Bariatric surgical anatomy and mechanisms of action

Analysis of the Immunohistochemical Expression of Ghrelin in the Gastric Mucosa and Correlation with Weight Loss After Sleeve Gastrectomy

INTRODUCTION

Sleeve gastrectomy is one of the main techniques used to treat severe obesity. The study of the immunohistochemical expression of ghrelin in the gastric mucosa has already been related to weight loss and can be a promising method to predict the surgical outcome.

PURPOSE

To analyze the immunohistochemical expression of ghrelin in the gastric mucosa and its correlation with weight loss, comorbidities, and inflammatory changes after sleeve gastrectomy.

METHODS

Thirty-five patients submitted to sleeve gastrectomy were evaluated, 29 of whom were female (82.9%), with a mean age of 35.2 years and an average body mass index of 38.1 kg/m². Endoscopic samples of the mucosa were collected, whose ghrelin expression was evaluated in a semi-quantitative way through the stained antibody area. These data were correlated with weight loss at 3, 6, and 12 months and with the control of comorbidities, and inflammatory alterations.

RESULTS

The average total weight loss (TWL%) was 17.7, 26.4, and 32.1%, respectively, at 3, 6, and 12 months. A negative correlation was found between the immunohistochemical expression of ghrelin in the endoscopic biopsy of the fundus and weight loss at 3 (s =  - 0.536; p = 0.001) and 6 months (s =  - 0.339; p = 0.047).

CONCLUSION

The immunohistochemical expression of ghrelin in the mucosa of the gastric fundus was negatively correlated with early weight loss after sleeve gastrectomy.

Abdominal Panniculectomy: Determining the Impact of Diabetes on Complications and Risk Factors for Adverse Events

BACKGROUND

The prevalence of obesity along with bariatric surgery and massive weight loss requiring panniculectomy is increasing in the United States. The effect of diabetes mellitus on outcomes following panniculectomy remains poorly defined despite its prevalence. This study aims to evaluate the impact of diabetes mellitus on complications following panniculectomy and determine risk factors for adverse events.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients undergoing panniculectomy between 2010 and 2015. Patients were stratified based on diabetes status.

RESULTS

Review of the database identified 7035 eligible patients who underwent panniculectomy, of which 770 (10.9 percent) were diabetic. Multivariate regression showed that diabetes mellitus was a significant risk factor for wound dehiscence (OR, 1.92; 95 percent CI, 1.41 to 3.15; p = 0.02). Obesity was a significant risk factor for superficial (OR, 2.78; 95 percent CI, 1.53 to 3.69; p < 0.001) and deep (OR, 1.52; 95 percent CI, 1.38 to 3.97; p = 0.01) incisional surgical-site infection. Smokers were also at an increased risk for superficial (OR, 1.42; 95 percent CI, 1.19 to 1.75; p = 0.03) and deep (OR, 1.63; 95 percent CI, 1.31 to 2.22; p = 0.02) incisional surgical-site infection.

CONCLUSIONS

Diabetes mellitus is an independent risk factor for wound dehiscence following panniculectomy. Obesity and smoking were significant risk factors for superficial and deep incisional surgical-site infection. These results underscore the importance of preoperative risk factor evaluation in patients undergoing panniculectomy for safe outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Surgical Management of Metabolic Syndrome Related to Morbid Obesity

Current treatment approaches in morbid obesity are multimodal in nature. Combination therapies include increases in moderate-intensity aerobic and resistance exercise; behavioral lifestyle changes to increase compliance with diet and activity recommendations; medical nutrition therapy; intensive medical therapy; and metabolic surgical procedures, such as gastric bypass and vertical sleeve gastrectomy. This article focuses on the preoperative evaluation and proper patient selection for metabolic surgery. The procedures are discussed relative to their anatomy, metabolic mechanism of action, and common adverse effects.

Endoscopic Retrograde Cholangiopancreatography in Surgically Altered Anatomy

ERCP in surgically altered anatomy requires the endoscopist to fully understand the procedural goals and the reconstructed anatomy before proceeding. Altered anatomy presents a variety of challenges unique to enteroscopy, and others related to accessing the biliary or pancreatic duct from unusual orientations. Both side-viewing and forward-viewing endoscopes, as well as single and double balloon techniques, are available for ERCP in these settings. Endoscope selection largely depends on the anatomy and length of reconstructed intestinal limbs. Endoscopist experience with performing ERCP in surgically altered anatomy is the most important factor for determining outcomes and success rates.

Post-Bariatric Body Contouring

BACKGROUND

The "epidemic" of obesity has recently been accompanied by a new "epidemic" of massive weight loss. The demand for post-bariatric contouring is rising and, as such, it is extremely important for plastic surgeons to be well versed in the treatment of these patients. Unfortunately, the problem is not solely surgical.

OBJECTIVES

The aim of this article is to understand the nutritional and psychological complications that can occur in patients following massive weight loss, to understand the anatomic deformities in massive weight loss as a means to correct those deformities surgically, and to understand the complications from post-bariatric contouring procedures in an effort to avoid them.

METHODS

This article discusses the nutritional and psychological considerations in the massive weight loss patient, anatomical considerations in this patient group, and the surgical techniques designed to address these anatomic concerns. Important pertinent studies are reviewed and discussed.

RESULTS

Anatomical changes are encountered in each region of the body: there are surgical options available to correct them, although potential complications are associated with these surgical procedures. These surgical options are reviewed as well as the risk and benefits associated with them.

CONCLUSIONS

There are many problems that need to be addressed in the massive weight loss patient prior to embarking on surgical treatment. Additionally, surgery on massive weight loss patients has unique considerations that distinguish these operations from those performed on the non-bariatric population.

Sleeve gastrectomy improves obstructive sleep apnea syndrome (OSAS): 5 year longitudinal study

BACKGROUND

Obstructive sleep apnea syndrome (OSAS) is prevalent among morbidly obese patients. Evaluation of the specific effects of sleeve gastrectomy (SG) on upper airway function has not been reported. Given the possibility that some patients will not respond despite weight loss, no studies have investigated whether other mechanisms may be responsible for persistent OSAS after bariatric surgery.

OBJECTIVES

To evaluate by subjective and objective assessment the impact of SG on upper respiratory physiology in the long-term.

SETTING

University Hospital, Division of Bariatric and ENT Surgery, in Italy.

METHODS

Thirty-six consecutive patients with OSAS who underwent laparoscopic SG were prospectively enrolled. The effect of SG on respiratory function and OSAS was followed for 5 years.

RESULTS

All patients completed the 5-year follow-up. A significant (P<.001) improvement in modified Epworth Sleepiness Scale questionnaire (ESS) was obtained in 91.6% (33/36) of patients. The Apnea/Hypopnea index (AHI) improved in 80.6% (29/36) of patients after surgery (from 32.8 ± 1.7 to 5.8 ± 1.2 (P<.001), 4.9 ± 1.7). The remaining 19.4% (7/36) of patients with a positive ESS and/or AHI all had an associated respiratory resistance due to nasal obstructive diseases.

CONCLUSION

SG improved OSAS overall, but patients who did not improve or only partially improved despite weight loss were found to have an associated nasal responsible pathology. How these patients will respond to nasal surgery and whether a 2-step procedure should be recommended for OSAS patients requires further study.

Routine Screening Endoscopy before Bariatric Surgery: Is It Necessary?

Background: Routine esophagogastroduodenoscopy (EGD) prior to bariatric surgery has not been consistently shown to change the management of the patient. A study was performed to estimate the proportion of patients undergoing bariatric surgery evaluation who had abnormal findings on preoperative EGD that resulted in alteration of management and, second, to evaluate potential risk factors for occurrence of abnormal findings on the EGD. Methods: An observational, retrospective study in which all 232 patients who were cleared to undergo bariatric surgery and who underwent preoperative EGD between 2006 and 2013 were included at a single tertiary dedicated bariatric center for weight loss management. Abnormal findings on screening EGD and medical or surgical management alteration based on the EGD findings were reviewed. Results: Abnormal findings on screening EGD were found in 143 patients (61.6%). Thirty-five patients had medical management altered (15.1%), while four patients (1.7%) had surgical management altered. Being aged >55 years and the presence of gastroesophageal reflux disease were associated with occurrence of an abnormal finding on screening EGD. Conclusions: While abnormalities on preoperative EGD are often found in patients undergoing bariatric surgery evaluation, rarely do the findings change surgical management. Alternative methods for screening for common GI conditions should be considered in appropriate patients.

Body image concerns in obese women seeking bariatric surgery

Purpose

– The purpose of this paper is to assess multidimensional body image concerns in a sample of obese women seeking bariatric surgery at an outpatient hospital clinic in Hamilton, Ontario, Canada.

Design/methodology/approach

– A sample of obese adult women seeking bariatric surgery at an outpatient medical clinic in Hamilton, Ontario, Canada (n=148) completed various self-report measures of body image concerns, including body image dysphoria, body image quality of life, body image investment, and appearance satisfaction. Participant scores were compared to normative data. Correlations between body image concern measures and body mass index (BMI) were examined.

Findings

– Participants endorsed more body image dysphoria, more negative body image quality of life, and less appearance satisfaction than normative samples. BMI was not correlated with body image concern scores.

Practical implications

– Interventions aimed at reducing body image disturbance in obese women should target multiple components of body image concern. Decisions about who should receive interventions should not be based on BMI status.

Originality/value

– The majority of research on body image concerns focuses exclusively on evaluative constructs such as body image dissatisfaction. The current study examined affective, cognitive, and behavioural body image constructs. A better understanding of the multidimensional nature of body image concerns in obese women seeking bariatric surgery informs the development of effective, targeted interventions.

Surgical interventions for obesity and metabolic disease

Obesity continues to be a growing problem in both the developed and the developing world. Its strong link with co-morbid conditions such as type 2 diabetes, hypertension, obstructive sleep apnea, and depression presents an increasing strain on health care systems around the world. Diet and exercise alone has been shown to be largely ineffective at managing obesity. Surgery is the only evidence-based method of allowing morbidly obese patients to lose weight and to maintain this weight loss. Weight-reduction in obese individuals from bariatric surgery has also been found to markedly improve obesity-related co-morbid conditions, particularly, type 2-diabetes. Diabetic remission from bariatric surgery has resulted in the inclusion of bariatric surgery, by the International Diabetes Taskforce, as a treatment modality for type-2 diabetes. This consensus statement named four surgical options that have been found to be effective in both weight-loss and in inducing diabetes remission. These four surgical procedures lead to weight-loss through restrictive and malabsorptive mechanisms. Each specific operation has a different level of efficacy in inducing weight-loss and diabetic remission, as well as distinct types and rates of complications. This article reviews the best evidence that exists for the effectiveness and complications of these four operations.

Endoscopic approach to the bile duct in the patient with surgically altered anatomy

Endoscopic retrograde cholangiopancreatography (ERCP) in surgically altered anatomy can be technically challenging, because of three main problems that must be overcome: (1) endoscopically traversing the altered luminal anatomy, (2) cannulating the biliary orifice from an altered position, and (3) performing biliary interventions with available ERCP instruments. This article addresses the most common and most challenging variations in anatomy encountered by a gastroenterologist performing ERCP. It also highlights the innovations and progress that have been made in coping with these anatomic variations, with special attention paid to altered anatomy from bariatric surgery.