Bariatric surgery in liver cirrhosis

Introduction

Obesity is frequently associated with its hepatic manifestation, the nonalcoholic fatty liver disease (NAFLD). The most effective treatment for morbid obesity is bariatric surgery (BS) also improving NAFLD and liver function. In patients where NAFLD has already progressed to liver cirrhosis, BS can be considered a high-risk procedure. Hence, consideration of the procedure and the most appropriate timing is crucial.

Material and Methods

Obese patients suffering from NAFLD who underwent BS from two German University Medical Centers were retrospectively analyzed.

Results

Twenty-seven patients underwent BS. Most common procedures were laparoscopic Roux-en-Y-gastric (RYGB) and laparoscopic sleeve gastrectomy (SG). All patients suffered from liver cirrhosis Child A. A preoperative transjugular portosystemic shunt (TIPS) was established in three patients and failed in another patient. Postoperative complications consisted of wound healing disorders (n = 2), anastomotic bleeding (n = 1), and leak from the staple line (n = 1). This patient suffered from intraoperatively detected macroscopic liver cirrhosis. Excess weight loss was 73% and 85% after 1 and 2 years, respectively. Two patients suffered from postoperative aggravation of their liver function, resulting in a higher Child-Pugh score, while three could be removed from the waiting list for a liver transplantation.

Conclusion

BS leads to weight loss, both after SG and RYGB, and potential improvement of liver function in liver cirrhosis. These patients need to be considered with care when evaluated for BS. Preoperative TIPS implantation may reduce the perioperative risk in selected patients.

Duodenal intussusception of the remnant stomach after biliopancreatic diversion: a case report

Background

We present a rare case of an antegrade intussusception of the remnant stomach four years after a biliopancreatic diversion.

Case presentation

A 55-year-old female patient presented with epigastric pain in our emergency room. Laboratory parameters showed an anemia as well as elevated transaminases and hyperbilirubinemia. The CT scan showed an intussusception of the remnant stomach into the duodenum followed by cholestasis. At laparotomy the remnant stomach was resected.

Conclusion

Bowel obstruction and intussusception after bariatric surgery are a rare but often unrecognized complication. Sonography as well as a CT scan should be performed. The exploratory laparoscopy however is the most valuable diagnostic tool in patients with suspected intussusception, due to the high rate of non-specific symptoms and misinterpreted radiographic investigations.

[Robot-assisted vs laparoscopic gastric bypass : First experiences with the DaVinci system in bariatric surgery]

Conventional laparoscopy is the gold standard in bariatric surgery. Internationally, robot-assisted surgery is gaining in importance. Up to now there are only few reports from Germany on the use of the system in bariatric surgery. Since January 2017 we have been performing robot-assisted gastric bypass surgery. It remains unclear whether the use of the robotic system has advantages over the well-established laparoscopic technique. Within a period from January to early August 2017 a total of 53 gastric bypass operations were performed. Of these 16 proximal redo Roux-en-Y gastric bypass operations were performed with the DaVinci Si system versus 29 laparoscopic procedures. A retrospective analysis of the perioperative course was carried out. Body weight, body mass index (BMI), Edmonton obesity staging system (EOSS) and American Society of Anesthesiologists (ASA) classification did not show significant differences. There were also no significant differences in terms of estimated blood loss, intraoperative complications, duration of surgery, postoperative inflammatory parameters and weight loss. There was no mortality and no need for revisional surgery in either group. After laparoscopic surgery there was a delayed occurrence of a leak of the gastrojejunostomy followed by readmission and endoscopic negative pressure wound therapy. The results show that the proximal Roux-en-Y gastric bypass can be performed safely and efficiently using the DaVinci surgical system. Significant differences to the conventional laparoscopic procedure were not found. Larger randomized controlled trials are needed to define the role of the DaVinci system in bariatric surgery.

[Immunological Markers in Organ Transplantation]

The immunological monitoring in organ transplantation is based mainly on the determination of laboratory parameters as surrogate markers of organ dysfunction. Structural damage, caused by alloreactivity, can only be detected by invasive biopsy of the graft, which is why inevitably rejection episodes are diagnosed at a rather progressive stage. New non-invasive specific markers that enable transplant clinicians to identify rejection episodes at an earlier stage, on the molecular level, are needed. The accurate identification of rejection episodes and the establishment of operational tolerance permit early treatment or, respectively, a controlled cessation of immunosuppression. In addition, new prognostic biological markers are expected to allow a pre-transplant risk stratification thus having an impact on organ allocation and immunosuppressive regimen. New high-throughput screening methods allow simultaneous examination of hundreds of characteristics and the generation of specific biological signatures, which might give concrete information about acute rejection, chronic dysfunction as well as operational tolerance. Even though multiple studies and a variety of publications report about important advances on this subject, almost no new biological marker has been implemented in clinical practice as yet. Nevertheless, new technologies, in particular analysis of the genome, transcriptome, proteome and metabolome will make personalised transplantation medicine possible and will further improve the long-term results and graft survival rates. This article gives a survey of the limitations and possibilities of new immunological markers in organ transplantation.

Control of intestinal allograft rejection by FTY720 and costimulation blockade

INTRODUCTION

The clinical application of small bowel transplantation (SBTx) is hampered by its pronounced immunogenicity. In this study we examined the effects of the novel immunosuppressant FTY720 and costimulation blockade by an anti-CD40L mAb (MR-1) in a stringent mouse model of SBTx.

METHODS

SBTx was performed in mice with a full MHC mismatch (donors: C3H=H-2(k); recipients: C57BL/6=H-2(b)). Recipients were divided into four groups: 1, untreated group; 2, MR1 monotherapy (500 microg IV on days 0, 2, 4, and 7); 3, FTY720 monotherapy (1 mg/kg body weight PO for 14 consecutive days after transplantation); 4, FTY720 plus MR1-treated group. Graft rejection grades were assessed by H&E staining. Graft mesenteric lymph nodes (MLNs), Peyer's patches (PPs), as well as intraepithelial lymphocytes (IELs) and lamina propria lymphocytes (LPLs) were analyzed by flow cytometry and three-color immunofluorescence staining.

RESULTS

Neither FTY720 nor MR1 monotherapy was efficient in preventing the rejection of mouse intestinal allografts, whereas FTY720 plus MR1 profoundly inhibited the rejection response at the 14th posttransplant day. The infiltration of host lymphocytes was reduced in graft MLNs, PPs, IELs, and LPLs by FTY720 therapy. FTY720 plus MR1 inhibited host CD8(+) T-cell infiltration in graft LPLs when compared with grafts treated with FTY720 only. Additionally, two subpopulations, CD11b(+high) Gr1(-) and CD11b(+intermediate) Gr1(+) cells, were decreased in FTY720-treated grafts.

CONCLUSIONS

FTY720 plus MR1 efficiently delayed intestinal allograft rejection in a mouse model by preventing the infiltration of host lymphocytes, particularly of CD8(+) cells.