Abdullah Almulaifi

Laparoscopic sleeve gastrectomy for type 2 diabetes mellitus: predicting the success by ABCD score

BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is becoming a primary bariatric surgery for obesity and related diseases. This study presents the outcome of LSG with regard to the remission of type 2 diabetes mellitus (T2 DM) and the usefulness of a grading system to categorize and predict outcome of T2 DM remission. METHODS A total of 157 patients with T2 DM (82 women and 75 men) with morbid obesity (mean body mass index 39.0±7.4 kg/m(2)) who underwent LSG from 2006 to 2013 were selected for the present study. The ABCD score is composed of the patients age, body mass index, C-peptide level, and duration of T2 DM (yr). The remission of T2 DM after LSG was evaluated using the ABCD score. RESULTS At 12 months after surgery, 85 of the patients had complete follow-up data. The weight loss was 26.5% and the mean HbA1c decreased from 8.1% to 6.1%. A significant number of patients had improvement in their glycemic control, including 45 (52.9%) patients who had complete remission (HbA1c<6.0%), another 18 (21.2%) who had partial remission (HbA1c<6.5%), and 9 (10.6%) who improved (HbA1c<7%). Patients who had T2 DM remission after surgery had a higher ABCD score than those who did not (7.3±1.7 versus 5.2±2.1, P<.05). Patients with a higher ABCD score were also at a higher rate of success in T2 DM remission (from 0% in score 0 to 100% in score 10). CONCLUSION LSG is an effective and well-tolerated procedure for achieving weight loss and T2 DM remission. The ABCD score, a simple multidimensional grading system, can predict the success of T2 DM treatment by LSG.

Effect of Bariatric Surgery vs Medical Treatment on Type 2 Diabetes in Patients With Body Mass Index Lower Than 35: Five-Year Outcomes.

IMPORTANCE It has been well recognized that metabolic surgery has short-term benefits for mildly obese patients with type 2 diabetes mellitus (T2DM), but how long these effects can be sustained is uncertain. OBJECTIVE To compare the 5-year efficacy between gastrointestinal metabolic surgery and medical treatment on glycemic control and diabetes remission in patients with T2DM and body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) lower than 35. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study compares long-term outcomes for mildly obese patients with T2DM receiving metabolic surgery (n = 52) vs medical treatment (n = 299). The surgical group, enrolled from August 20, 2007, to June 25, 2008, and followed up through December 31, 2013, received standard sleeve gastrectomy (n = 19) or bypass (n = 33) procedures in a regional hospital. The medical group, selected from a nationwide community cohort that was recruited from August 27, 2003, to December 31, 2005, and followed up through December 31, 2012, was matched with the surgical group by age, BMI, and diabetes duration. MAIN OUTCOMES AND MEASURES Glycated hemoglobin (HbA1c) reduction and prolonged complete and partial diabetes remission (defined as HbA1c <6.0% and 6.0%-6.5% of total hemoglobin [Hb; to convert to proportion of total Hb, multiply by 0.01], respectively, for those who were exempted from any antidiabetic drugs for 5 years). RESULTS At the end of the fifth year, the surgical group had a mean weight loss of 21.0% (from a mean [SD] BMI of 31.0 [2.4] to 24.5 [2.7]), their mean (SD) HbA1c decreased from 9.1% (2.1%) to 6.3% (1.1%) of total Hb, 18 participants (36.0%) had complete remission, 14 (28.0%) had partial remission, 1 (1.9%) died, and 1 (1.9%) had end-stage renal disease. In the same follow-up period in the medical group, 3 (1.2%) had complete remission, 4 (1.6%) had partial remission, 9 (3.0%) died, and 2 (0.7%) had end-stage renal disease; their mean HbA1c remained around 8% of total Hb (mean [SD], 8.1% [1.8%] of total Hb at baseline and 8.0% [1.6%] of total Hb at 5 years), and BMI also stayed similar (mean [SD], 29.1 [2.4] at baseline and 28.8 [2.6] at 5 years). The HbA1c reduction and complete and partial remission rates were all significantly larger in the surgical group as compared with the medical group (all P < .001). However, the mortality rate and end-stage renal disease incidence were not significantly different in these 2 comparison groups (P = .66 and .37, respectively). CONCLUSIONS AND RELEVANCE For mildly obese patients with T2DM, the improvement in glycemic control from metabolic surgery lasts at least 5 years. However, the survival benefit and lifelong adverse outcomes require more than 5 years to be established.

Duodenal–jejunal bypass with sleeve gastrectomy versus the sleeve gastrectomy procedure alone: the role of duodenal exclusion

BACKGROUND Laparoscopic sleeve gastrectomy (SG) has become accepted as a stand-alone procedure as a less complex operation than laparoscopic duodenojejunal bypass with sleeve gastrectomy (DJB-SG). OBJECTIVES The aim of this study was to compare one-year results between DJB-SG and SG. SETTING University hospital. METHODS A total of 89 patients who received a DJB-SG surgery were matched with a group of SG that were equal in age, sex, and body mass index (BMI). Complication rates, weight loss, and remission of co-morbidities were evaluated after 12 months. RESULTS The mean preoperative patient BMI in the DJB-SG and SG groups was similar. There were more patients with type 2 diabetes mellitus (T2DM) in the DJB-SG group than in the SG group. The mean operative time and length of hospital stay (LOS) were significantly longer in the DJB-SG group than in the SG group. At 12 months after surgery, the BMI was lower and excess weight loss higher in DJB-SG than SG. Remission of T2DM was greater in the DJB-SG group. Low-density lipoprotein, total cholesterol, and metabolic syndrome (MS) improved after operation in both groups. CONCLUSIONS In this study DJB-SG was superior to SG in T2DM remission, triglyceride improvement, excess weight loss, and lower BMI at 1 year after surgery. Adding duodenal switch to sleeve gastrectomy increases the effect of diabetic control and MS resolution.

Acute gastric remnant dilatation, a rare early complication of laparoscopic mini‐gastric bypass

Several thousands of laparoscopic mini‐gastric bypass have been performed globally by a number of surgeons. There is growing evidence that mini‐gastric bypass is a safe and effective procedure. We report a rare case of massive gastric remnant dilation in a 45‐year‐old man after laparoscopic mini‐gastric bypass. Acute gastric dilatation is a surgical emergency. In our case, a triad of clinical suspicion, laboratory profile, and emergency radiologic investigation were essential for early diagnosis and management. Image‐guided gastrostomy tube placement provides an effective decompression of the gastric remnant. A literature review revealed no previous reports of similar complications in mini‐gastric bypass.

Bariatric versus diabetes surgery after five years of follow up

BACKGROUND Bariatric surgery (BS) is totally different from diabetes surgery (DS) in the patient characters, goals of surgery, and management although similar in surgical procedure. Comparison of BS and DS with long-term data is lacking. MATERIALS AND METHODS A retrospective review of patients who received BS and patients who received DS at Min-Sheng General Hospital from 2007 to 2013 was designed. All inpatient and outpatient follow-up data were analyzed. Patients undergoing BS for the treatment of morbid obesity were compared with patients undergoing metabolic surgery for the treatment of type 2 diabetes mellitus (T2DM). Patients who received revision surgeries were excluded. The main outcome measures were: (1) operation risk; (2) weight loss; and (3) diabetes remission. RESULTS Between 2007 and 2013, 2073 patients who received BS and 741 patients who received DS were recruited from both centers. DS patients were older (41.1 ± 10.9 years vs. 33.1 ± 9.3 years, p < 0.05) and were more likely to be male (40.2% vs. 28.2%, p < 0.05) and to have diabetes (100% vs. 6.0%, p < 0.05), however, they had similar body mass index (BMI) (37.9 ± 8.0 vs. 38.5 ± 9.7, p = 0.78) compared to the BS patients. Surgical procedures are significantly different between the two groups (73.3% of the DS surgeries were gastric bypass procedure, whereas this procedure made up only 47.1% of BS surgeries). Although the major complication rates were similar (2.0% vs. 2.4%), the DS program had a significant higher mortality rate than the BS program (0.54% vs. 0.1%; p < 0.05). At the 5-year follow-up time point, 58.0% of the BS patients had achieved successful results (weight loss > 30%) and 80% of the DS patients had complete remission of their diabetes [hemoglobin A1c (HbA1c) < 6.0%]. Both the DS and the BS group had good results in up to 85% of the patients at the 5-year follow-up time point. CONCLUSION The clinical profiles were very different between the BS and the DS programs. Both programs achieved the desired outcomes equally well, however, the DS program had a higher risk than the BS program.

Reply to the Letter “Gastric Remnant Dilatation: a Rare Technical Complication Following Laparoscopic One Anastomosis (Mini) Gastric Bypass”

Dear Sir, We read with great interest the article titled, BGastric remnant dilatation: A rare technical complication following Laparoscopic One Anastomosis (Mini) Gastric Bypass.^ [1] We would like to add our experience in the hope that this will complement the information, considering that we reported the first case in the world [2]. Acute gastric dilatation is a surgical emergency after Roux-en-Y gastric bypass (RYGB), usually known as biliopancreatic obstruction caused by obstruction at enteroenterostomy [3]. Although the incidence is low, this complication is an important cause of death after RYGB [4]. The laparoscopic mini gastric bypass (MGB) first reported by Rutledge was gradually accepted as an alternative to RYGB with better weight loss and less complication, especially in less intestinal obstruction [5]. New names such as one anastomotic gastric bypass (OAGB) or single anastomosis gastric bypass (SAGB) were proposed [6]. Although SAGB or MGB is a simplified bypass procedure with less complication than RYGB, acute gastric dilatation is still a possible early complication [7]. Acute gastric dilatation after MGB is less severe than that after RYGB because it does not carry a risk of developing a fulminant pancreatitis, although it may cause gastric wall perforation or necrosis if diagnosis is delayed. The diagnosis can be suspected on a plain abdominal radiograph that shows a distended fundus and then confirmed by using computed tomography (CT). About this rare complication, the most important point is to avoid complications, especially in the learning curve of this procedure. The author described elaborately in their letter the cause and prevention of developing acute gastric dilatation of MGB. I agree with the author that attention should be paid at the first cut when trying to create a long narrow gastric tube and leave a space of 2 cm from the greater curvature side. Instead of using a 60-mm stapler for the first cut, we preferred to use a 45-mm stapler for the first cut, which may reduce the risk of overcutting at the antrum. In the letter, the authors discussed the management of this complication and proposed to use diagnostic laparoscopy and correction surgery in emergency situations. The authors argued that tube gastrostomy adding 2% to operative risk was misleading. Today, percutaneous drainage of gastric remnant dilatation by CT scan or with echo guidance can be easily performed under local anesthesia [8–10]. The drainage is effective for symptom relief and to avoid emergency operation, whichmight put the patient in an unnecessary risk. An elective surgery can be arranged later. Corrective operation may be needed if the narrowing at the antrum persists. Either a sideto-side anastomosis, as the author suggested, or resection of the remnant stomach can resolve the problem. Thus far, we have experienced three cases (0.15%) of acute gastric dilatation among 2000 cases of SAGB. The incidence is lower than the incidence of 0.8% after RYGB [7]. Two of the three cases were successfully managed with percutaneous drainage. One patient received an elective surgery to remove the remnant stomach 1 month later because of persistent symptomatic narrowing. One patient presented with gastric bleeding and acute gastric dilatation filled with blood clot. Emergency laparoscopic surgery was performed to evacuate the blood clot, and continuous suture of the stapler line for hemostasis was applied. All the patients were discharged within 3 days uneventfully. In conclusion, this rare complication should be * Wei-Jei Lee wjlee_obesssurg_tw@yahoo.com.tw

Roux-en-Y gastric bypass for lower esophageal submucosal cancer in an obese diabetic patient.

laifi@ Obesity is becoming an epidemic health problem and has been identified as an independent risk factor for the development of gastroesophageal reflux disease and Barretts esophagus, which increases the incidence of esophageal cancer (EsC) [1]. Routine esophagogastroduodenoscopy (EGD) before bariatric/metabolic surgery has a high diagnostic yield and it can alter or delay the surgical management in 4.9– 9.4% of cases [2,3]. We report a case of early EsC in an obese diabetic patient treated with laparoscopic Roux-en-Y gastric bypass (LRYGB).