases from United Kingdom.

Mini Gastric Bypass is a promising bariatric procedure with multiple apparent benefits. Ours is the first unit within the National Health Service of the United Kingdom to be routinely performing this procedure. This retrospective cohort study reports our experience with first 125 procedures. Data were retrospectively analysed from a prospective database. Information was further supplemented by interviewing team members, contacting patients' general practitioners and telephonic follow-up. The mean follow-up was 11.4 months. There were 86 (68.8%) females and the mean age was 45 (range 20-70) years. Mean weight and body mass index was 135.8 (range 85-244) kilograms and 48.1 (range 34.5-73.8) kg m(-2) , respectively. The mean operating time was 92.4 (range 45-150) minutes and the mean post-operative hospital stay was 2.2 (range 2-17) days. There was no leak, one 30-day reoperation and no mortality in this study. Three patients required late reoperations and four patients developed marginal ulcers. At 6 months follow-up (n = 114), 27.5 (range 11.4-47.4) % total body weight loss and 60.1 (range 23.2-117.5) % excess body weight loss was seen. The figures at 12 months follow-up (n = 65) were 36.8 (range 23.7-55.4) % and 79.5 (range 44.9-138.3) %, respectively. This study demonstrates early safety and efficacy of Mini Gastric Bypass in a carefully selected British obese population in a high-volume centre.

Preoperative endoscopy may reduce the need for revisional surgery for gastro-oesophageal reflux disease following laparoscopic sleeve gastrectomy.

Laparoscopic sleeve gastrectomy is a safe and effective bariatric operation, but postoperative reflux symptoms can sometimes necessitate revisional surgery. Roux-en-Y gastric bypass is the preferred operation in morbidly obese patients with gastro-oesophageal reflux disease. In 2011, we introduced preoperative endoscopy to assess for hiatus hernia or evidence of oesophagitis in conjunction with an assessment of gastro-oesophageal reflux symptoms for all patients undergoing bariatric surgery with a view to avoid sleeve gastrectomy for these patients. A prospectively maintained database was used to identify patients who underwent sleeve gastrectomy before and after we changed the unit policy. The need for revisional surgery in patients with troublesome gastro-oesophageal reflux disease was examined. Prior to 2011, 130 patients underwent sleeve gastrectomy, and 11 (8.5%) of them required conversion to Roux-en-Y gastric bypass for symptomatic reflux disease. Following the policy change, 284 patients underwent sleeve gastrectomy, and to date, only five (1.8%) have required revisional surgery (p = 0.001). Baseline demographics were comparable between the groups, and average follow-up period was 47 and 33 months, respectively, for each group. Preoperative endoscopy and a detailed clinical history regarding gastro-oesophageal reflux symptoms may improve patient selection for sleeve gastrectomy. Avoiding sleeve gastrectomy in patients with reflux disease and/or hiatus hernia may reduce the incidence of revisional surgery.

Revisional laparoscopic Roux-en-Y gastric bypass following failed laparoscopic adjustable gastric banding.

BACKGROUND: Obesity is a worldwide epidemic and surgery is the only proven long-term treatment. The two most commonly performed bariatric procedures are laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB). There are advocates of both procedures but LAGB is associated with potentially high failure rates and may require conversion to an alternative procedure. METHODS: This study reports our unit results for failed LAGB converted to LRYGB and compares them to primary LRYGB patients. All patients undergoing revisional LRYGB from July 2006 to December 2011 were included in the study. Comparisons were made to patients undergoing primary LRYGB over the same time period for post-operative weight loss, complications and length of stay. RESULTS: Of the patients, 722 were analysed of which 55 underwent revisional surgery. There was no statistical difference in percentage of excess weight loss at 6 months, 1 year or 2 years following surgery between the primary and revisional surgery cohorts (54.5, 63.7, 65.2 vs 51.6, 59.5, 59.4, p = NS). There was no difference in morbidity, mortality or length of stay between the two groups. Revisional LRYGB was carried out as a single surgery in 43 (78 %) patients. CONCLUSIONS: Revisional LRYGB surgery can be carried out safely and efficiently in experienced bariatric units. Good short- and medium-term weight loss can be achieved with no increase in morbidity, mortality or length of hospital stay. This study adds weight to the argument that LRYGB is the revisional procedure of choice following failed LAGB.

Laparoscopic adjustable gastric banding: a 10-year single-centre experience of 575 cases with weight loss following surgery.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is one of the commonest bariatric procedures in the UK. This study reports our experience with this procedure over the last 10 years. METHODS: A prospectively maintained database of all the patients undergoing LAGB at our centre between March 2000 and August 2010 was analysed. RESULTS: Five hundred seventy-five patients underwent LAGB at our centre. There was no mortality in this series. Early (30-day) morbidity rate was 2.2 %. Late complications (20 %) comprised: 78 repositioning of the inflation port in 65 patients, repositioning of band in 24 patients (4 %), removal of band in 20 patients (3.4 %), conversion to bypass in 41 patients (7 %), diagnostic laparoscopy in 1 patient and subtotal gastrectomy in 1 patient. Median follow-up was 29 months. The median of percentage of weight loss (%WL) and excess body weight loss (EBWL) was 18.3 and 40 %, respectively, at ≥ 5 years post-LAGB. Patients with body mass index (BMI) over 50 kg/m(2) were compared to those with BMI ≤ 50 kg/m(2). No significant difference was noted in the weight loss between both of these groups. No significant difference was noted with regards to weight loss between patients <60 and >60 years of age. CONCLUSIONS: In this cohort of patients, %WL and EBWL were 18.3 and 40 % ≥ 5 years after LAGB, respectively, and early and late complication rates were 2.2 and 20 %, respectively. Majority of late complications were in the first 100 patients. Multifactorial causes included the surgical learning curve and patient selection process.

Type 2 diabetes, bariatric surgery and the risk of subsequent gestational diabetes.

Women with pre-existing abnormal glucose regulation are certain to develop gestational diabetes in pregnancy and pre-gestational type 2 diabetes will become more difficult to control. However, an increasing number of women with type 2 diabetes have had bariatric surgery. In this group, the effect of pregnancy on glucose metabolism is unknown. We report two women with type 2 diabetes who underwent laparoscopic gastric bypass surgery with normalization of plasma glucose levels. During subsequent pregnancy, maternal blood glucose levels remained completely normal throughout. This is remarkable given the predisposition to abnormal glucose tolerance and the ongoing obesity, in the face of the insulin resistance of pregnancy. Women with prior type 2 diabetes reversed by gastric bypass surgery are not at high risk for gestational diabetes.

Oesophageal function in tracheoesophageal fistula speakers after laryngectomy.

OBJECTIVES: Patients who have undergone tracheoesophageal puncture for surgical voice restoration often use unnaturally high oesophageal air pressures during speech. This study examined the effect of high oesophageal air pressure on oesophageal body motility, lower oesophageal sphincter function and dyspeptic symptoms. DESIGN: Cross-sectional study using several investigative tests of oesophageal function. MATERIALS AND METHODS: Sixteen patients who used tracheoesophageal fistula speech underwent several investigations, including: oesophageal manometry, videofluoroscopy, barium swallow, and tracheal pressure measurements during speech. The patients were also asked to complete a dyspepsia questionnaire. RESULTS: We demonstrated that more than 50 per cent of these patients had subjective or objective disordered oesophageal function. Videofluoroscopy and manometry identified oesophageal dysmotility in the same patients. CONCLUSION: Oesophageal function appears to be altered by tracheoesophageal fistula speech. However, our study showed that there is no contraindication to proceeding with tracheoesophageal fistula voicing even in patients with a history of oesophageal dysfunction.

Randomized clinical trial assessing impact of a lightweight or heavyweight mesh on chronic pain after inguinal hernia repair.

BACKGROUND: Severe chronic pain is a long-term problem that may occur after inguinal hernia repair. The aim of this randomized study was to compare pain of any severity at 12 months after inguinal hernia repair with a partially absorbable lightweight mesh (LW group) or with a non-absorbable heavyweight mesh (HW group). METHODS: Patients were assessed for pain at 1, 3 and 12 months by questionnaire, and were examined clinically at 12 months. RESULTS: Some 321 patients were included in an intention-to-treat analysis, 162 in the LW group and 159 in the HW group. At 12 months, significantly fewer patients in the LW group than in the HW group had pain of any severity: 39.5 versus 51.6 per cent (difference-12.1 (95 per cent confidence interval-23.1 to-1.0) per cent; P = 0.033). The recurrence rate was higher in the LW group (5.6 versus 0.4 per cent; P = 0.037). Five of eight recurrences in LW group were associated with a single participating centre. CONCLUSION: Use of lightweight mesh was associated with less chronic pain but an increase in hernia recurrence after inguinal hernia repair. The latter may be related to technical factors associated with fixation of such meshes rather than any inherent defect in the mesh.

Sporadic medullary thyroid carcinoma associated with toxic multinodular goitre.

First described in 1959, medullary thyroid carcinoma (MTC) arises from parafollicular C cells distributed throughout the thyroid, and may occur in one of two clinical forms, sporadic (80%) or familial. Familial MTC may present as a palpable thyroid nodule, but may also be diagnosed by screening relatives of an index case for a raised basal serum calcitonin or a rise in calcitonin following a stimulated pentagastric test. Both tests are highly sensitive for C-cell hyperplasia and MTC. Sporadic cases of MTC most commonly present as asymptomatic thyroid nodules with normal thyroid function tests. In this note, the history of a patient is presented in which a sporadic MTC was associated with goitre and both symptoms and biochemical evidence of thyrotoxicosis.

Transurethral resection of the prostate without routine antibiotic prophylaxis: screening for complications.

In a prospective study of 61 patients undergoing transurethral resection of the prostate without antibiotic prophylaxis there were no major postoperative complications in 55 cases (90%). A bacteriological screen involving culture of a preoperative sample of urine, an immediate preoperative urethral swab, prostatic chippings, immediate postoperative blood cultures and catheter-removal sample of urine was carried out to investigate the ability to detect infective complications. The blood cultures had a predictive value of 80% (sensitivity 80%, specificity 93%). However, the result was available in time to influence management in only one of four patients with postoperative septicaemia.

Large-scale ambulatory study of postprandial jejunal motility in irritable bowel syndrome.

BACKGROUND: The relationship of small-bowel dysmotility to dietary intake in irritable bowel syndrome (IBS) is obscure. METHODS: This study evaluated postprandial jejunal motility in IBS patients classified as constipation-predominant (n = 25) or diarrhoea-predominant (n = 35) and compared results against 18 volunteers. Twenty-four-hour ambulatory jejunal manometry was carried out in all subjects, and recordings were analysed by microcomputer and visual assessment. RESULTS: By means of analysis of variance (fitting factors for channels, meals, and time periods) postprandial contraction frequency was greater in both patient groups compared with normal (constipation-predominant versus normal, diarrhoea-predominant versus normal; P < 0.001). In the constipation-predominant cohort, contraction amplitudes were lower (constipation-predominant versus normal; P < 0.002). Discrete cluster contractions occurred with similar frequency and duration in both patient and volunteer groups. CONCLUSIONS: Quantitative differences of postprandial jejunal contraction characteristics have been shown between patients with IBS and healthy volunteers. Contraction frequency is greater than normal in both diarrhoea- and constipation-predominant categories, whereas contraction amplitudes are lower in constipation-predominant patients.

Assessment of the physical properties of endoscopic retrieval systems.

BACKGROUND: A reliable method of retrieval of laparoscopically resected organs is required. The physical properties of three commercial systems available for clinical use (two plastic, one woven fabric) were examined. METHODS: Pig abdominal walls and gallbladders containing steel balls to represent gallstones were used to simulate organ retrieval on 60 occasions. The performance of retrieval bags was measured in terms of the temporal profile of pressure developed inside the bag, the force on the bag during withdrawal, and whether or not the bag could be retrieved intact. The force versus elongation relationship was also determined for each bag. RESULTS: Although there was a wide range of maximum pressures recorded (14-320 mmHg) with each retrieval system, the mean pressures in the plastic systems were significantly higher. The forces recorded during attempted withdrawal of both plastic bags were significantly lower than those with the fabric system (BERT bag: mean (range) 87 (25-165) N; Endocatch: 40 (7-123) N; Endopouch: 40 (14-68) N; P = 0.005 Endocatch versus BERT, P = 0.004 Endopouch versus BERT). The BERT bags tore more easily at the site of the grasper. CONCLUSION: Plastic retrieval systems were less likely to burst than fabric systems when subjected to simulated retrieval, and required less force for withdrawal. Plastic systems may therefore be associated with less tumour seeding or gallstone spillage as a consequence of bag disruption.

Importance of reflux symptoms in functional dyspepsia.

The relation between symptom severity in gastro-oesophageal reflux disease (GORD) and quantitated oesophageal acid reflux is variable. Furthermore, when oesophageal acid exposure lies within the conventional normal range, the cause of the symptoms is unknown. This prospective study evaluated 24 hour ambulatory oesophageal pH profiles in relation to objective symptom scores in 100 dyspeptic patients who were free from ulcer and gall stones. Twenty patients had raised oesophageal acid exposure and reflux symptoms consistent with GORD, and 80 had oesophageal pH profiles within the conventional normal range. Forty four of the 80 had severe or moderate reflux symptoms and were classified as having reflux like functional dyspepsia (RFD); 36 had minimal or absent reflux symptoms, and were categorised as having non-reflux dyspepsia (NFD). While oesophageal pH profiles lay within the conventional normal range in both functional dyspepsia subgroups, patients with RFD had consistently greater acid exposure values as follows: mean (SEM) total oesophageal acid exposure time, RFD 16.2 (2.56) min v NFD 9.05 (2.0) min (p < 0.03); percentage of time with pH < 4, RFD 1.4 (0.2) v NFD 0.8 (0.2) (p < 0.03); DeMeester scores, RFD 12.8 (0.5) v NFD 11.4 (0.4) (p < 0.03). The RFD group had a pain/reflux event correlation of 23.8 (5.3)% v 8.1 (3.7)% for the NFD group (p < 0.01). This study shows that patients with RFD have oesophageal acid exposure that lies below the diagnostic threshold for GORD, but exceeds that of patients with NFD. The high pain/reflux event correlation in RFD, suggests that subthreshold oesophageal acid exposure may be associated with troublesome reflux symptoms.