Beatrice Kern

Improvement in glucose metabolism after bariatric surgery: comparison of laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy: a prospective randomized trial.

Background:The exclusion of the proximal small intestine is thought to play a major role in the rapid improvement in the metabolic control of diabetes after gastric bypass. Objective:In this randomized, prospective, parallel group study, we sought to evaluate and compare the effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) with those of laparoscopic sleeve gastrectomy (LSG) on fasting, and meal-stimulated insulin, glucose, and glucagon-like peptide-1 (GLP-1) levels. Methods:Thirteen patients were randomized to LRYGB and 14 patients to LSG. The mostly nondiabetic patients were evaluated before, and 1 week and 3 months after surgery. A standard test meal was given after an overnight fast, and blood samples were collected before and after food intake in both groups for insulin, GLP-1, glucose, PYY, and ghrelin concentrations. This trial was registered in www.clinicaltrials.gov (NCT00356213) before the first patient was randomized. Results:Body weight and body mass index decreased markedly (P < 0.002) and comparably after either procedure. Excess BMI loss was similar at 3 months (43.3 ± 12.1% vs. 39.4 ± 9.4%, P > 0.36). After surgery, patients had markedly increased postprandial plasma insulin and GLP-1 levels, respectively (P < 0.01) after both of these surgical procedures, which favor improved glucose homeostasis. Compared with LSG, LRYGB patients had early and augmented insulin responses as early as 1-week postoperative; potentially mediating improved early glycemic control. After 3 months, no significant difference was observed with respect to insulin and GLP-1 secretion between the 2 procedures. Conclusion:Both procedures markedly improved glucose homeostasis: insulin, GLP-1, and PYY levels increased similarly after either procedure. Our results do not support the idea that the proximal small intestine mediates the improvement in glucose homeostasis.

Early Results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): A Prospective Randomized Trial Comparing Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass

Objective:Laparoscopic sleeve gastrectomy (LSG) has been proposed as an effective alternative to the current standard procedure, laparoscopic Roux-en-Y gastric bypass (LRYGB). Prospective data comparing both procedures are rare. Therefore, we performed a randomized clinical trial assessing the effectiveness and safety of these 2 operative techniques. Methods:Two hundred seventeen patients were randomized at 4 bariatric centers in Switzerland. One hundred seven patients underwent LSG using a 35-F bougie with suturing of the stapler line, and 110 patients underwent LRYGB with a 150-cm antecolic alimentary and a 50-cm biliopancreatic limb. The mean body mass index of all patients was 44 ± 11.1 kg/m2, the mean age was 43 ± 5.3 years, and 72% were female. Results:The 2 groups were similar in terms of body mass index, age, sex, comorbidities, and eating behavior. The mean operative time was less for LSG than for LRYGB (87 ± 52.3 minutes vs 108 ± 42.3 minutes; P = 0.003). The conversion rate was 0.9% in both groups. Complications (<30 days) occurred more often in LRYGB than in LSG (17.2% vs 8.4%; P = 0.067). However, the difference in severe complications did not reach statistical significance (4.5% for LRYGB vs 1% for LSG; P = 0.21). Excessive body mass index loss 1 year after the operation was similar between the 2 groups (72.3% ± 22% for LSG and 76.6% ± 21% for LRYGB; P = 0.2). Except for gastroesophageal reflux disease, which showed a higher resolution rate after LRYGB, the comorbidities and quality of life were significantly improved after both procedures. Conclusions:LSG was associated with shorter operation time and a trend toward fewer complications than with LRYGB. Both procedures were almost equally efficient regarding weight loss, improvement of comorbidities, and quality of life 1 year after surgery. Long-term follow-up data are needed to confirm these facts.

Predictors of outcome in treatment of morbid obesity by laparoscopic adjustable gastric banding: results of a prospective study of 380 patients

BACKGROUND We investigated the outcome predictors of laparoscopic gastric banding (LAGB) for morbidly obese patients. METHODS From December 1996 to November 2004, a total of 380 consecutive unselected patients (78% female; median age 40 yr, range 17-66; body mass index 44.3 kg/m(2), range 35-75) were prospectively evaluated and underwent LAGB. The follow-up rate after a median of 5 years (range 1.5-9.4) was 98%. A survival model was applied, and a multivariate Cox proportional hazard model was used to calculate the hazard ratios for the influential factors. RESULTS Of the 380 patients, 128 (33.7%) had their bands removed. Of these 128 patients, 2.4% declined another operation, 18.2% underwent biliopancreatic diversion with duodenal switch, 7.1% underwent laparoscopic Roux-en-Y gastric bypass, and 6% underwent laparoscopic sleeve gastrectomy. The excess weight loss of the remaining 252 patients (66.3%) with a band in situ (including 21 patients after rebanding) was 40%, and only 25% reached an excess weight loss >50%. Older age, binge eating disorder, and sweet-eating behavior were predictors of a poor outcome after LAGB. In contrast, sex, primary body mass index, and co-morbidities had no influence on outcome. CONCLUSION LAGB was less successful in older patients and in patients with binge eating disorder or sweet-eating behavior. These patients might be candidates for a different bariatric procedure.

Five-year results of laparoscopic sleeve gastrectomy.

BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is gaining popularity, but studies reporting long-term results are still rare. The objective of this study was to present the 5-year outcome concerning weight loss, modification of co-morbidities, and late complications. METHODS This is a retrospective analysis of a prospective cohort with a minimal follow-up of 5 years. A total of 68 patients underwent LSG either as primary bariatric procedure (n = 41) or as redo operation after failed laparoscopic gastric banding (n = 27) between August 2004 and December 2007. At the time of LSG, the mean body mass index (BMI) was 43.0 ± 8.0 kg/m(2), the mean age 43.1 ± 10.1 years, and 78% were female. The follow-up rate was 100% at 1 year postoperatively, 97% after 2 years, and 91% after 5 years; the mean follow-up time was 5.9 ± 0.8 years. RESULTS The average excessive BMI loss was 61.5% ± 23.4% after 1 year, 61.1% ± 23.4% after 2 years, and 57.4% ± 24.7% after 5 years. Co-morbidities improved considerably; a remission of type 2 diabetes could be reached at 85%. The following complications were observed: 1 leak (1.5%), 2 incisional hernias (2.9%), and new-onset gastroesophageal reflux in 11 patients (16.2%). Reoperation due to insufficient weight loss was necessary in 8 patients (11.8%). CONCLUSIONS LSG was effective 5.9 years postoperatively with an excessive BMI loss of almost 60% and a considerable improvement or even remission of co-morbidities.

Ferguson Hemorrhoidectomy: Long-Term Results and Patient Satisfaction After Ferguson’s Hemorrhoidectomy

PURPOSEPerioperative morbidity and long-term results after hemorrhoidectomy (Ferguson’s technique) were evaluated as a basis for comparison with new methods such as stapled hemorrhoidectomy.METHODSAll records of patients who underwent conventional hemorrhoidectomy between January 1, 1993 and December 31, 1997 (five years) were retrospectively analyzed. The surgical technique was Ferguson closed hemorrhoidectomy. Long-term results were evaluated with a standardized questionnaire that was sent to all patients.RESULTSFive-hundred-fourteen patients (195 female, 319 male) with a mean age of 52 (range, 22–96) years were evaluated. Postoperatively, seven patients had a relevant hemorrhage, and two had to undergo reoperation (reoperation rate within 30 days, 0.4 percent). In 15 cases (3 percent) patients received urinary catheters for postoperative urinary retention. Mortality was 0 percent. The questionnaire was returned by 403 patients (78.4 percent). The mean follow-up was 4.7 (range, 2.1–7.8) years. The leading symptom was relieved in 275 patients (67.4 percent), ameliorated in 111 (27.2 percent), and unchanged or worse in 22 (5.4 percent). Incontinence (soiling) was not present in 291 (71.7 percent) patients, light in 86 (21.2 percent), moderate in 25 (6.1 percent), and severe in 4 (0.98 percent). Reoperation rate for recurrent hemorrhoids was 0.8 percent. Patients evaluated the surgical result as excellent in 286 (70.5 percent) cases, good in 87 (21.4 percent), moderate in 25 (6.2 percent), and bad in 8 (1.9 percent) cases.CONCLUSIONFerguson closed hemorrhoidectomy results in very low rates of perioperative morbidity. Long-term results demonstrate high patient satisfaction and low incontinence and reoperation rates. It could be the gold standard to which other techniques are compared.

Reduction in Slippage with 11-cm Lap-Band® and Change of Gastric Banding Technique

Background: Slippage occurs after 2-18% of gastric bandings performed by the perigastric technique (PGT). We investigated the slippage-rate before and after the introduction of the pars flaccida technique (PFT) and the 11-cm Lap-Band®, and the long-term results of the re-operated patients. Methods: Between Dec 1996 and Feb 2004, 360 patients with a mean BMI of 44 kg/m2 were operated. The PGT (n=168) and PFT9.75 (n=15) groups received the 9.75-cm Lap-Band®, and the PFT11 group (n=177) received the new 11-cm Lap-Band®. Follow-up rate was 99%. Results: Slippage occurred in a total of 31 patients from all groups (PGT, n=28, or 17%; PFT9.75, n=1, or 7%; PFT11, n=2, or 1%). Average yearly re-operation rate for slippage in the first 3 years postoperatively was 3.8%, 2.2% and 0.9%, respectively. Laparoscopic re-banding was necessary for posterior (n=19) or lateral (n=12) slippage. The late postoperative course after re-banding was: uneventful 58%, weight regain 35% and/or esophageal motility disorder 23%, secondary band intolerance 20%, and one persistent posterior slippage. 8 patients (26%) needed biliopancreatic diversion. Conclusion: Since the introduction of the PFT and the 11-cm Lap-Band®, we observed a significant reduction in slippage rate and no posterior slippage. Re-banding had a less favorable long-term result than did first-procedure banding.

Mitochondrial DNA content in human omental adipose tissue

BackgroundImpairment of mitochondrial function plays an important role in obesity and the development of insulin resistance. The aim of this project was to investigate the mitochondrial DNA copy number in human omental adipose tissue with respect to obesity.MethodsThe mitochondrial DNA (mtDNA) content per single adipocyte derived from abdominal omental adipose tissue was determined by quantitative RT-PCR in a group of 75 patients, consisting of obese and morbidly obese subjects, as well as non-obese controls. Additionally, basal metabolic rate and fat oxidation rate were recorded and expressed as total values or per kilogram fat mass.ResultsMtDNA content is associated with obesity. Higher body mass index (BMI) resulted in a significantly elevated mtDNA count (ratio = 1.56; p = 0.0331) comparing non-obese (BMI < 30) to obese volunteers (BMI ≥ 30). The mtDNA count per cell was not correlated with age or gender. Diabetic patients showed a trend toward reduced mtDNA content. A seasonal change in mtDNA copy number could not be identified. In addition, a substudy investigating the basal metabolic rate and the fasting fat oxidation did not reveal any associations to the mtDNA count.ConclusionsThe mtDNA content per cell of omental adipose tissue did not correlate with various clinical parameters but tended to be reduced in patients with diabetes, which may partly explain the impairment of mitochondrial function observed in insulin resistance. Furthermore, the mtDNA content was significantly increased in patients suffering from obesity (BMI above 30). This might reflect a compensatory response to the development of obesity, which is associated with impairment of mitochondrial function.

Important mitochondrial proteins in human omental adipose tissue show reduced expression in obesity

Obesity is associated with impaired mitochondrial function. This study compares mitochondrial protein expression in omental fat in obese and non-obese humans. Omental adipose tissue was obtained by surgical biopsy, adipocytes were purified and mitochondria isolated. Using anion-exchange chromatography, SDS-PAGE and mass-spectrometry, 128 proteins with potentially different abundances in patient groups were identified, 62 of the 128 proteins are mainly localized in the mitochondria. Further quantification of 12 of these 62 proteins by immune dot blot analysis revealed four proteins citrate synthase, HADHA, LETM1 and mitofilin being inversely associated with BMI, and mitofilin being inversely correlated with gender.

Bolus Obstruction of Pouch Outlet by a Granular Bulk Laxative after Gastric Banding

Background: Constipation is an occasional problem after gastric banding and is often caused by insufficient liquid intake. As a result, the use of laxatives is widespread in such patients. Depending on the laxative, improper use can lead to bolus obstruction above the band, as occurred in this case. Case Report: A 59-year-old female with uncomplicated laparoscopic adjustable gastric banding presented 2 months after surgery with food and liquid intolerance and dysphagia after ingestion of a granular bulking laxative. Despite deflating the band, the bolus could not be washed out. Endoscopic extraction was required, revealing a 4×2 cm bolus of the laxative and a small compression ulcer. Discussion: Patients not complying with nutritional recommendations after gastric banding may have insufficient liquid intake and, consequently, constipation. Under these conditions, the use of a granular bulking laxative entails the risk of esophageal obstruction above the band. Conclusion: Nutritional counseling after gastric banding should include the recommendation of liquid intake of at least 1.5 l/day. If constipation occurs, osmotic or paraffin oil laxatives should be used instead of bulking laxatives.

The Use of Recombinant Coagulation Factor VIIa (NovoSeven ® ) in Severe Diverticular Bleeding

We report a 68-year-old man with sigmoid colon carcinoma who previously underwent an anterior resection. Five years later, he developed a severe diverticular bleeding which required multiple blood transfusions. He underwent an emergent low anterior colectomy with a right colostomy to protect the anastomosis. Nine days after the operation, he had another severe bleeding. Due to his elderly age and two previous colectomies, recombinant coagulation factor VIIa (rFVIIa) was given to avoid re-operation. The bleeding stopped after two doses of rFVIIa, 80 � g/kg followed by 40 � g/kg one hour later. There was no bleeding recurrence.