Long-term effect of ileogastrostomy surgery for morbid obesity on diabetes mellitus and sleep apnea

BACKGROUND

The long-term effects of ileogastrostomy surgery for morbid obesity on diabetes mellitus and sleep apnea were investigated.

METHODS

All patients who had the ileogastrostomy for morbid obesity at the Bariatric Surgery Clinic of St. Paul's Hospital between 1997 and 2002 were registered in the International Bariatric Surgery Registry (IBSR). In 2005, IBSR follow-up was supplemented with a survey.

RESULTS

Of the 592 consecutive patients registered in the IBSR, 311 were available for follow-up. Of the 15 patients who had diabetes mellitus preoperatively, 12 (80%) had cure of their diabetes mellitus and 3 (20%) were improved. Remission or improvement of diabetes occurred early postoperatively. Of the 20 who had sleep apnea preoperatively, 11 (55%) were cured and 6 (30%) were improved.

CONCLUSIONS

This is the first report of the long-term effect of the ileogastrostomy on diabetes mellitus and sleep apnea. The ileogastrostomy was associated with rapid improvement or normalization of diabetes mellitus, similar to the biliopancreatic diversion and the Roux-en-Y gastric bypass, but faster than other bariatric operations. Improvement in sleep apnea was slower and was related to weight loss, similar to other bariatric operations.

The bilio-intestinal bypass

BACKGROUND

Since 1990 we adopted the bilio-intestinal bypass (BIBP) for all morbid obese patients eligible to a malabsorption procedure. Since 2001 we used laparoscopic technique.

MATERIALS AND METHODS

102 patients; mean age 35.4 (18-54) years; preoperative mean weight Kg 148.3 (105-225); mean preoperative BMI 54.1 kg/m2 (40-66.2); mean follow-up 10 years (1-22). 83 patients underwent open and 19 laparoscopic BIBP. The operation was performed with five lap ports. Section of the jejunum 30 cm from the Treitz and of mesentery was made by linear stapler. The cholecysto-jejunal anastomosis was completed with 45 mm linear stapler. A side-to-side anastomosis between the proximal jejunum and the last 12-18 cm of the ileum was created by firing a 60 mm linear stapler. On the excluded ileum an anti-reflux valve system was hand-sutured.

RESULTS

Five years post-operatively mean weight was 89 (62-130) kg, mean BMI was 31 (24-41) kg/m2. Two patients of the 19 laparoscopic patients were converted in open surgery for adhesions post-appendectomy. The main late complications were incisional hernia (19.3%) and abdominal bloating (2.9%). The reversal and conversion rate was 65%. There was no death.

CONCLUSION

Our experience showed that five years post-BIBP the weight loss was satisfactory in 90.7% of patients. Using laparoscopic technique it is possible to reduce pain, in-hospital time, respiratory and thromboembolic complications, convalescence and incisional hernia.

The progress in bariatric surgery

Morbid obesity, caused by fat tissue accumulation, is a serial multi-factorial chronic disease, with rapidly increasing prevalence in most countries in the world including Poland. Conservative treatment of morbid obesity is almost always unsatisfactory and that is why several surgical methods have been developed. There are four kind of methods: malabsorbtive procedures; restrictive procedures; malabsorbtive/restrictive procedures and experimental procedures. The development of bariatric surgery goes back to 1952 and since that time it has been evolving dynamically. All the surgical methods have benefits and disadvantages. Presently the introduction of minimally invasive surgical techniques seems to be very safe, efficient and cost-effective in treatment for morbid obesity. New methods are also being evaluated, such as gastric myo-electrical stimulation. Bariatric surgery will still be developing until we understand all the factors responsible for it is origin.

Jejunoileal bypass reversal: effect on renal function, metabolic parameters and stone formation

PURPOSE

While the effect of jejunoileal bypass (JIB) reversal has been well studied regarding hepatic function, there is little information regarding the effect of reversal on renal function and even less data regarding the metabolic urinary stone environment. We evaluated the results of JIB reversal on renal function, the urinary stone milieu and the clinical development of recurrent calculi in affected patients.

MATERIALS AND METHODS

From 1995 to 2003, 4 female patients with a mean age of 48.2 years underwent JIB reversal primarily for refractory stone disease. The clinical and metabolic courses prior to and following bypass reversal were reviewed specifically to evaluate renal function, serum and urinary metabolic stone profiles, and clinical stone formation.

RESULTS

At initial presentation following JIB all 4 patients had significantly increased 24-hour urinary oxalate (range 80 to 160 mg, mean 112.5, normal less than 50) and significantly low 24-hour urinary citrate (range 5 to 62 mg, mean 21.5, normal greater than 320). Following reversal 24-hour urinary oxalate normalized to between 31 and 36 mg (mean 33.75). However, 24-hour urinary citrate continued to be low (range 215 to 248 mg, mean 226.5). After JIB reversal all 4 patients continued to have new stones until the commencement of urinary alkalization, following which only 1 had 1 calculus, which occurred 47 months after reversal. After JIB mean serum creatinine was 1.48 mg/dl (range 0.8 to 1.9) and mean urinary creatinine excretion was 0.91 mg per hour (range 0.69 to 1.15). After JIB reversal mean serum creatinine was 1.28 mg/dl (range 0.6 to 2.0) and mean urinary creatinine excretion was 1.0 mg per hour (range 0.85 to 1.10).

CONCLUSIONS

JIB reversal normalizes 24-hour urinary oxalate. While urinary citrate improves, it continues to be low and such patients are at high risk for recurrent stone formation. However, in this setting appropriate replacement therapy has a significant and positive impact on that propensity.

[History and pathophysiologic analysis of the various techniques in bariatric surgery]

Bariatric surgery for the treatment of morbid obesity or overweight refractory to medical therapy was born at the beginning of second half of the twentieth century, and its first steps were uncertain and with a not jet well definite purpose. In fact the main result to be pursued seemed to be simply the reduction of body weight, and any change of anatomy of the digestive tract able to reduce the absorbtion of nutrients was judged adequate. But very early the adverse consequences of malabsorption so obtained became evident, and other operations possibly free from those complications were devised and clinically tested. So aside the by-pass operations many other surgical procedures found their room, all of them aiming to fight the ever more diffuse obesity of the people. This historical review of the various surgical procedures attempted in these last sixty years for morbid obesity is very interesting for a better understanding of the problem and to have a solid basis for future rational choices.

[Technical options in bariatric surgery and their mechanisms of action]

In recent years, bariatric surgery has enjoyed a high level of approval. There are several technical and surgical options. Most of the departments of obesity surgery perform usually the same procedure, when just in a few center the procedure can be adapted depending on the patient need. In this paper the most popular technical choices in our country are presented based on the Consensus Conference that is taking place now in the Italian Society of Obesity Surgery (SICOB), in order to give our guidelines and policies.

Comparison of changes in lipid profile after bilio-intestinal bypass and gastric banding in patients with morbid obesity

BACKGROUND

The presence of hypercholesterolemia is currently not considered a selection criteria for performing gastric restrictive or diversionary bariatric surgery.

METHODS

We prospectively investigated the effects of the bilio-intestinal bypass (BI-bypass) with a wide cholecysto-jejunal anastomosis and of adjustable gastric banding (AGB) on blood lipid concentrations in obese patients. To clarify the mechanism of the hypocholesterolemic effect of the BI-bypass, daily fecal sterol excretion was measured by gas-liquid chromatography (GLC).

RESULTS

At 1 year after BI-bypass compared to baseline, the hypercholesterolemic (n=18) and the normocholesterolemic (n=19) patients significantly reduced total (-38% and -27%, respectively), LDL (-47% and -24%, respectively) and HDL (-11% and -13%, respectively) cholesterol and total / HDL cholesterol ratio (-25% and -13%, respectively). At 1 year after AGB, the total / HDL cholesterol ratio was significantly decreased (-11%) compared to baseline in hypercholesterolemic (n=12) but not in normocholesterolemic (n=6) patients, while total and LDL cholesterol were not affected in both groups. At 3 years after BI-bypass compared to baseline, the hypercholesterolemic (n=9) and the normocholesterolemic (n=11) patients significantly reduced total (-43% and -28%, respectively) and LDL (-53% and -29%, respectively) cholesterol and total / HDL cholesterol ratio (-38% and -21%, respectively). The BI-bypass induced a significant (P <0.005; n=7) 6-fold increase in mean fecal cholesterol output.

CONCLUSIONS

The BI-bypass but not the AGB leads to a persistent and marked beneficial effect on blood LDL cholesterol associated with an increased cholesterol fecal output. BI-bypass but not AGB is indicated in morbidly obese patients with hypercholesterolemia.

Surgical options for obesity

Several bariatric procedures are available that have excellent long-term weight loss results and are backed by several large clinical trials. Purely restrictive procedures like VBG have fallen out of favor because of inadequate long-term weight loss. Gastric bypass and the BPD are well-studied and show significant resolution of obesity-related comorbidities. Long-term nutritional consequences are seen more commonly after malabsorptive procedures like the BPD than after hybrid malabsorptive-restrictive procedures like the gastric bypass. Because compliance and long-term nutritional follow-up are mandatory after any bariatric procedure, purely malabsorptive procedures should be reserved for super obese patients who are at risk for inadequate long-term weight loss. Furthermore, minimally invasive techniques have evolved and essentially have eliminated the high incidence of postoperative wound complications and incisional hernias frequently seen after open gastric bypass. Until the development ofa similarly successful procedure, gastric bypass will continue to be the gold standard bariatric procedure with its concurrent sustained weight loss benefits and resolution of comorbidities.

Metabolic complications of bariatric surgery: diagnosis and management issues

Acute complications after bariatric surgery include rhabdomyolysis and immobilization hypercalcemia. The most common long-term metabolic complications following bariatric surgery are anemia and metabolic bone disease. Neuropathy, acute Wemicke's encephalopathy and vitamin A deficiency also occur. Prevention, diagnosis,and treatment of these disorders are necessary parts of lifelong care after bariatric surgery.

[A new method of surgical treatment of morbid obesity]

The article presents results of surgical treatment of 48 patients with morbid obesity and concomitant metabolic disorders in the clinic of Faculty Surgery of the Bashkir state medical university. A new means of vertical gastroplasty is described allowing to prevent the early development of reflux-esophagatis and to reduce the number of postoperative complications. Stable reduction of the body mass was obtained in 7 patients with morbid obesity by using the method in the clinical practice.

Cardiovascular risk factors in obese patients treated with jejunoileal bypass operation: a 25-year follow-up study

OBJECTIVE

Jejunoileal (JI) bypass was a widely performed surgical procedure for morbid obesity in the 1970s. The purpose of this study was to assess cardiovascular risk factors and mortality in patients 25 years or more after this operation.

MATERIAL AND METHODS

All (n = 36) patients operated on for obesity with JI bypass at Haukeland University Hospital between 1971 and 1976 were evaluated. Survivors (n = 28) participated in a follow-up that included clinical examination and biochemical tests. Preoperative data were compared with data at 1 year (3 years) and 25 years. Causes of death were identified for the deceased.

RESULTS

For the 23 patients alive with intact JI shunts at 25 years there was a statistically significant lowering of body mass index (BMI) (p < 0.01), systolic blood pressure (p < 0.05), diastolic blood pressure (p < 0.001) and serum cholesterol (p < 0.05) compared to before the operation. There was no statistically significant change in fasting blood glucose or serum triglyceride. The serum insulin level was normal in all but one (21/22) of the patients examined. Three out of 26 patients with intact JI shunts, and 5 out of 10 patients with reversed JI shunts, had died.

CONCLUSION

For patients with intact shunts there is a persistent reduction in body weight, serum cholesterol and blood pressure, and a reduced insulin resistance 25 years after JI bypass.

Surgical treatment of obesity: a review

Obesity is a chronic disease due to excess fat storage, a genetic predisposition, and strong environmental contributions. This problem is worldwide, and the incidence is increasing daily. There are medical, physical, social, economic, and psychological comorbid conditions associated with obesity. There is no cure for obesity except possibly prevention. Nonsurgical treatment has been inadequate in providing sustained weight loss. Currently, surgery offers the only viable treatment option with longterm weight loss and maintenance for the morbidly obese. Surgeries for weight loss are called bariatric surgeries. There is no one operation that is effective for all patients. Gastric bypass operations are the most common operations currently used. Because there are inherent complications from surgeries, bariatric surgeries should be performed in a multidisciplinary setting. The laparoscopic approach is being used by some surgeons in performing the various operations. The success rate--usually defined as >50% excess weight loss that is maintained for at least five years from bariatric surgery--ranges from 40% in the simple to >70% in the complex operations. The weight loss from surgical treatment results in significant improvements and, in some cases, complete resolution of comorbid conditions associated with obesity. Patients undergoing surgery for obesity need lifelong nutritional supplements and medical monitoring.

Clinical and cost effectiveness of surgery for morbid obesity: a systematic review and economic evaluation

OBJECTIVE

To assess the clinical and cost effectiveness of surgery for people with morbid obesity.

DESIGN

A systematic review of randomised control trials (RCTs), prospective clinical trials and economic evaluations identified from 14 electronic databases (including Medline, Cochrane library and Embase from their inception to October 2001), bibliographies and consultation with experts and manufacturers was performed to assess the clinical and cost effectiveness of different surgical procedures and nonsurgical management for morbid obesity. An economic evaluation was undertaken to assess cost effectiveness in the UK.

SUBJECTS

People diagnosed as morbidly obese, defined as a body mass index (BMI) (weight in kilograms/height in metres(2)) >40 kg/m(2), or with a BMI>35 kg/m(2) with serious comorbid disease, in whom previous nonsurgical interventions had failed.

MEASUREMENTS

The outcomes assessed included weight change, quality of life, peri- and postoperative morbidity and mortality, revision rates and obesity comorbidities. Cost effectiveness was modelled from these data and presented as cost per quality-adjusted life year (QALY).

RESULTS

Included studies differed in methodological quality. Surgery resulted in a significantly greater loss of weight (23-37 kg more weight) than nonsurgical treatment, which was maintained to 8 years and led to improvements in quality of life and comorbidities. The economic evaluation of surgery compared with nonsurgical management suggested that surgery was cost effective at pound 11000 per QALY. Comparisons of the different types of surgery were equivocal.

CONCLUSION

Surgery for morbid obesity appears to be clinically and cost effective. Because of the nature of the evidence, particularly the uncertainty in the clinical and economic evaluations, it is difficult to distinguish between the different surgical procedures.

Stapled Roux-en-Y anastomosis: an illustrated technique

A technique is described to create a wide enteroenterostomy or Roux-en-Y anastomosis.

[History and present status of surgical treatment of morbid obesity]

Problems of extreme and morbid obesity take on constantly considerable relevance in 21st century. The prevalence of the obesity (BMI--Body Mass Index > 30 kg/m2) is still on the increase worldwide. In the Czech Republic approximately 16% of male and 20% of female in the age of 20-65 years are obese (BMI > 30 kg/m2). To begin with the effective cure is always indicate in case of the obesity over BMI > 30. The bariatric surgery is indicating in the occurrence of failure of conservative care of morbidly obese patients with recurrences of overweight. The morbid obesity with serious associate health complications often represents the vital danger of the patient's life. The development of the bariatric surgery passed from resections of the bowel, gastric bypasses, biliopancreatic diversions, horizontal gastroplasties to in the present the most frequently used methods as the vertical bandage gastroplasty (VBG) and the gastric bandage (GB). The standard applications of the miniinvasive laparoscopic methods with significant decrease of postoperative complications radical changes of the bariatric surgery in the present years.

Obesity and its surgical management

Obesity is increasing in epidemic proportions world-wide. Even mild degrees of obesity have adverse health effects and are associated with diminished longevity. For this reason aggressive dietary intervention is recommended. Patients with body mass indices exceeding 40 have medically significant obesity in which the risk of serious health consequences is substantial, with concomitant significant reductions in life expectancy. For these patients, sustained weight loss rarely occurs with dietary intervention. For the appropriately selected patients, surgery is beneficial. Various operations have been proposed for the treatment of obesity, many of which proved to have serious complications precluding their efficacy. A National Institutes of Health Consensus Panel reviewed the indications and types of operations, concluding that the banded gastroplasty and gastric bypass were acceptable operations for treating seriously obese patients. Surgical treatment is associated with sustained weight loss for seriously obese patients who uniformly fail nonsurgical treatment. Following weight loss there is a high cure rate for diabetes and sleep apnea, with significant improvement in other complications of obesity such as hypertension and osteoarthritis.

Enterogastric brake in rats with segmental bowel resection: role of capsaicin-sensitive nerves

1. Unabsorbed nutrients in the distal gut inhibit upper gastrointestinal motility. 2. The aim of the present study was to investigate changes in gastric motility following segmental resections and to evaluate the role of capsaicin-sensitive afferent neurons that may be responsible for these changes. 3. Wistar albino rats of both sexes (200-250 g) were used. Under aseptic conditions and anaesthesia (100 mg/kg ketamine), a baby-feeding tube was placed distal to the resection in either the ileum or caecum for intraluminal perfusion of saline or 20 lipid. In one group of rats, capsaicin was perfused (0.6) for afferent denervation. One group of rats underwent jejunal and ileal resections with end-to-end anastomosis of the remaining segments and were cannulated distal to these anastomosis. Ten days after the surgery, the percentage gastric emptying of a solid meal was calculated. 4. Intra-ileal (18) and intracaecal (34) lipid perfusions delayed gastric emptying compared with groups perfused with saline (54 and 74, respectively; P< 0.001 and P< 0.01). The delay in gastric emptying by ileal perfusion was significantly greater than that following caecal perfusion (P< 0.05). With both resections, gastric emptying was delayed compared with sham groups (P< 0.05-0.01). Local administration of capsaicin abolished the inhibitory effect of lipid on gastric emptying in healthy intact rats and in the jejunal-resection group, whereas a partial reversal was seen in the ileal-resection group. 5. In conclusion, the present data demonstrate that in both healthy intact rat groups and in short bowel groups, capsaicin-sensitive extrinsic neurons participate in brake mechanisms of the distal gut.

[Method of inter-intestinal anastomosis in surgical treatment of complicated colonic cancer]

The elaborated method of colorectal anastomosis formation was applied for the intestinal continuity restoration after its resection for obturative colonic tumoral ileus. Insufficiency of anastomotic sutures was not revealed. Postoperative complications had occurred in 2 (6.9%) of patients. All the patients have survived.

How effective is extensive nonsurgical treatment of patients with clinically active Crohn's disease of the terminal ileum in preventing surgery?

BACKGROUND/AIMS

The purpose of this study is to determine the effectiveness of extensive nonsurgical management of patients with clinically active Crohn's disease of the terminal ileum and to identify parameters that could predict failure of this nonsurgical approach.

METHODS

All consecutive patients hospitalized for the first time because of active Crohn's disease of the terminal ileum between 1985 and 1994 were included. Two groups of patients were defined. Patients who responded favorably to the extensive treatment protocol (group I), and patients in whom an ileocolic resection had been performed (group II). Treatment and patient characteristics were related to outcome.

RESULTS

Twenty-nine (38%) of the 76 patients were treated successfully by nonsurgical management (group I) and did not have surgery until the end of follow-up (mean 8.0 years, range 3-12 years). In total, 47 patients (62%) had ileocolic resection (group II). Logistic regression analysis revealed that a longer time between onset and exacerbation of this disease, the presence of stenosis and extraintestinal manifestations were independent predictors of failure of nonsurgical treatment.

CONCLUSION

Prolonged medical treatment is effective in only one third of the clinically admitted patients. It should be applied with caution particularly in patients exhibiting stenosis, extraintestinal manifestations or a known history of Crohn's disease of more than 5 years.

[Principles of surgical treatment of morbid obesity]

The incidence of morbid obesity has steadily increased over the last few years. Although conservative treatment of morbidly obese patients made some progress (e.g. Xenical), a persistent weight reduction can hardly be achieved in these patients. The possibility of a minimal invasive approach lead to a revival of the surgical therapy of morbid adiposity. The laparoscopic gastric banding became an attractive therapy for patients presenting with a body mass index greater than 40 kg/m2. However, the long-term follow-up after laparoscopic gastric banding increasingly shows the limit of this surgical approach and emphasises the importance of a determined preoperative patient selection. This article reviews the clinical basics and functional mechanisms of different surgical methods to treat morbid obesity comparing their advantages and disadvantages. Due to the widely and nowadays very popular application of laparoscopic gastric banding, this operative method is described in detail.

[X-ray and radiological aspects of primary and reconstructive jejunal interposition]

The late outcomes of primary and reconstructive jejunogastroplasty for motor and evacuatory dysfunctions of the graft and the gastrointestinal tract as whole were studied. Based of X-ray and radioisotopic findings, the paper shows the procedure used to form an artificial stomach from the large intestinal loop to obtain an invaginational valve at the site of jejunoduodenal atastomosis to be beneficial. This procedure makes it possible to recover the evacuatory function of the stomach removed, to prevent a number of postgastrectomic and postresectional disorders in the late postoperative period. Dynamic hepatobiliary scintigraphy was shown to be effective in examining the functional outcomes of gastric surgery and in diagnosing suspected reflux.

Ileogastrostomy or jejunoileal bypass with drainage of the bypassed bowel into the stomach

Ileogastrostomy was first performed for morbid obesity in 1982. In this review, the rationale and technique for the operation are described, and the results and complications discussed. An interesting aspect in a changing world is the lack of modification that has occurred in the surgery, and the possibility of long-term results which are rare in bariatric surgery. The techniques of wound closure have changed, however. The surgery is simple to perform and achieves excellent weight loss and reversal of co-morbid conditions such as non-insulin-dependent diabetes mellitus, but requires long-term follow-up. The principal long-term problem is calcium oxalate renal stones, with occasional patients having troublesome diarrhoea.