Dimitris Papamargaritis

Influence of the Learning Curve on Safety and Efficiency of Laparoscopic Sleeve Gastrectomy

BackgroundLaparoscopic sleeve gastrectomy (LSG) is a relatively new bariatric procedure, and data regarding the learning curve are scarce. The aim of this study is to assess how the procedure can be safely implanted in a newly established bariatric unit and to define the learning curve.MethodsProctorship and mentorship in bariatric surgery were attended by two surgeons who were previously experienced in advanced laparoscopic surgery. The first consecutive 102 patients who underwent LSG in our newly established bariatric center were included. Patients were divided into three groups of 34 (groups 1, 2, and 3) according to case sequence. Data on demographics, operative time, conversion rate, hospital stay, morbidity, mortality, and excess weight loss (EWL) over time were compared between the groups.ResultsThe operative time was significantly lower in groups 2 (p = 0.016) and 3 (p = 0.003) compared to group 1. The learning curve was flat up to the 68th case. A significant decrease in hospital stay was noted for group 3 compared to groups 1 (p < 0.001) and 2 (p = 0.002). The conversion rate, mortality and morbidity rates, and EWL did not differ significantly between the groups. Mortality was 0.98% and procedure-related morbidity was 7.8%.ConclusionsLSG can be safely and efficiently performed in a newly established bariatric center following a mentorship procedure. Proficiency seems to require 68 cases. The operative time and hospital stay may significantly decrease with experience early in the learning curve, as opposed to mortality and morbidity rates, conversion rate, and EWL.

Changes in gut hormone profile and glucose homeostasis after laparoscopic sleeve gastrectomy

BACKGROUND Changes in glucagon-like peptide-1 (GLP-1) and peptide YY (PYY) levels after bariatric surgery have been proposed as a mechanism for long-term maintenance of weight loss and improvement in glucose homeostasis postoperatively. The objective of the present study was to assess the changes in GLP-1, PYY, insulin, and glucose levels after laparoscopic sleeve gastrectomy (SG). METHODS Ten morbidly obese patients without type 2 diabetes (3 male, 7 female; body mass index [BMI] 47.92±2.06 kg/m(2)) were evaluated preoperatively and at 6 weeks, 6 months, and 12 months after SG. Total GLP-1, total PYY, insulin, and glucose were measured in fasting state and every 30 minutes after ingestion of 75 g glucose for a total time of 120 minutes. RESULTS BMI decreased markedly postoperatively (P<.001). Postprandial total GLP-1 and total PYY responses, measured by the area under the curve (AUC), were significantly increased by the sixth postoperative week compared with preoperative period (P<.001). Fasting insulin levels were markedly decreased postoperatively at all time points (all P<.01). Insulin AUC decreased progressively throughout the first postoperative year (P = .04), whereas glucose AUC decreased significantly at 6 and 12 months postoperatively (both P<.01). Insulin sensitivity measured by the Matsuda index increased progressively postoperatively. First phase insulin secretion remained unchanged. CONCLUSION Postprandial total GLP-1 and total PYY levels increased significantly at 6 weeks post-SG and remained elevated for at least 1 year. These findings may indicate their involvement in better glucose homeostasis and weight loss maintenance after SG.

Hepcidin levels in diabetes mellitus and polycystic ovary syndrome

Increased body iron is associated with insulin resistance. Hepcidin is the key hormone that negatively regulates iron homeostasis. We hypothesized that individuals with insulin resistance have inadequate hepcidin levels for their iron load.

Copper, selenium and zinc levels after bariatric surgery in patients recommended to take multivitamin-mineral supplementation

BACKGROUND Bariatric surgery is widely performed to improve obesity-related disorders, but can lead to nutrient deficiencies. In this study we examined serum trace element concentrations before and after bariatric surgery. METHODS We obtained serum trace element concentrations by inductively coupled plasma-mass spectrometry (ICP-MS) method in 437 patients (82% women, median preoperative body-mass index 46.7 kg/m(2) [interquartile range 42-51]) undergoing either gastric banding (22.7%), sleeve gastrectomy (20.1%), or gastric bypass (57.3%) procedures. Trace element data were available for patients preoperatively (n = 44); and 3 (n = 208), 6 (n = 174), 12 (n = 122), 18 (n = 39), 24 (n = 44) and 36 months (n = 14) post-operatively. All patients were recommended to take a multivitamin-mineral supplement after surgery. RESULTS Copper deficiency was found in 2% of patients before surgery; and after surgery deficiency rates ranged from 0 to 5% with no significant change in median concentrations during follow-up (p = 0.68). Selenium deficiency was reported in 2% of patients before surgery; and after surgery deficiency rates ranged from 11 to 15% with a near-significant change in median concentrations (p = 0.056). Zinc deficiency was reported in 7% before surgery; and after surgery deficiency rates ranged from 7 to 15% with no significant change in median concentrations (p = 0.39). CONCLUSIONS In bariatric surgery patients recommended to take multivitamin-mineral supplements, serum copper, zinc and selenium concentrations were mostly stable during the first years after bariatric surgery. There was a possible tendency for selenium concentrations to decline during the early postoperative period.

Complicated Gallstones after Laparoscopic Sleeve Gastrectomy

Background. The natural history of gallstone formation after laparoscopic sleeve gastrectomy (LSG), the incidence of symptomatic gallstones, and timing of cholecystectomy are not well established. Methods. A retrospective review of prospectively collected database of 150 patients that underwent LSG was reviewed. Results. Preoperatively, gallbladder disease was identified in 32 of the patients (23.2%). Postoperatively, eight of 138 patients (5.8%) became symptomatic. Namely, three of 23 patients (13%) who had evident cholelithiasis preoperatively developed complicated cholelithiasis. From the cohort of patients without preoperative cholelithiasis, five of 106 patients (4.7%) experienced complicated gallstones after LSG. Total cumulative incidence of complicated gallstones was 4.7% (95% CI: 1.3–8.1%). The gallbladder disease-free survival rate was 92.2% at 2 years. No patient underwent cholecystectomy earlier than 9 months or later than 23 months indicating the post-LSG effect. Conclusion. A significant proportion of bariatric patients compared to the general population became symptomatic and soon developed complications after LSG, thus early cholecystectomy is warranted. Routine concomitant cholecystectomy could be considered because the proportion of patients who developed complications especially those with potentially significant morbidities is high and the time to develop complications is short and because of the real technical difficulties during subsequent cholecystectomy.

Morbidity and mortality of diabetes with surgery

The prevalence of Type 2 diabetes mellitus (T2DM) has increased; as a result the number of patients with T2DM undergoing surgical procedures has also increased. This population is at high risk of macrovascular (cardiovascular disease, peripheral vascular disease) or microvascular (retinopathy, nephropathy or neuropathy) complications, both increasing their perioperative morbidity and mortality. Diabetes patients are more at risk of poor wound healing, respiratory infection, myocardial infarction, admission to intensive care, and increased hospital length of stay. This leads to increased inpatient costs. The outcome of perioperative glycaemia management remains a significant clinical problem without a universally accepted solution. The majority of evidence on morbidity and mortality of T2DM patients undergoing surgery comes from the setting of cardiac surgery; there was less evidence on noncardiac surgery and bariatric surgery. Bariatric surgery is increasingly performed in patients with severe obesity complicated by T2DM, but is distinguished from general surgery as it immediately improves the glucose homeostasis postoperatively. The improvements in glycaemia are thought to be independent of weight loss and this requires different postoperative management. Patients usually have to follow specific preoperative diets which lead to improvement in glycaemia immediately before surgery. Here we review the available data on the mortality and morbidity of patients with T2DM who underwent elective surgery (cardiac, non-cardiac and bariatric surgery) and the current knowledge of the impact that preoperative, intraoperative and postoperative glycaemic management has on operative outcomes.

Impact of perioperative management of glycemia in severely obese diabetic patients undergoing gastric bypass surgery

BACKGROUND Roux-en-Y gastric bypass (RYGB) surgery is associated with rapid postsurgical improvement in glycemic control in patients with type 2 diabetes mellitus (T2 DM). However, there is little outcome-based evidence to guide the glycemic management of this patient group preoperatively. OBJECTIVES We conducted 2 pilot studies randomizing patients to assess the impact of intensive glucose management pre- and post-RYGB on clinical outcomes after surgery. SETTING University hospital. METHODS In the GLUCOSURG-pre randomized controlled trial (RCT), 34 obese T2 DM patients with glycated hemoglobin (HbA1 c) ≥8.5% (69 mmol/mol) undergoing RYGB were randomly assigned to receive either glucose optimization or no optimization 3 months preoperatively. In the GLUCOSURG-post RCT, 35 obese T2 DM patients on insulin were randomly assigned to either intensive or conservative glucose management up to 2 weeks post- RYGB. HbA1c at 1 year post-RYGB was the primary outcome. RESULTS In GLUCOSURG-pre, the HbA1 c at 1 year postsurgery was -3.0% (51.9 mmol/mol) in the optimized and -4.0% (45.4 mmol/mol) in the nonoptimized groups (P = .06). In GLUCOSURG-post, there were no significant differences in HbA1 c at 1 year postsurgery between the intensive and conservative groups [-2.4% (44.3 mmol/mol)] versus [-2.3% (44.3 mmol/mol), P = .73)]. CONCLUSIONS Our pilot studies suggested that neither intensive management of glycemia in the 3 months pre- RYGB, nor the first 2 weeks post-RYGB resulted in better glycemic control one year after surgery. RYGB has substantial effects on glucose control, and additional intensive glucose-lowering interventions do not confer clinical benefits compared to conservative approaches.

Treatment of Morbid Obesity: Intensive Lifestyle Intervention vs. Bariatric Surgery

Obesity has reached an epidemic dimension composing a serious threat to health systems worldwide. It has been associated with numerous comorbidities including cardiovascular disease, type 2 diabetes mellitus, cancer, nonalcoholic fatty liver disease, arthritis, infertility, eating disorders, unemployment and a reduced quality of life. Bariatric surgery is currently the only effective treatment for severe obesity. Non-surgical treatment modalities include lifestyle changes, diet and/or exercise, with pharmacotherapy and less invasive medical devices. This article therefore aims to discuss the available therapy options including surgical and non-surgical treatments as well as to compare both modalities regarding their clinical effectiveness.

Esophageal motility after laparoscopic sleeve gastrectomy

Background Laparoscopic sleeve gastrectomy (LSG) modifies the upper gastrointestinal tract motility. Controversial data currently exist. The aim of the study was to evaluate esophageal motility before and after LSG. Patients and methods Morbid obese patients scheduled for LSG underwent reflux symptoms evaluation and manometry preoperatively and postoperatively. The preoperative and postoperative results were compared and analyzed. Results Eighteen patients were enrolled. Heartburn and regurgitation improved in 38.9% and 11.1% of the patients, but deteriorated in 11.1% and 27.8% of the patients, respectively. Lower esophageal sphincter (LES) total length decreased postoperatively (p=0.002). Resting and residual pressures tended to decrease postoperatively (mean difference [95% confidence interval]: −4 [−8.3/0.2] mmHg, p=0.060; −1.4 [−3/0.1] mmHg, p=0.071, respectively). Amplitude pressure decreased from 95.7±37.3 to 69.8±26.3 mmHg at the upper border of LES (p=0.014), and tended to decrease at the distal esophagus from 128.5±30.1 to 112.1±35.4 mmHg (p=0.06) and mid-esophagus from 72.7±34.5 to 49.4±16.7 mmHg (p=0.006). Peristaltic normal swallow percentage increased from 47.2±36.8 to 82.8±28% (p=0.003). Postoperative regurgitation was strongly negatively correlated with LES total length (Spearman’s r=−0.670). When groups were compared according to heartburn status, statistical significance was observed between the groups of improvement and deterioration regarding postoperative residual pressure and postoperative relaxation (p<0.002, p<0.002, respectively). With regard to regurgitation status, there was statistically significant difference between groups regarding preoperative amplitude pressure at the upper border of LES (p<0.056). Conclusion Patients developed decreased LES length and weakened LES pressure after LSG. Esophageal body peristalsis was also affected in terms of decreased amplitude pressure, especially at the upper border of LES. Nevertheless, body peristalsis was normalized postoperatively. LSG might not deteriorate heartburn. Regurgitation might increase following LSG due to shortening of LES length, particularly in patients with range of preoperative amplitude pressure at the upper border of LES of 38.9–92.6 mmHg.