WHEN SHOULD BE CONVERTED LAPAROSCOPIC SLEEVE GASTRECTOMY TO LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS DUE TO GASTROESOPHAGEAL REFLUX?

GASTRIC PLICATION ASSOCIATED WITH FUNDOPLICATION IN INDIVIDUALS WITH CLASS I OBESITY AND GASTROESOPHAGEAL REFLUX DISEASE: WEIGHT LOSS OUTCOMES, REFLUX-RELATED SYMPTOMS, ENDOSCOPIC AND pH MONITORING FINDINGS

BACKGROUND

The association of gastric plication with fundoplication is a reliable option for the treatment of individuals with obesity associated with gastroesophageal reflux disease.

AIMS

To describe weight loss, endoscopic, and gastroesophageal reflux disease-related outcomes of gastric plication with fundoplication in individuals with mild obesity.

METHODS

A retrospective cohort study was carried out, enrolling individuals who underwent gastric plication with fundoplication at a tertiary private hospital from 2015-2019. Data regarding perioperative and weight loss outcomes, endoscopic and 24-hour pH monitoring findings, and gastroesophageal reflux disease-related symptoms were analyzed.

RESULTS

Of 98 individuals, 90.2% were female. The median age was 40.4 years (IQR 32.1-47.8). The median body mass index decreased from 32 kg/m2 (IQR 30,5-34) to 29.5 kg/m2 (IQR 26.7-33.9) at 1-2 years (p<0.05); and to 27.4 kg/m2 (IQR 24.1-30.6) at 2-4 years (p=0.059). The median percentage of total weight loss at 1-2 years was 7.8% (IQR -4.1-14.7) and at 2-4 years, it was 16.4% (IQR 4.3-24.1). Both esophageal and extra-esophageal symptoms showed a significant reduction (p<0.05). A significant decrease in the occurrence of esophagitis was observed (p<0.01). The median DeMeester score decreased from 30 (IQR 15.1-48.4) to 1.9 (IQR 0.93-5.4) (p<0.0001).

CONCLUSIONS

The gastric plication with fundoplication proved to be an effective and safe technique, leading to a significant and sustained weight loss in addition to endoscopic and clinical improvement of gastroesophageal reflux disease.

SHORTEN PREOPERATIVE FASTING AND INTRODUCING EARLY EATING ASSISTANCE IN RECOVERY AFTER GASTROJEJUNAL BYPASS?

Rational:

The metabolic response to surgical trauma is enhanced by prolonged preoperative fasting, contributing to increased insulin resistance. This manifestation is more intense on the 1^st and 2^nd postoperative days and is directly proportional to the size of the operation.

Aim:

To compare whether preoperative fasting abbreviation and early postoperative refeeding associated with intraoperative and postoperative fluid restriction interfere in the evolution of patients undergoing gastrojejunal bypass.

Methods:

Eighty patients indicated for Roux-en-Y gastrojejunal bypass were selected. They were randomly divided into two groups: Ringer Lactate (RL) group, who underwent a 6 hours solids fasting, with the administration of 50 g of maltodextrin in 100 ml of mineral water 2 hours before the beginning of anesthesia; and Physiologic Solution (PS) group, who underwent a 12 hours solids and liquids fasting. Anesthesia was standardized for both groups. During the surgical procedure, 1500 ml of ringer lactate solution was administered in the RL and 2500 ml of physiological solution (0.9% sodium chloride) in the PS. In both groups, the occurrence of bronchoaspiration was analyzed during intubation, and the residual gastric volume was measured after opening the abdominal cavity. In the postoperative period in Group RL, patients started a liquid diet 24 hours after the end of the operative procedure; whilst for PS group, fasting was maintained for the first 24 hours, it was prescripted 2000 ml of physiological solution and a restricted liquid diet after 36 hours. Each patient underwent CPK, insulin, sodium, potassium, urea, creatinine, PaCO2, pH and bicarbonate dosage in the immediate postoperative period, and 48 hours later, the exams were repeated.

Results:

There were no episodes of bronchoaspiration and gastrojejunal fistulas in either group. In the analysis of the residual gastric volume of the PS and RL groups, the mean volumes were respectively 16.5 and 8.8, which shows statistical significance between the groups. In laboratory tests, there was no difference between groups in sodium; PS group showed a higher level of serum potassium (p=0.029); whilst RL group showed a higher urea and creatinine values; CPK values were even for both; PS group demonstrated a higher insulin level; pH was higher in PS group; sodium bicarbonate showed a significant difference at all times; PaCO2 values in RL group was higher than in PS. In the analysis of the incidence of nausea and flatus, no statistical significance was observed between the groups.

Conclusions:

The abbreviation of preoperative fasting and early postoperative refeeding of Roux-en-Y gastrojejunal bypass with the application of ERAS or ACERTO Project accelerated the patient’s recovery, reducing residual gastric volume and insulin level, and do not predispose to complications.

ANTI-REFLUX PROCEDURES AFTER ROUX-EN-Y GASTRIC BYPASS

BACKGROUND

Roux-en-Y gastric bypass (RYGB) has been the choice of bariatric procedure for patients with symptomatic reflux - and is known to be effective in reducing the need for anti-reflux medication postoperatively. However, a small number of RYGB patients can still develop severe reflux symptoms that require a surgical intervention.

AIM

To examine and describe the patient population that requires an anti-reflux procedure after RYGB evaluating demographics, characteristics, symptoms and diagnosis.

METHODS

A retrospective chart review was performed on 32 patients who underwent a hiatal hernia repair and/or Nissen fundoplication after RYGB Jul 1st, 2014 and Dec 31st, 2019. Patients were identified using the MBSAQIP database and their electronic medical records were reviewed.

RESULTS

Most patients were female (n=29, 90.6%). The mean age was 52.8 years and the mean body mass index (BMI) was 34.1 kg/m2 at the time of anti-reflux procedure. Patients underwent the anti-reflux procedure at a mean of 7.9 years after the RYGB procedure. The mean percentage of excess BMI loss during the time between RYGB and anti-reflux procedure was 63.4%.

CONCLUSIONS

Female patients with a significant weight loss may develop a severe reflux symptoms years after RYGB. Complaints of reflux after RYGB should not be overlooked. Careful follow-up and appropriate treatment (including surgical intervention) is needed for this population.

GASTRIC TWIST AFTER SLEEVE GASTRECTOMY: A PROPOSAL FOR ENDOSCOPIC CLASSIFICATION

ABSTRACT - BACKGROUND: The twisting of the gastric tube is one of the main causes of persistent reflux and food intolerance after sleeve gastrectomy (SG). To date, there is no classification for gastric twist after SG. OBJECTIVE: This study aimed to propose an endoscopic classification for this condition and outline the clinical profile of these patients with sleeve gastrectomy. METHODS: Patients in the postoperative period of SG presenting endoscopic findings of gastric twist were included. All patients underwent an esophagogastroduodenoscopy 12 months after SG. The classification proposed consists of three degrees: degree I: mild rotation of the staple line without relevant shrinkage of the gastric lumen; degree II: moderate rotation of the staple line, leading to a focal area of fixed narrowing that requires additional maneuvers for its transposition; and degree III: severe rotation of the staple line leading to stenosis, with increased difficulty for transposition or complete blockage. RESULTS: Out of 2,723 patients who underwent SG, 45 (1.6%) presented gastric twist. Most patients were female (85%), with mean age of 39±10.4 years. In all, 41 (91.1%) presented degree I, 3 (6.7%) presented degree II, and 1 (2.2%) had degree III. Most patients were asymptomatic (n=26). Vomiting was the most prevalent symptom (15.5%). Statistically significant correlation of twisting degrees was not observed for both the presence of symptoms and the degrees of esophagitis. CONCLUSION: Gastric twist after SG is rare, with generally mild and asymptomatic presentation. The endoscopic classification was not statistically related to clinical presentation but set the ground for further analysis.

GASTROESOPHAGEAL SYMPTOMS AFTER LAPAROSCOPIC GASTRIC BYPASS: MISTAKES IN PERFORMING THE PROCEDURE?

Laparoscopic Roux-en-Y gastric bypass (LGB) is the recommended procedure for morbidly obese patients with gastroesophageal reflux disease (GERD). However, there have been reported gastroesophageal reflux symptoms or esophagitis after LGB. Few functional esophageal studies have been reported to date.

The Mid-Term Effects of Transit Bipartition with Sleeve Gastrectomy on Glycemic Control, Weight Loss, and Nutritional Status in Patients with Type 2 Diabetes Mellitus: a Retrospective Analysis of a 3-Year Follow-up

BACKGROUND

Metabolic surgery is an effective treatment method for glycemic control and weight loss in obese patients with type 2 diabetes mellitus (T2DM). This study aimed to present the mid-term metabolic effects and weight loss results of the patients with T2DM who underwent transit bipartition with sleeve gastrectomy (TB-SG).

METHODS

A total of 32 obese patients with T2DM who underwent TB-SG were included in the study. The T2DM remission status after surgery was evaluated. The postoperative glycemic variables, weight loss, lipid profile, and nutritional profile were also compared with the baseline values.

RESULTS

At 36 months after surgery, T2DM remission occurred in 27 patients (84.3%) and the mean BMI decreased from 44.70 ± 9.34 to 29.75 ± 2.19 kg/m². The percentage of total weight loss (TWL) and excess weight loss (EWL) was 33.84% and 77.19%, respectively. The mean LDL values significantly decreased compared to baseline; however, the mean HDL did not significantly differ. No significant difference was observed regarding the mean albumin, vitamin B12, and folic acid levels.

CONCLUSION

TB-SG procedure seems promising in terms of T2DM remission and weight loss with less malnutrition and vitamin deficiency in treating obese patients with T2DM.

Bariatric Surgery in Adolescents: To Do or Not to Do?

Pediatric obesity is a multifaceted disease that can impact physical and mental health. It is a complex condition that interweaves biological, developmental, environmental, behavioral, and genetic factors. In most cases lifestyle and behavioral modification as well as medical treatment led to poor short-term weight reduction and long-term failure. Thus, bariatric surgery should be considered in adolescents with moderate to severe obesity who have previously participated in lifestyle interventions with unsuccessful outcomes. In particular, laparoscopic sleeve gastrectomy is considered the most commonly performed bariatric surgery worldwide. The procedure is safe and feasible. The efficacy of this weight loss surgical procedure has been demonstrated in pediatric age. Nevertheless, there are barriers at the patient, provider, and health system levels, to be removed. First and foremost, more efforts must be made to prevent decline in nutritional status that is frequent after bariatric surgery, and to avoid inadequate weight loss and weight regain, ensuring successful long-term treatment and allowing healthy growth. In this narrative review, we considered the rationale behind surgical treatment options, outcomes, and clinical indications in adolescents with severe obesity, focusing on LSG, nutritional management, and resolution of metabolic comorbidities.

GERD after Bariatric Surgery. Can We Expect Endoscopic Findings?

Background and Objectives: Bariatric surgery remains the gold standard treatment for morbidly obese patients. Roux-en-y gastric bypass and laparoscopic sleeve gastrectomy are the most frequently performed surgeries worldwide. Obesity has also been related to gastroesophageal reflux disease (GERD). The management of a preoperative diagnosis of GERD, with/without hiatal hernia before bariatric surgery, is mandatory. Endoscopy can show abnormal findings that might influence the final type of surgery. The aim of this article is to discuss and review the evidence related to the endoscopic findings after bariatric surgery. Materials and Methods: A systematic review of the literature has been conducted, including all recent articles related to endoscopic findings after bariatric surgery. Our review of the literature has included 140 articles, of which, after final review, only eight were included. The polled articles included discussion of the endoscopy findings after roux-en-y gastric bypass and laparoscopic sleeve gastrectomy. Results: We found that the specific care of bariatric patients might include an endoscopic diagnosis when GERD symptoms are present. Conclusions: Recent evidence has shown that endoscopic follow-up after laparoscopic sleeve gastrectomy could be advisable, due to the pathological findings in endoscopic procedures in asymptomatic patients.