Jejunoileal bypass as the main procedure in the onset of immune-related conditions: the model of BADAS

SpA plus IBD or IBD plus SpA: Does commutative property apply?

The term spondyloarthritis (SpA) encompasses a group of interrelated disorders characterised by the involvement of the musculoskeletal system as well as extra-articular manifestations like acute anterior uveitis, psoriasis and inflammatory bowel diseases (IBD). Likewise, IBD may present with various extra-intestinal manifestations among which those involving the musculoskeletal system, namely peripheral and axial SpA are the most common. The identification of patients with both SpA and IBD is of paramount importance in clinical practice since the coexistence of these two entities has been associated with great disability and decreased quality of life. In order to achieve an early diagnosis of IBD-SpA it is instrumental that rheumatologists seek for gastrointestinal symptoms in SpA patients and likewise that gastroenterologists seek for inflammatory musculoskeletal symptoms in patients with IBD. This narrative review aims at critically appraising the available evidence about SpA occurring in IBD patients versus IBD occurring in patients with SpA and at highlighting similarities and differences between the two scenarios.

The Bowel-Associated Arthritis-Dermatosis Syndrome (BADAS): A Systematic Review

Bowel-associated arthritis-dermatosis syndrome (BADAS) is a rare neutrophilic dermatosis that was first described in 1971 in patients who underwent bypass surgery for obesity. Over the years, the number of reported cases associated with medical gastroenterological conditions, particularly inflammatory bowel disease (IBD), has progressively increased. To date, there are no systematic reviews in the literature on BADAS. The design of an a priori protocol was based on PRISMA guidelines, and a search of PubMed and Scopus databases was conducted for articles published between 1971 and 2023 related to the topic. Fifty-one articles including 113 patients with BADAS were analyzed in this systematic review. Bariatric surgery and IBD were the most frequently reported causes of BADAS, accounting for 63.7% and 24.7% of all cases, respectively. A total of 85% of cases displayed the typical dermatological presentation, including urticarial maculopapular lesions centered by a vesicopustule, with the majority of lesions located on the upper limbs (73.5%). Polyarthralgia or localized arthritis were always present. Atypical presentations included cellulitis-like, erythema-nodosum-like, Sweet-syndrome-like and pyoderma-gangrenosum-like manifestations. Gastrointestinal symptoms were frequently observed in IBD-related cases (67.9%). The histopathology showed a neutrophilic infiltrate (96.6%). The most commonly used treatment regimens consisted of systemic corticosteroids, metronidazole and tetracyclines, either alone or in combination. A relapsing-remitting course was observed in 52.1% of patients. In conclusion, BADAS is a neutrophilic dermatosis that presents with a wide variety of cutaneous manifestations, both typical and atypical. Gastrointestinal symptoms are frequently observed, particularly in cases related to IBD. The histopathology is clear but not specific compared with other neutrophilic dermatoses. The diagnosis can be challenging, but the relapsing-remitting course and the strong association with polyarthralgia and gastrointestinal disease can aid in the diagnosis.

Endoscopic management of refractory leak and gastro-cutaneous fistula after laparoscopic sleeve gastrectomy: a randomized controlled trial

BACKGROUND

Gastro-cutaneous fistula is a rare complication after laparoscopic sleeve gastrectomy (LSG) with incidence of occurrence 1-2%. Most of gastro-cutaneous fistulae do not respond to conservative management and need intervention either surgically or endoscopically.

METHODS

This prospective randomized clinical study included referred patients who had LSG performed at our department or other centers, and complicated with post-LSG leak or gastro-cutaneous fistula between December/2019 and March/2021. Included patients were ASA Physical status I-II. Primary and secondary outcomes were recurrence of the fistula and mortality in each group after the intervention during the 18 months follow-up period, respectively.

RESULTS

Thirty patients were randomized into two groups: Surgery Group (SG, n = 15) and Endoscopy Group (EG, n = 15). Mean age of patients was 42.3 ± 8.7 and 42.6 ± 8.3 years-old in SG and EG, respectively. Females constituted 73.3% and 80% in SG and EG, respectively. Median time-to-gastric leak post LSG was six (range: 4-7) days in both groups. SG patients were surgically managed with primary repair of the gastric fistula and gastrojejunostomy in 13 patients or converting SG into Roux-en-Y gastric bypass in two patients, while EG patients were endoscopically managed with stitching, stenting, stenting and dilation, and clipping and dilation in 5, 4, 4 and 2 patients, respectively. Incidence of recurrent leak during 1^st week was significantly higher in SG than EG (p < 0.001). No mortality reported in EG, while 2 patients died in SG (p = 0.48).

CONCLUSION

Endoscopic intervention may offer a successful modality in managing post-LSG gastric leak and gastro-cutaneous fistula that do not respond to conservative measures in stable patients.

Laparoscopic sleeve gastrectomy: A role of inflammatory markers in the early detection of gastric leak

Setting:

Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a bariatric option. Gastric leak (GL) is the most dreaded septic complication of LSG. Early detection and treatment of this complication may improve outcomes.

Objectives:

This study investigates biomarkers that might be useful to predict GL before its clinical presentation in patients who underwent LSG.

Patients and Methods:

This study, prospective observational, was carried out in 151 patients, who underwent LSG for morbid obesity between February 2014 and October 2019. Blood samples were collected before the operation and on post-operative days one, three and five to dose serum C-reactive protein (CRP), pro-calcitonin (PCT), fibrinogen, white blood cells (WBCs) count and neutrophil-to-lymphocyte ratio (NLR).

Results:

GL occurred in 6 patients (3.97%). According to the receiver operating characteristics curve, NLR detected leak with remarkably higher sensitivity (100%) and specificity (100%) than CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5. Moreover, the area under the curve (AUC) of NLR (AUC = 1) was higher than the AUC of CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5, suggesting important statistical significance.

Conclusions:

Because NLR and PCT detected GL with remarkably higher sensitivity and specificity than CRP, fibrinogen and WBC, these two markers seem to be more accurate for the early detection of this complication.

Drain Amylase Levels in the Early Diagnosis of Gastric Leak after Laparoscopic Sleeve Gastrectomy

OBJECTIVES

Laparoscopic sleeve gastrectomy is gaining popularity as a bariatric option. Gastric leak is the most dreaded septic complication after this procedure. This study investigated levels of drain amylase that could be useful for predicting gastric leak before its clinical presentation.

SUBJECTS AND METHODS

This prospective observational study was carried out in 167 patients who underwent sleeve gastrectomy for morbid obesity between February 2014 and March 2020. Measurement of drain amylase levels (DALs) was adapted as a routine procedure. The results of the receiver operative characteristic (ROC) curve analysis revealed an optimal drain amylase levels cutoff point of 814.18 IU/L. Consequently, the DALs were classified as DALs &lt814.18 or DALs ≥814.18 for all subsequent analyses.

RESULTS

Gastric leak occurred in 6 patients. Drain amylase levels of 167 patients were tested. The mean value for patients without leak was 71.13 ± 72.11 IU/L; for patients with leak, it was 4,687 ± 6,670 IU/L (p &lt 0.001). Using ROC curve analysis, the mean ± standard error of the area under the curve for DALs on postoperative day 1 was 0.9927 ± 0.0075, CI = 0.978-1.00, and a cutoff level at 814.18 IU/L for predicting gastric leak achieved 83.33% sensitivity and 100% specificity with positive predictive value of 100% and negative predictive value 99.38%. All patients with a leak, but one, had a drain amylase level &gt;814.18 IU/L.

CONCLUSION

The determination of drain amylase levels after sleeve gastrectomy is a significant indicator of gastric leak with high sensitivity and specificity.

Indocyanine Green Fluorescent Angiography During Laparoscopic Sleeve Gastrectomy: Preliminary Results

INTRODUCTION

Indocyanine green (ICG) fluorescent angiography has been routinely applied for various laparoscopic procedures to evaluate the tissue blood supply. A promising branch for this technology is represented by bariatric surgery, especially to estimate the risk of gastric leak after laparoscopic sleeve gastrectomy (LSG), which seems mainly related to ischemia of the stomach.

MATERIALS AND METHODS

43 consecutive patients from January 2018 to March 2019 underwent in our institution LSG with intravenous injection of 5 ml ICG after the realization of gastric tube to evaluate the blood supply of the gastric tube.

RESULTS

In all 43 cases, there have been no adverse events related to ICG. The vascular supply to stomach was estimated "satisfactory" along the stapled line in all cases. However, one patient showed signs and symptoms indicative of gastric leak in the fifth post-op day and diagnosis was confirmed by CT scan with Gastrografin.

CONCLUSIONS

From our preliminary data, the intraoperative view of the blood supply of the stomach does not seem to represent a prognostic factor for the risk of gastric leak, suggesting a complex multifactorial etiology (intragastric hypertension? Abnormal inflammatory response?) which needs further data to be established.

Reducing complications in post-bariatric plastic surgery: our experience and literature review

Background: With the rise in obesity, there has been a similar increase in bariatric surgery. This resulted in numerous patients losing significant weight with accompanying circumferential body contouring issues. This has led to an amazing increase in the number of body contouring procedures performed. Methods: The aim of this work is to revise the cases of body contouring in 78 ex-obese patients who underwent body contouring surgery in the Department of Health Life and Environmental Sciences – Plastic Reconstructive and Aesthetic Plastic Surgery Section, from 2007 to 2016. Results: The authors have noticed a deep relationship between adverse events and cigarette smoking and with pre-operative BMI. Regardless of these variables, the authors focused on the protocol for the management of patients, which required a collaboration between medical and nursing staff. Conclusions: Ex-obese patients have an important risk for complications, but the comparison of our personal data with those of the international literature confirms the efficacy of our management protocol with regard to the prevention of complications. (www.actabiomedica.it)

Axial Spondyloarthritis after bariatric surgery: a 7-year retrospective analysis

BACKGROUND

In recent decades, obesity has become a public health problem in many countries. The objective of this study was to evaluate the main joint and extra-articular manifestations related to spondyloarthritis (SpA) after bariatric surgery (BS) in a retrospective cohort.

METHODS

Demographic, clinical, laboratory and imaging data from nine patients whose SpA symptoms started after a BS have been described. Modified New York (mNY) criteria for ankylosing spondylitis (AS) and the Assessment of Spondyloarthritis International Society (ASAS) criteria for axial (ax-SpA) and peripheral (p-SpA) spondyloarthritis were applied.

RESULTS

The mean weight reduction after BS was 49.3 ± 21.9 kg. The BS techniques were Roux-en-Y gastric bypass (n = 8; 88.9%) and biliopancreatic diversion with duodenal switch (n = 1; 11.1%). Four (44.4%) patients had no axial or peripheral pain complaints before BS, while the other four (44.4%) had sporadic non-inflammatory back pain that had been attributed to obesity. One patient (11.1%) had persistent chronic back pain. In all nine cases, patients reported back pain onset or pattern (intensity or night pain) change after BS (mean time 14.7 ± 18 months). In addition, 8 of them (88.9%) were human leukocyte antigen (HLA)-B27 positive. All nine patients could be classified according to ASAS criteria as ax-SpA and five (55.6%) patients were classified as AS, according to the mNY criteria.

CONCLUSION

Our data highlight a temporal link between SpA onset symptoms and the BS, suggesting a possible causal plausibility between the two events.

Complications of postlaparoscopic sleeve gastric resection: review of surgical technique

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become a very frequent procedure in bariatric surgery. Despite its simplicity, it can have serious complications. Among these, gastric leak is one of the most feared complications. Numerous intraoperative maneuvers have been suggested in an attempt to decrease the incidence of leak. In our center, we decided to study one of the intraoperative measures proposed, which consists in positioning the suture machine to 1.5 cm from His corner.

METHODS

This retrospective study reported 101 cases of LSG performed in our center from 2012 to 2017. The patients were divided into two groups, with comparable anthropometric parameters and comparable inclusion criteria. In the two groups the operative technique used was the same, except for a maneuver: in the second group, attention was paid to keep a distance from the angle of at least 1.5 cm.

RESULTS

On a total of 101 procedures performed, the overall complication rate was 4,95%. In group 1 the rate of gastric staple line leak was 6.78%. In group 2 the rate was 2.38%.

CONCLUSIONS

The analyzed surgical technique seems to decrease the risk of leak without significantly impacting weight loss, and we have noticed in our clinical experience a decrease in the incidence of fistula from the time this measure was adopted. Also the statistical analysis encourage the continuation of experimentation.

A unique case report of jejunoileal bypass reversal with review of the literature

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 Jejunoileal bypass is a surgery of the past however still affects patients being see by surgeons today.

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The pathophysiology is complicated and it should be known these patients suffer from chronic kidney disease, liver failure, chronic diarrhea and many vitamin deficiencies.

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Bypass reverseal can help preserve kidney function but may not reverse damages already done.

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From our experience, Bypassed bowel incorporation back into enteric tract can produced a immune response causing functional obstruction only relieved by removal of this bowel.

Introduction

Jejunoileal bypass (JIB) was an effective treatment for morbid obesity in the 1970s, but shortly after it fell out of favor due to horrific side effects, including liver failure, nephrolithiasis and drastic vitamin deficiencies. Although there are few living people with JIB, the management of these patients can be challenging.

Case presentation

We describe a case of a 58-year-old female with a history of JIB 46 years prior who had an impending renal failure due to nephrolithiasis. She underwent a jejunostomy feeding tube prior to reversal. After reversal, our patient developed failure to thrive with functional obstruction of the newly incorporated small bowel. This bypassed bowel underwent a severe inflammatory transformation after the introduction of enteric feeds, suggesting an immunological type response to antigens in food. It wasn’t until a long and debilitating 12 months and resection of this inflamed bowel that our patient was able to regain bowel function and gain weight.

Conclusion

Jejunoileal bypass is an archaic procedure for morbid obesity. Due to its debilitating and at times lethal side effects, it has been replaced with newer techniques. Despite advances, there are still patients out there who have had a jejunoileal bypass. This case report and review of the literature details our experience with this procedure.