Dino Kröll

Effect of Laparoscopic Sleeve Gastrectomy vs Laparoscopic Roux-en-Y Gastric Bypass on Weight Loss in Patients With Morbid Obesity: The SM-BOSS Randomized Clinical Trial

Importance Sleeve gastrectomy is increasingly used in the treatment of morbid obesity, but its long-term outcome vs the standard Roux-en-Y gastric bypass procedure is unknown. Objective To determine whether there are differences between sleeve gastrectomy and Roux-en-Y gastric bypass in terms of weight loss, changes in comorbidities, increase in quality of life, and adverse events. Design, Setting, and Participants The Swiss Multicenter Bypass or Sleeve Study (SM-BOSS), a 2-group randomized trial, was conducted from January 2007 until November 2011 (last follow-up in March 2017). Of 3971 morbidly obese patients evaluated for bariatric surgery at 4 Swiss bariatric centers, 217 patients were enrolled and randomly assigned to sleeve gastrectomy or Roux-en-Y gastric bypass with a 5-year follow-up period. Interventions Patients were randomly assigned to undergo laparoscopic sleeve gastrectomy (n = 107) or laparoscopic Roux-en-Y gastric bypass (n = 110). Main Outcomes and Measures The primary end point was weight loss, expressed as percentage excess body mass index (BMI) loss. Exploratory end points were changes in comorbidities and adverse events. Results Among the 217 patients (mean age, 45.5 years; 72% women; mean BMI, 43.9) 205 (94.5%) completed the trial. Excess BMI loss was not significantly different at 5 years: for sleeve gastrectomy, 61.1%, vs Roux-en-Y gastric bypass, 68.3% (absolute difference, −7.18%; 95% CI, −14.30% to −0.06%; P = .22 after adjustment for multiple comparisons). Gastric reflux remission was observed more frequently after Roux-en-Y gastric bypass (60.4%) than after sleeve gastrectomy (25.0%). Gastric reflux worsened (more symptoms or increase in therapy) more often after sleeve gastrectomy (31.8%) than after Roux-en-Y gastric bypass (6.3%). The number of patients with reoperations or interventions was 16/101 (15.8%) after sleeve gastrectomy and 23/104 (22.1%) after Roux-en-Y gastric bypass. Conclusions and Relevance Among patients with morbid obesity, there was no significant difference in excess BMI loss between laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass at 5 years of follow-up after surgery. Trial Registration clinicaltrials.gov Identifier: NCT00356213

Effect of Laparoscopic Sleeve Gastrectomy vs Laparoscopic Roux-en-Y Gastric Bypass on Weight Loss in Patients With Morbid Obesity

Importance Sleeve gastrectomy is increasingly used in the treatment of morbid obesity, but its long-term outcome vs the standard Roux-en-Y gastric bypass procedure is unknown. Objective To determine whether there are differences between sleeve gastrectomy and Roux-en-Y gastric bypass in terms of weight loss, changes in comorbidities, increase in quality of life, and adverse events. Design, Setting, and Participants The Swiss Multicenter Bypass or Sleeve Study (SM-BOSS), a 2-group randomized trial, was conducted from January 2007 until November 2011 (last follow-up in March 2017). Of 3971 morbidly obese patients evaluated for bariatric surgery at 4 Swiss bariatric centers, 217 patients were enrolled and randomly assigned to sleeve gastrectomy or Roux-en-Y gastric bypass with a 5-year follow-up period. Interventions Patients were randomly assigned to undergo laparoscopic sleeve gastrectomy (n = 107) or laparoscopic Roux-en-Y gastric bypass (n = 110). Main Outcomes and Measures The primary end point was weight loss, expressed as percentage excess body mass index (BMI) loss. Exploratory end points were changes in comorbidities and adverse events. Results Among the 217 patients (mean age, 45.5 years; 72% women; mean BMI, 43.9) 205 (94.5%) completed the trial. Excess BMI loss was not significantly different at 5 years: for sleeve gastrectomy, 61.1%, vs Roux-en-Y gastric bypass, 68.3% (absolute difference, −7.18%; 95% CI, −14.30% to −0.06%; P = .22 after adjustment for multiple comparisons). Gastric reflux remission was observed more frequently after Roux-en-Y gastric bypass (60.4%) than after sleeve gastrectomy (25.0%). Gastric reflux worsened (more symptoms or increase in therapy) more often after sleeve gastrectomy (31.8%) than after Roux-en-Y gastric bypass (6.3%). The number of patients with reoperations or interventions was 16/101 (15.8%) after sleeve gastrectomy and 23/104 (22.1%) after Roux-en-Y gastric bypass. Conclusions and Relevance Among patients with morbid obesity, there was no significant difference in excess BMI loss between laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass at 5 years of follow-up after surgery. Trial Registration clinicaltrials.gov Identifier: NCT00356213

Wernicke Encephalopathy: a Future Problem Even After Sleeve Gastrectomy? A Systematic Literature Review

Wernicke encephalopathy (WE) is a serious complication of bariatric surgery with significant morbidity and mortality. A few cases have been reported in the literature, mainly in patients after a Roux-en-Y gastric bypass. Since sleeve gastrectomy (SG) has become a more established and popular bariatric procedure, WE is expected to appear more frequently after SG. We performed a literature review on WE after SG, and 13 cases have been found to be sufficiently documented. The risk of WE needs to be considered in patients with a prolonged vomiting episode and any type of neurological symptoms, independent of the presence of any surgical complications.

Epstein-barr virus in gastro-esophageal adenocarcinomas - single center experiences in the context of current literature.

Epstein–Barr virus (EBV)-associated gastric carcinomas (GC) represent a distinct and well-recognized subtype of gastric cancer with a prevalence of around 10% of all GC. In contrast, EBV has not been reported to play a major role in esophageal adenocarcinomas (EAC) and adenocarcinomas of the gastro-esophageal junction (GEJ). We report our experiences on EBV in collections of gastro-esophageal adenocarcinomas from two surgical centers and discuss the current state of research in this field. Tumor samples from 465 primary resected gastro-esophageal adenocarcinomas (118 EAC, 73 GEJ, and 274 GC) were investigated. Presence of EBV was determined by EBV-encoded small RNAs (EBER) in situ hybridization. Results were correlated with pathologic parameters (UICC pTNM category, Her2 status, tumor grading) and survival. EBER positivity was observed in 14 cases. None of the EAC were positive for EBER. In contrast, we observed EBER positivity in 2/73 adenocarcinomas of the GEJ (2.7%) and 12/274 GC (4.4%). These were of intestinal type (seven cases) or unclassifiable (six cases), while only one case was of diffuse type according to the Lauren classification. No association between EBV and pT, pN, or tumor grading was found, neither was there a correlation with clinical outcome. None of the EBER positive cases were Her2 positive. In conclusion, EBV does not seem to play a role in the carcinogenesis of EAC. Moreover, adenocarcinomas of the GEJ show lower rates of EBV positivity compared to GC. Our data only partially correlate with previous reports from the literature. This highlights the need for further research on this distinct entity. Recent reports, however, have identified specific epigenetic and genetic alterations in EBV-associated GC, which might lead to a distinct treatment approach for this specific subtype of GC in the future.

Exocrine Pancreatic Insufficiency after Roux-en-Y gastric bypass

BACKGROUND Gastric resection, short bowel syndrome, and diabetes mellitus are risk factors for development of exocrine pancreatic insufficiency (EPI). Reasons are multifactorial and not completely elucidated. OBJECTIVES To determine the prevalence of EPI after distal (dRYGB) and proximal Roux-en-Y gastric bypass (pRYGB) and to assess the influence of respective limb lengths. SETTING University hospital, Switzerland. METHODS The study comprised 188 consecutive patients who underwent primary dRYGB (common channel<120 cm, biliopancreatic limb 80-100 cm) or pRYGB (alimentary limb = 155 cm, biliopancreatic limb 40-75 cm) and who were followed-up for at least 2 years. Patients with a history of gastrointestinal or hepatobiliary resection (except for cholecystectomy), postoperative pregnancy, and any revision of RYGB (gastric pouch, limb lengths) were excluded. EPI was defined by clinical symptoms in combination with fecal pancreatic elastase-1<200 μg/g stool or fecal pancreatic elastase-1>200 and<500 μg/g stool and positive dechallenge-rechallenge test with pancreatic enzyme replacement therapy. RESULTS Mean follow-up was 52.2 months (range 24-120). Seventy-nine patients (42%) underwent dRYGB, and 109 (58%) underwent pRYGB. Of those, 59 (31%) patients were diagnosed with EPI after a mean 12.5±16.3 months. There was a significant difference between dRYGB and pRYGB groups in initial body mass index (dRYGB 47.1±8.1 kg/m(2) versus pRYGB 42.7±6.1 kg/m(2); P<.01), patients in Obesity Surgery Mortality Risk Score group C (13% versus 3%; P = .02), and prevalence of EPI (48% versus 19%; P<.01). Neither overall small bowel length nor absolute or relative limb lengths were influencing factors on EPI after dRYGB. CONCLUSION Prevalence of EPI after dRYGB (48%) and pRYGB (19%) is of clinical importance. There was no significant difference in absolute or relative limb lengths between EPI and non-EPI groups after dRYGB.

Complex hernias with loss of domain in morbidly obese patients: role of laparoscopic sleeve gastrectomy in a multi-step approach

BACKGROUND Morbid obesity and its associated co-morbidities are risk factors for the development of abdominal hernias, add complexity to their repair, and increase perioperative risk. Repair of hernias with loss of domain (LoD) is further complicated by risk of abdominal compartment syndrome. A staged concept with an initial weight loss procedure might enable a reposition of the herniated viscera, improve co-morbidities for, and prohibit abdominal compartment syndrome in the subsequent repair. OBJECTIVE To evaluate a multistep treatment strategy that entails initial laparoscopic sleeve gastrectomy (LSG) followed by open repair in the treatment of complex hernias with LoD in morbidly obese patients SETTING: University hospital METHODS: Retrospective analysis of all patients (n = 15) with morbid obesity and hernias with LoD treated in a staged concept between April 2010 and December 2015 RESULTS: Median initial body mass index was 45 kg/m2. All hernias were recurrent incisional hernias with≥2 failed repairs. No major complications occurred during or after LSG. After a median of 185 days, the second stage at a median body mass index of 33.6 kg/m2 was performed. No bowel resections were needed. The only major perioperative complication was pneumonia in 2 patients (13%). Within 24 months (6-68) after the second step, there were 3 reoperations (small recurrence [7%], infected seroma [7%], and infected mesh [7%]). One patient (7%) was lost to follow-up after 2 years. CONCLUSION A 2-step approach to treat massive hernias with LoD in morbidly obese patients is safe and effective. LSG as initial weight loss procedure addresses LoD successfully without a need for further preoperative measures to condition for hernia repair.

Impact of peritumoral and intratumoral budding in esophageal adenocarcinomas

Tumor budding has prognostic significance in many carcinomas and is defined as the presence of detached isolated single cells or small cell clusters up to 5 cells at the invasion front (peritumoral budding [PTB]) or within the tumor (intratumoral budding [ITB]). For esophageal adenocarcinomas (EACs), there are currently only few data about the impact of this morphological feature. We investigated tumor budding in a large collective of 200 primarily resected EACs. Pancytokeratin staining was demonstrated to be superior to hematoxylin and eosin staining for the detection of buds with substantial to excellent interobserver agreement and used for subsequent analysis. PTB and ITB were scored across 10 high-power fields (HPFs). The median count of tumor buds was 130/10 HPFs for PTB (range, 2-593) and 80/10 HPFs for ITB (range, 1-656). PTB and ITB correlated significantly with each other (r = 0.9; P < .001). High PTB and ITB rates were seen in more advanced tumor categories (P < .001 each); tumors with lymph node metastases (P < .001/P = .002); and lymphatic, vascular, and perineural invasion and higher tumor grading (P < .001 each). Survival analysis showed an association with worse survival for high-grade ITB (P = .029) but not PTB (P = .385). However, in multivariate analysis, lymph node and resection status, but not ITB, were independent prognostic parameters. In conclusion, PTB and ITB can be observed in EAC to various degrees. High-grade budding is associated with aggressive tumor phenotype. Assessment of tumor budding, especially ITB, may provide additional prognostic information about tumor behavior and may be useful in specific cases for risk stratification of EAC patients.

Influences of Obesity and Bariatric Surgery on the Clinical and Pharmacologic Profile of Rivaroxaban

The health implications of obesity are myriad and multifaceted. Physiologic changes associated with obesity can affect the absorption, distribution, metabolism, and excretion of administered drugs, thereby altering their pharmacologic profiles. In 2016, the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis published recommendations about the use of direct oral anticoagulants (DOACs) in obese patients. This guidance provides uniform recommendations for all DOACs, yet data suggest that individual agents may be affected to different degrees by obesity. Moreover, there are no recommendations currently available to guide DOAC use in bariatric surgery patients, in whom anatomic and physiologic changes to the digestive system can influence drug pharmacokinetics. Our review of the available literature indicates that the clinical profile of the DOAC rivaroxaban is not affected by high weight or bariatric surgery; hence, it does not appear that rivaroxaban dosing needs to be altered in these patient populations.

Expression patterns of programmed death-ligand 1 in esophageal adenocarcinomas: comparison between primary tumors and metastases

Expression analysis of programmed death-ligand 1 (PD-L1) may be helpful in guiding clinical decisions for immune checkpoint inhibition therapy, but testing by immunohistochemistry may be hampered by heterogeneous staining patterns within tumors and expression changes during metastatic course. PD-L1 expression (clone SP142) was investigated in esophageal adenocarcinomas using tissue microarrays (TMA) from 112 primary resected tumors, preoperative biopsies and full slide sections from a subset of these cases (n = 24), corresponding lymph node (n = 55) and distant metastases (n = 17). PD-L1 expression was scored as 0.1–1, >1, >5, >50% positive membranous staining of tumor cells and any positive staining of tumor-associated inflammatory infiltrates and/or stroma cells. There was a significant correlation with overall PD-L1 expression between the full slide sections and the TMA (p = 0.001), but not with the corresponding biopsies. PD-L1 expression in tumor cells >1% was detected in 8.0% of cases (9/112) and 51.8% of cases (58/112) in tumor-associated inflammatory infiltrates and/or stroma cells of primary tumors. Epithelial expression in metastases was found in 5.6% of cases (4/72) and immune cell expression in 18.1% of cases (13/72), but did not correlate with the expression pattern in the primary tumor. Overall PD-L1 expression in the primary tumor did not influence survival. However, PD-L1 expression was correlated with the number of CD3+ tumor-infiltrating lymphocytes in the tumor center, and a combinational score of PD-L1 status/CD3+ tumor-infiltrating lymphocytes was correlated with patients’ overall survival.

What Causes Late Perforation of the Jejuno-Jejunal Anastomosis After Roux-en-Y Gastric Bypass Surgery?

To the Editor: Laparoscopic Roux-en-Y gastric bypass (RYGB) is a common surgical treatment for morbid obesity that is being used more and more frequently and is still widely regarded today as the gold standard in weight loss surgery. There are, however, a number of short-term and long-term sequelae that may occur after surgery. Complications related to this intervention occurring more than 30 days postoperatively and requiring readmission are defined as late complications. These select intestinal complications include small-bowel obstructions (the most frequently reported late complication), hernias, anastomotic strictures, and marginal or stomal ulceration [1]. Late perforation at the site of the jejunojejunal (JJ) anastomosis appears to be very rare. The incidence of JJ anastomotic perforation has been reported to be under 1 % in the literature [2, 3]. To our best knowledge, only ten cases have been reported following bariatric surgery, five of them in Obesity Surgery, and the reason for perforation has not always been apparent [2–7]. We would like to present an additional case of late perforation at the JJ anastomosis, which occurred 11 months after laparoscopic RYGB performed at another hospital in a patient with an initial BMI of 42 kg/m. We would appreciate hearing about similar observations made by other clinicians. A 36-year-old woman with a total excess weight loss (EWL) of 30 % was admitted to the emergency department with severe, cramping abdominal pain and severe diarrhea. Clinical examination revealed a tender abdomen. Laboratory findings were normal except for an elevated leukocyte count of 14,700/μl. Free air in the abdomen was detected by CT scan, and the patient was immediately transferred to the operating room. After initial exploratory laparoscopy, an open technique was applied because of extensive peritonitis. A 5-mm perforation was identified at the mesenteric site of the JJ anastomosis. Specimens were obtained for microbiological cultures. The perforation was excised, and primary closure was performed with interrupted absorbable sutures. Intravenous antimicrobial agents and proton pump inhibitors were administered for 14 days. The patient denied taking any ulcerogenic drugs, consuming a l coho l , and smok ing . S t rep tococcus gallolyticus , Klebsiella oxytoca, and Aeromonas hydrophila grew in culture. The postoperative course was favorable. In previous reports, potential causes of perforation have included the following: distal obstruction (increased intraluminal pressure; caused by a bezoar [6] * Dino Kröll dino.kroell@insel.ch