Abraham Abdemur

Laparoscopic conversion of laparoscopic sleeve gastrectomy to gastric bypass for intractable gastroesophageal reflux disease.

Laparoscopic sleeve gastrectomy (LSG) has proved to be a safe and efficacious step or stand-alone surgical procedure for the treatment of morbid obesity. An increase in the body mass index and the accumulation of visceral fat are associated with a twoto threefold increased risk of developing reflux symptoms [1]. Long-term complications appear to have a low incidence; however, in recent publications, gastroesophageal reflux disease (GERD) has been reported to occur in 27% of patients 6 years after the procedure. Roux-en-Y gastric bypass (RYGB) appears to be the only successful treatment option for this adverse effect.

Outcomes of bariatric surgery in patients with body mass index <35 kg/m2

BACKGROUND Patients who are categorized with class I obesity have a body mass index (BMI) of 30-34.99 kg/m(2). This population of patients has a predisposition to diabetes, hypertension, and dyslipidemia. The aim of the present study was to investigate the improvements of these co-morbidities in a class I obese population that had undergone a bariatric procedure. METHODS After internal review board approval and with adherence to the Health Insurance Portability and Accountability Act guidelines, a retrospective review was performed of a prospectively maintained database of 42 class I obese patients who underwent a bariatric procedure at our institution during a 10-year period, from February 2000 to May 2010. The fasting glucose level, glycosylated hemoglobin level, lipid profile, initial weight, and BMI were measured in the preoperative and postoperative periods. RESULTS Our patient population consisted of 30 women and 12 men, with a preoperative mean BMI of 33.9 kg/m(2). Laparoscopic sleeve gastrectomy was performed in 24 patients (57%), laparoscopic Roux-en-Y gastric bypass in 8 (19%), and laparoscopic adjustable gastric banding in 10 (24%). Of these 42 patients, 25 (60%) had type 2 diabetes, 1 patient was glucose intolerant, 27 (64%) had arterial hypertension, 25 (60%) had dyslipidemia, 17 (40%) had sleep apnea, and 8 (19%) had osteoarthritis. The postoperative findings included a mean BMI of 26.5 kg/m(2) and a mean weight loss of 41.4 lb. Of the 25 diabetic patients, 5 (20%) gained remission and 12 (48%) improvement of their diabetic status. The single patient with glucose intolerance showed improvement. Of the 27 patients with arterial hypertension, 9 (33%) showed remission and 13 (52%) improvement. Dyslipidemia resolved in 5 patients (20%) and improved in 13 (52%). Obstructive sleep apnea resolved in 10 (59%) and improvement was seen in 1 patient (6%). Finally, osteoarthritis resolved in 1 patient (12%) and improved in 5 (63%). CONCLUSION Bariatric surgery can significantly improve or resolve co-morbid metabolic conditions in patients with class I obesity.

The foregut theory as a possible mechanism of action for the remission of type 2 diabetes in low body mass index patients undergoing subtotal gastrectomy for gastric cancer

BACKGROUND The question of whether pure metabolic surgery could be used in nonobese patients with type 2 diabetes has been considered. The objective of this study was to assess the comparative effects of the Billroth I (BI) and Billroth II (BII) reconstruction methods on remission of type 2 diabetes in nonobese patients undergoing subtotal gastrectomy for cancer. METHODS The charts of 404 patients who underwent radical subtotal gastrectomy for cancer between January 2008 and December 2010 were retrospectively reviewed. From these patients, 49 with type 2 diabetes were included in this study. Diabetes remission rates, the percentage change in fasting plasma glucose levels, glycated hemoglobin levels, body mass index, and fasting total cholesterol levels at 2 years were observed. Outcomes were compared using propensity scores and inverse probability-weighting adjustment that reduced treatment-selection bias. Covariate-adjusted logistic regression models were assessed. RESULTS The 2-year diabetes remission rate for the 23 patients who underwent BI reconstruction was 39.1%, compared with 50.0% for the 26 patients who underwent BII reconstruction. At 2 years, the BII group showed lower glycated hemoglobin levels (BI, 6.4%; BII, 6.1%; P = .003) and had greater percent reductions in their average glycated hemoglobin levels from baseline (BI,-11.6%; BII,-14.5%; P = .043). BII reconstruction was significantly associated with an increased diabetes remission rate (odds ratio, 3.22; 95% confidence interval, 1.05-9.83) in covariate-adjusted logistic regression analysis. CONCLUSIONS These propensity score-adjusted analyses of patients who had undergone subtotal gastrectomy indicated that BII reconstruction was associated with increased diabetes remission compared with BI reconstruction during the 2-year follow-up period. This study suggests the possibility of employing the surgical duodenal switch for the treatment of nonobese type 2 diabetes patients.

Morphology, localization, and patterns of ghrelin-producing cells in stomachs of a morbidly obese population.

Background: The role of the hormone ghrelin in the pathogenesis of morbid obesity is unclear. Researchers have identified its involvement in multifunctional activities that include appetite regulation, intestinal motility, release of growth hormone, and cell proliferation. The purpose of this study is to investigate and distinguish a pattern, if present, in ghrelin-producing cells and to record their distribution and quantity in a heterogenic morbidly obese population. Setting: The Bariatric & Metabolic Institute, Section of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, FL. Materials and Methods: Thirty-six patients who underwent sleeve gastrectomy for morbid obesity were evaluated for number and distribution of gastric ghrelin. Sections of fundus, body, and antrum were evaluated by using a ghrelin antibody staining technique. The gross specimens were divided into the following 3 zones: (1) fundus; (2) body; and (3) antrum. Three sections were then submitted from each zone. The ghrelin cells were counted using an image analyzer (MetaMorph; Universal Imaging Corporation, Downingtown, PA) after staining the blocks with antighrelin antibody. Counting ghrelin cells was standardized, and for each section 10 high-power fields were examined at ×4000. Our statistical analysis entailed a Student t test to compare the number of cells by age, sex, race, diabetic/nondiabetic, and body mass index. A P-value <0.05 was considered statistically significant. Results: Thirty-six patients (female 20/male 16) were studied. The average age of these patients was 45.6 (18 to 71) years. Race distribution was as follows: whites, 50% (18); African American, 13.9% (5); and Hispanic, 36.1% (13). Patients with diabetes comprised 13.9% of the cohort (5). Average body mass index was 44.9 kg/m2 (31 to 70). Significant differences in ghrelin cell distribution were found when comparing gastric anatomy location. Ghrelin cells were significantly more abundant in the gastric fundus when compared with the body and the antrum. Quantities of cells in the antrum were significantly higher in the Hispanic population (P=0.0054). No significant differences among other groups were observed. Conclusions: In conclusion, ghrelin-producing cells seem to be more abundant in the fundus of morbidly obese patients. No significant differences were found in terms of number of cells by age, sex, presence of diabetes, or body mass index. There was an incidental finding of a higher concentration of these cells located in the antrum of the Hispanic population when compared with the white cohort.

Diagnosis and Treatment of Dumping Syndrome After Gastric Bypass for Morbid Obesity

Dumping syndrome (DS) refers to a group of gastrointestinal and vasomotor symptoms that occur after the ingestion of a meal. The large number of patients undergoing bariatric surgery has dramatically increased the prevalence of DS. Uncontrolled severe dumping can result in sitophobia and weight loss, leading to malnutrition. In many patients, effective control of symptoms can be achieved with dietary and lifestyle modifications. If this approach is unsatisfactory, medical therapy is the following step, and in some cases surgery might be considered. Diagnosis and management of dumping syndrome is detailed in this chapter.