Andrew Jenkinson

Type 2 diabetes remission 2 years post Roux‐en‐Y gastric bypass and sleeve gastrectomy: the role of the weight loss and comparison of DiaRem and DiaBetter scores

The comparative efficacy of Roux‐en‐Y gastric bypass (RYGB) and sleeve gastrectomy on Type 2 diabetes remission and the role of weight loss are unclear. The DiaRem diabetes remission prediction score uses HbA1c, age and diabetes medications but not diabetes duration. The aim of this study was to compare the DiaRem with the DiaBetter score that includes diabetes duration, upon combined (complete plus partial) 2‐year post‐surgery diabetes remission in people following RYGB and sleeve gastrectomy, and to investigate the relationship between weight loss and diabetes remission.

A case of severe anorexia, excessive weight loss and high peptide YY levels after sleeve gastrectomy

Summary Sleeve gastrectomy (SG) is the second most commonly performed bariatric procedure worldwide. Altered circulating gut hormones have been suggested to contribute post-operatively to appetite suppression, decreased caloric intake and weight reduction. In the present study, we report a 22-year-old woman who underwent laparoscopic SG for obesity (BMI 46 kg/m2). Post-operatively, she reported marked appetite reduction, which resulted in excessive weight loss (1-year post-SG: BMI 22 kg/m2, weight loss 52%, >99th centile of 1-year percentage of weight loss from 453 SG patients). Gastrointestinal (GI) imaging, GI physiology/motility studies and endoscopy revealed no anatomical cause for her symptoms, and psychological assessments excluded an eating disorder. Despite nutritional supplements and anti-emetics, her weight loss continued (BMI 19 kg/m2), and she required nasogastric feeding. A random gut hormone assessment revealed high plasma peptide YY (PYY) levels. She underwent a 3 h meal study following an overnight fast to assess her subjective appetite and circulating gut hormone levels. Her fasted nausea scores were high, with low hunger, and these worsened with nutrient ingestion. Compared to ten other post-SG female patients, her fasted circulating PYY and nutrient-stimulated PYY and active glucagon-like peptide 1 (GLP1) levels were markedly elevated. Octreotide treatment was associated with suppressed circulating PYY and GLP1 levels, increased appetite, increased caloric intake and weight gain (BMI 22 kg/m2 after 6 months). The present case highlights the value of measuring gut hormones in patients following bariatric surgery who present with anorexia and excessive weight loss and suggests that octreotide treatment can produce symptomatic relief and weight regain in this setting. Learning points Roux-en-Y gastric bypass and SG produce marked sustained weight reduction. However, there is a marked individual variability in this reduction, and post-operative weight loss follows a normal distribution with extremes of ‘good’ and ‘poor’ response. Profound anorexia and excessive weight loss post-SG may be associated with markedly elevated circulating fasted PYY and post-meal PYY and GLP1 levels. Octreotide treatment can produce symptomatic relief and weight regain for post-SG patients that have an extreme anorectic and weight loss response. The present case highlights the value of measuring circulating gut hormone levels in patients with post-operative anorexia and extreme weight loss.

Laparoscopic Heller's myotomy for achalasia after gastric bypass: A case report

INTRODUCTION Disorders of the oesophagus have been linked to surgical bariatric procedures and obesity. However the relationship between achalasia and gastric bypass is not clearly understood and has only recently been reported following gastric bypass. PRESENTATION OF CASE We present the case of a 53-year-old woman who re-presented following a gastric bypass with a new diagnosis of achalasia. This was treated successfully with laparoscopic Hellers Myotomy with discharge from hospital 10 days post operatively. DISCUSSION It is not clear whether achalasia is a complication of gastric bypass procedures. This is only the second reported case of the condition developing after this operation. The mechanism by which it may develop is yet to be clearly established. CONCLUSION This case highlights the need to investigate further a possible link between achalasia and gastric bypass and to manage susceptible patients accordingly in the pre-operative stage.

Early Effect of Bariatric Surgery on Urogenital Function in Morbidly Obese Men

INTRODUCTION Obesity is an independent risk factor for erectile dysfunction (ED) and lower urinary tract symptoms (LUTS). Bariatric surgery has been shown to improve erectile function and urinary symptoms in medium- to long-term studies (3- to 12-month postoperative follow-up). AIM To investigate the early effect (1 month postoperatively) of bariatric surgery on ED and LUTS, which has not previously been investigated. METHODS Morbidly obese men (body mass index > 35 kg/m2) undergoing bariatric surgery were asked to complete the International Index of Erectile Function (IIEF) and International Prostate Symptom Score (IPSS) questionnaires before surgery and 1, 3, and 6 months after surgery. MAIN OUTCOME MEASURE The influence of bariatric surgery on urogenital function, body mass index, fasting blood glucose, and glycated hemoglobin were analyzed using parametric and non-parametric tests for paired samples. RESULTS Of 30 patients who completed the study, 18 reported ED (IIEF score < 25) and 14 reported moderate or severe LUTS (IPSS ≥ 8) before the operation. Twelve patients had ED and moderate or severe LUTS. IIEF score, IPSS, body mass index, percentage of weight loss, fasting blood glucose, and glycated hemoglobin showed significant and rapid improvement after bariatric surgery starting at the 1-month postoperative time point and improvement continued throughout the study in all patients with ED or moderate to severe LUTS. CONCLUSION This is the first study showing improvement in erectile and urinary function within 1 month after bariatric surgery, an effect that was parallel to glycemic improvement and weight loss.

Gastro-cutaneous fistula 4 years after a fully resolved staple line leak in sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG) has become a mainstream procedure in the management of obesity. Staple line leak is a challenging complication. We report a unique case of successfully treated leak after sleeve gastrectomy, presented ex novo 4 years later as a gastro-cutaneous fistula (GCF). Nothing similar was found in the literature. A 31-year-old woman underwent an LSG, complicated by an early type I leak treated successfully. After 4 years of clinical remission, the leak presented as a GCF. The conservative approach failed and a laparoscopic fistulectomy was first attempted, but after recurrence a completion gastrectomy was performed. A staple line leak is one of the most important complications after sleeve gastrectomy. Once chronic it evolves into GCF, the treatment of which is challenging. Given the absence of guidelines, experience is fundamental in its management. In our case, eventually a total gastrectomy was required.

Timing of pregnancy in obese women after bariatric surgery.

AIMS There is an increased risk of preterm and small-for-gestational-age births associated with bariatric surgery, especially if maternal early pregnancy body mass index (BMI) is <30.0kg/m(2). However, the relationship between timing of pregnancy post-bariatric surgery and effects on pregnancy outcome are unknown. The aim of this study was to investigate the timing of pregnancy post-bariatric surgery and compare early pregnancy BMI between women who became pregnant before or after the recommended 12month postoperative window. METHODS/RESULTS Women who underwent either sleeve gastrectomy or gastric bypass and subsequently became pregnant were offered antenatal care in a multidisciplinary high-risk clinic. There were 50 such pregnancies in women who attended our high-risk clinic (n=26 <12months and n=24 >12months postoperatively, mean estimated times to conception 31.9±12.6weeks and 102.8±37.7weeks respectively). There was no significant difference in early pregnancy BMI between groups (33.2±6.8kg/m(2) and 32.5+2.1kg/m(2) respectively, p=0.78). There were 6 miscarriages in each group, however more women in the <12month (n=8) than in the >12months group (n=2) were lost-to-follow-up (likelihood ratio 4.2, p=0.04). CONCLUSIONS Women who became pregnant <12months post-bariatric surgery were, for unknown reasons, less likely to attend follow-up in a specialist antenatal clinic than those who became pregnant >12months postoperatively. Further research is required to explore the relationship between timing of pregnancy post-bariatric surgery and pregnancy outcome and to identify predictors more clinically useful than early pregnancy BMI, in this high-risk pregnancy group.

Laparoscopy-assisted ERCP (LA-ERCP) following bariatric gastric bypass surgery: initial experience of a single UK centre

Background Bariatric gastric bypass surgery is being increasingly performed, but endoscopic retrograde cholangiopancreatography (ERCP) in these patients poses a unique challenge because of a lack of per-oral access to the stomach. Small series suggest a higher technical success rate using laparoscopy-assisted ERCP (LA-ERCP) than with an enteroscopic approach via the Roux-en-Y anastomosis. We present initial experience of LA-ERCP in our unit. Design Retrospective case series of consecutive patients undergoing LA-ERCP in our unit between September 2011 and July 2014. Data was retrieved from electronic, clinical and endoscopy records. Results Seven LA-ERCPs were performed. All seven patients were female, with median age 44 years (range 36–71). Indications included symptomatic bile duct stones (5/7), benign papillary fibrosis (1/7) and retained biliary stent (1/7). 5/7 (71%) patients had had a prior cholecystectomy. To facilitate LA-ERCP, laparoscopic gastrostomy ports were created in all patients. Duodenal access, biliary cannulation and completion of therapeutic aim were achieved in all patients. 6/7 (86%) patients required endoscopic sphincterotomy. The median duration of procedures was 94 min (range 70–135). Median postoperative length of stay was 2 days (range 1–9). One patient developed mild postprocedural acute pancreatitis, and another patient developed a mild port-site infection. Otherwise, no procedure-related complications were seen. All patients remained well on follow-up (median 14 months (range 1–35) from date of ERCP), with no evidence of further biliary symptoms. Conclusions Our early experience of LA-ERCP is that it is safe and effective. The technique may require particular consideration, as bariatric surgery is increasingly performed, in a patient group at significant risk of bile duct stones.