Federica del Genio

Prospective Assessment of Patient Selection for Antireflux Surgery by Combined Multichannel Intraluminal Impedance pH Monitoring

IntroductionSelecting gastroesophageal reflux disease (GERD) patients for surgery on the basis of standard 24-h pH monitoring may be challenging, particularly if this investigation does not correlate with clinical symptoms. Combined multichannel intraluminal impedance pH monitoring (MII-pH) is able to physically detect each episode of intraesophageal bolus movements, enabling identification of either acid or non-acid reflux episodes and thus establish the association of the reflux with symptoms.Materials and MethodsWe prospectively assessed and reviewed data from 314 consecutive patients who underwent MII-pH for GERD not responsive or not compliant to proton pump inhibitor therapy. One hundred fifty-three patients with a minimum follow-up of 1xa0year constituted the study population. Clinical outcomes and satisfaction rate were collected in all patients who underwent laparoscopic Nissen–Rossetti fundoplication. Outcomes were reported for patients with normal and ineffective peristalsis and for patients with positive pH monitoring, negative pH monitoring and positive total number of reflux episodes at MII, and negative pH monitoring and normal number of reflux episodes at MII and a positive symptom index correlation with MII.ResultsThe overall patient satisfaction rate was 98.3%. No differences were recorded in the clinical outcomes of the patients with preoperative normal and ineffective peristalsis. No differences in patients’ satisfaction and clinical postoperative DeMeester symptom scoring system were noted between the groups as determined by MII-pH.ConclusionMII-pH provides useful information for objective selection of patients to antireflux surgery. Nissen fundoplication provides excellent outcomes in patients with positive and negative pH and positive MII monitoring or Symptom Index association. More extensive studies are needed to definitively standardize the useful MII-pH parameters to select the patient to antireflux surgery.

Sleeve Gastrectomy and Development of “De Novo” Gastroesophageal Reflux

BackgroundSleeve gastrectomy (SG) is currently gaining popularity due to an excellent efficacy combined to minimal anatomic changes. However, some concerns have been raised on increased risk of postoperative gastroesophageal reflux disease (GERD) due to gastric fundus removal, section of the sling muscular fibers of gastroesophageal junction, reduced antral pump function, and gastric volume. We undertook the current study to evaluate by means of high-resolution impedance manometry (HRiM) and combined 24-h pH and multichannel intraluminal impedance (MII-pH) the impact of SG on esophageal physiology.MethodsIn this study, 25 consecutive patients had HRiM and MII-pH before and after laparoscopic SG. The following parameters were calculated at HRiM: lower esophageal sphincter (LES) pressure and relaxation, peristalsis, number of complete esophageal bolus transit, and mean total bolus transit time. The acid and non-acid GER episodes were assessed by MII-pH with the patient in both upright and recumbent positions.ResultsAt a median follow-up of 13xa0months, HRiM showed an unchanged LES function, increased ineffective peristalsis, and incomplete bolus transit. MII-pH showed an increase of both acid exposure of the esophagus and number of non-acid reflux events in postprandial periods.ConclusionsLaparoscopic SG is an effective restrictive procedure that creates delayed esophageal emptying without impairing LES function. A correctly fashioned sleeve does not induce de novo GERD. Retrograde movements and increased acid exposure are probably due to stasis and postprandial regurgitation.

Total fundoplication controls acid and nonacid reflux: evaluation by pre- and postoperative 24-h pH–multichannel intraluminal impedance

BackgroundStudies have demonstrated that Nissen fundoplication controls acid gastroesophageal reflux (GER). Combined 24-h pH and multichannel intraluminal impedance (MII-pH) allows detection of both acid and nonacid GER. Antireflux surgery is considered for any patient whose medical therapy is not efficient, particularly patients with nonacid gastroesophageal reflux disease (GERD). Nevertheless, fundoplication used to control nonacid reflux has not been reported to date.MethodsIn this study, 15 consecutive patients who underwent laparoscopic Nissen-Rossetti fundoplication had MII-pH both before and after the surgical procedure. The numbers of acid and nonacid GER episodes were calculated with the patient in both upright and recumbent positions.ResultsThe 24-h pH monitoring confirmed the postoperative reduction of exposure to acid (pxa0<xa00.05). Postoperatively, the total, acid, and nonacid numbers of GER episodes were reduced (pxa0<xa00.05).ConclusionAccording to the findings, MII-pH is feasible and well tolerated. It provides an objective means for evaluating the effectiveness of Nissen-Rossetti fundoplication in controlling both acid and nonacid GER.

Noninvasive Evaluation of Abdominal Fat and Liver Changes Following Progressive Weight Loss in Severely Obese Patients Treated with Laparoscopic Gastric Bypass

BackgroundObesity is a chronic complex disease, consequence of an unbalance between energy intake and expenditure and of the interaction between predisposing genotype and facilitating environmental factors. The aim of the study was to evaluate body composition, abdominal fat, and metabolic changes in a group of severely obese patients before and after laparoscopic gastric bypass (LGBP) at standardized (10% and 25%) total weight loss.MethodsTwenty-eight patients (14 M, 14 F; age 41.71u2009±u20096.9xa0years; body mass index (BMI) 49.76u2009±u20095.8xa0kg/m2) were treated with laparoscopic gastric bypass. All evaluations before surgery and after achieving ~10% and ~25% weight loss (WL). Body composition was assessed by bioimpedance analysis; resting metabolic rate (RMR) was measured by indirect calorimetry.ResultsBody weight, BMI, and waist circumference significantly decreased at 10% and 25% WL. We observed a significant reduction of both RMR (2,492u2009±u2009388 at entry vs. 2,098xa0±xa0346.6 at 10% WL vs. 2,035u2009±u2009312xa0kcal per 24xa0h at 25% WL, pu2009=u20090.001 vs. baseline) as well as of RMR corrected for fat-free mass (FFM; 35.7u2009±u20096.7 vs. 34.9u2009±u20099.0 at 10% WL vs. 33.5u2009±u20095.4 at 25% WL kilocalorie per kilogram FFMu2009×u200924xa0h, pu2009=u20090.041 vs. baseline). Body composition analysis showed a relative increase in FFM and a reduction of fat mass at 25% WL. A significant reduction in blood glucose, insulin, homeostasis model assessment index was observed. Ultrasonography showed a marked decrease in the signs of hepatic steatosis.ConclusionIn conclusion, our study confirms that LGBP is a safe procedure in well-selected severely obese patients and has early favorable effects on both metabolic parameters and body composition. Longer-term observations are required for in-depth evaluation of body composition changes.

Sleeve gastrectomy improves obstructive sleep apnea syndrome (OSAS): 5 year longitudinal study

BACKGROUNDnObstructive sleep apnea syndrome (OSAS) is prevalent among morbidly obese patients. Evaluation of the specific effects of sleeve gastrectomy (SG) on upper airway function has not been reported. Given the possibility that some patients will not respond despite weight loss, no studies have investigated whether other mechanisms may be responsible for persistent OSAS after bariatric surgery.nnnOBJECTIVESnTo evaluate by subjective and objective assessment the impact of SG on upper respiratory physiology in the long-term.nnnSETTINGnUniversity Hospital, Division of Bariatric and ENT Surgery, in Italy.nnnMETHODSnThirty-six consecutive patients with OSAS who underwent laparoscopic SG were prospectively enrolled. The effect of SG on respiratory function and OSAS was followed for 5 years.nnnRESULTSnAll patients completed the 5-year follow-up. A significant (P<.001) improvement in modified Epworth Sleepiness Scale questionnaire (ESS) was obtained in 91.6% (33/36) of patients. The Apnea/Hypopnea index (AHI) improved in 80.6% (29/36) of patients after surgery (from 32.8 ± 1.7 to 5.8 ± 1.2 (P<.001), 4.9 ± 1.7). The remaining 19.4% (7/36) of patients with a positive ESS and/or AHI all had an associated respiratory resistance due to nasal obstructive diseases.nnnCONCLUSIONnSG improved OSAS overall, but patients who did not improve or only partially improved despite weight loss were found to have an associated nasal responsible pathology. How these patients will respond to nasal surgery and whether a 2-step procedure should be recommended for OSAS patients requires further study.

Laparoscopic Sleeve Gastrectomy with Duodeno-Jejunal Bypass: A New Surgical Procedure for Weight Control. Feasibility and Safety Study in a Porcine Model

BackgroundOne limit of the Roux-en-Y gastric bypass (GBP) is the preclusion of exploring the bypassed stomach with conventional endoscopy and radiological studies. In this study, we explored the feasibility, safety, and weight progression of a new bariatric procedure that eliminates this inconvenience.MethodsEleven 40- to 50-kg Yorkshire pigs underwent laparoscopic sleeve gastrectomy and Roux-en-Y duodeno-jejunal bypass (SG-DJBP). Weight was monitored at postoperative daysxa015 and 30 and after 3xa0months; weight progression was compared with an identical group that underwent a sham procedure or GBP. At autopsy, surgical site was evaluated at microscopic and macroscopic level.ResultsMean operating time was 66u2009±u20095.76xa0min. All the survivors tolerated the procedure well, except one subject that experienced a gastric leak from the stapler line. The SG-DJBP had a had significantly slower weight gains than the sham group (Pu2009=u20090.005). The absence of histological abnormalities in the duodenal wall was confirmed at autopsy.ConclusionSG-DJBP is feasible and produces effects of weight progression comparable to those of GBP. Being a combination of previously standardized procedures, we are confident to propose this procedure as a bariatric alternative in humans. Long-term follow-up will be required to establish the efficacy on weight loss in humans.

Esophageal papilloma: Flexible endoscopic ablation by radiofrequency.

Squamous papilloma of the esophagus is a rare benign lesion of the esophagus. Radiofrequency ablation is an established endoscopic technique for the eradication of Barrett esophagus. No cases of endoscopic ablation of esophageal papilloma by radiofrequency ablation (RFA) have been reported. We report a case of esophageal papilloma successfully treated with a single session of radiofrequency ablation. Endoscopic ablation of the lesion was achieved by radiofrequency using a new catheter inserted through the working channel of endoscope. The esophageal ablated tissue was removed by a specifically designed cup. Complete ablation was confirmed at 3 mo by endoscopy with biopsies. This case supports feasibility and safety of as a new potential indication for Barrx(TM) RFA in patients with esophageal papilloma.

Remission of type 2 diabetes in patients undergoing biliointestinal bypass for morbid obesity: a new surgical treatment

BACKGROUNDnNutrient interaction with the mid-gut may play a role in improving type 2 diabetes mellitus (T2D) after bariatric surgery. However, Roux-en-Y gastric bypass, biliopancreatic diversion, and sleeve gastrectomy include diversion of food from the duodenum and/or partial gastrectomy. Biliointestinal bypass (BIBP) was introduced to eliminate the major side effects of jejunoileal bypass. It does not involve any change to the anatomy of the stomach or the duodenum. A prospective evaluation of the role of BIBP in glycemic control has not been reported.nnnOBJECTIVESnLongitudinal evaluation of T2D after BIBP.nnnSETTINGnUniversity hospitals in Europe and Canada.nnnMETHODnThe effects of BIBP on metabolism and glycemia in 28 consecutive patients with T2D were evaluated over 2 years.nnnRESULTSnDecreases (P<.001) in fasting glycemia, insulinemia, and homeostasis model assessment were observed 3 months after surgery, were improved after 1 year, and remained stable after 2 years. Glycosylated hemoglobin levels decreased at 3, 12, and 24 months after surgery (from 9.2±2.1 to 6.3±1.1 (P<.0001), 4.9±1.7 (P<.0001), and 4.8±1.1 (P<.0001), after 3, 12, and 24 months, respectively). Medical therapy was discontinued in 83% (20 of 24) of the patients; for the remaining 17% (4 of 24), therapy was reduced to oral hypoglycemic agents.nnnCONCLUSIONnBIBP had a favorable risk-benefit relationship and positive metabolic effects in the short term. How BIBP achieves optimal glycemic control and whether it improves β-cell function and/or insulin sensitivity require further study.

Morbid Obesity is Associated to Altered Fatty Acid Profile of Erythrocyte Membranes

Background: Morbid obesity is a pathologic condition associated to an increased incidence of several chronic conditions associated to increased risk of mortality. Erythrocyte fatty acid composition has been candidate as a biomarker of oxidative stress and consequently on the rate of aging and ultimately lifespan. To our knowledge, no study has investigated the total spectrum of lipid composition of erythrocyte membranes from obese individuals. The aim of this study was to compare the fatty acid composition of erythrocyte membranes derived from morbidly obese patients with healthy matched controls and long-living descendants. Methods: Gas chromatography was employed to determine fatty acid percentage of erythrocyte membranes from investigated groups. Results: Erythrocyte membranes from obese subjects had significantly lower percentage of monounsaturated fatty acids (16.0 ± 0.8 vs. 23.0 ± 4.5, p<0.01) and total trans fatty acid (0.2 ± 0.1 vs. 1.3 ± 1.2, p<0.001) than controls. Obese fatty acid profiles showed increased percent of total polyunsaturated fatty acid (36.5 ± 1.4 vs. 27.3 ± 10.9, p<0.001), polyunsaturated fatty acid n-3 (5.2 ± 0.9 vs. 2.6 ± 1.8, p <0.001) and n-6 (31.3 ± 1.7 vs. 25.0 ± 10.1, p<0.001). Interestingly, when obese fatty acid profiles are compared with long-living descendants, the former show opposite trends in the percentages of the main saturated and unsaturated residues of membrane phospholipids compared with nonagenarian offspring. Conclusion: This study shows that the erythrocyte membranes fatty acid composition of obese subjects differs from general population in a way opposite to the long-living descendants. If confirmed by further investigations, the fatty acid equilibration may become an additional target in the multidisciplinary strategy aimed to treat the obesity epidemic.

Endoscopic cervical bariatric surgery: follow-up study in a porcine model.

BackgroundThe realisation of bariatric surgery has to date modified the digestive process solely through procedures within the abdominal cavity. However, endocrine surgeons have recently demonstrated the feasibility of a minimally invasive approach to the neck. In this study, we explored the feasibility, safety and weight progression of a bariatric procedure performed at the neck.MethodsEleven 40–50xa0kg Yorkshire pigs underwent endoscopic placement of an adjustable band to the cervical esophagus (ECB). Weight was monitored at postoperative daysxa015, 30, and after 7xa0weeks; weight progression was compared with an identical group of pigs who underwent a sham procedure. At autopsy, the surgical site was evaluated in a microscopic and macroscopic manner.ResultsMean operating time was 66u2009±u20095.76xa0min. All pigs tolerated the procedure well, except one subject that experienced food intolerance. The ECB group experienced significantly slower weight gain than the sham group (Pu2009=u20090.005). Proper location of the band and absence of microscopic lesions at the esophageal wall were confirmed at autopsy and pathological examination.ConclusionBariatric surgery at the neck is feasible and produces effects on weight reduction. Further refinements and longer observation periods are required to propose this procedure as safe and effective alternative in humans.