George Skroubis

Comparison of Nutritional Deficiencies after Roux- en-Y Gastric Bypass and after Biliopancreatic Diversion with Roux-en-Y Gastric Bypass

Background: Patients undergoing either Roux-en-Y gastric bypass (RYGBP) or biliopancreatic diversion (BPD) with RYGBP are at risk of developing metabolic sequelae secondary to malabsorption.We compared the differences in nutritional complications between these two bariatric operations. Methods: A retrospective analysis of a prospective database was done. From June 1994 to December 2001, 243 morbidly obese patients underwent various bariatric procedures at our institution. Of these patients, 79 (BMI 45.6 ± SD=4.9) who underwent RYGBP (gastric pouch 15 ± 5ml, biliopancreatic limb 60-80 cm, alimentary limb 80-100 cm and common limb the remainder of the small intestine), and 95 super obese (BMI 57.2 ± 6.1) who underwent a BPD (gastric pouch 15 ± 5ml, biliopancreatic limb 150-200 cm, common limb 100 cm and alimentary limb the remainder of the small intestine), were selected and studied for the incidence of micronutrient deficiencies and level of serum albumin at yearly intervals postoperatively. A variety of nutritional parameters including Hb, Fe, ferritin, folic acid, vitamin B12 and serum albumin were measured preoperatively and compared postoperatively at 1, 3, 6, 12, 18 and 24 months, and yearly thereafter. Results: Nutritional parameters were compared preoperatively and at similar periods postoperatively. No statistically significant (P <0.05) difference in the occurrence of deficiency was observed between the groups for any of the nutritional parameters studied, except for ferritin, which showed a significant difference at the 2-year follow-up (37.7% low ferritin levels after RYGBP vs. 15.2% after BPD, P =0.0294). All of these deficiencies were mild, without clinical symptomatology and were easily corrected with additional supplementation of the deficient micronutrient, with no need for hospitalization. Regarding serum albumin, there was only one patient with a level below 3 g/dl in the RYGBP group and two in the BPD group.These three patients were hospitalized and received total parenteral nutrition for 3 weeks, without further complications. Conclusion:There was no significant difference in the incidence of deficiency of the nutritional parameters studied, except for ferritin, following RYGBP vs. BPD with RYGBP.The most common deficiencies encountered were of iron and vitamin B12. The incidence of hypoalbuminemia was negligible in both groups, with mean values above 4 g/dl.

Roux-en-Y Gastric Bypass versus a Variant of Biliopancreatic Diversion in a Non-Superobese Population: Prospective Comparison of the Efficacy and the Incidence of Metabolic Deficiencies

Background: In the non-superobese population, an agreement has not been made as to the optimal bariatric operation. The present study reports the results of a prospective comparison of Roux-en-Y gastric bypass (RYGBP) and a variant of biliopancreatic diversion (BPD) in a non-superobese population. Methods: From a cohort of 130 patients with BMI 35 to 50 kg/m2, 65 patients were randomly selected to undergo RYGBP and 65 to undergo BPD. All patients underwent complete follow-up evaluation at 1, 3, 6, and 12 months postoperatively and every year thereafter. Results: Patients in both groups have completed their second postoperative year. Mean % excess weight loss (%EWL) was significantly better after BPD at all time periods (12 months, P=0.0001 and 24 months, P=0.0003), and the %EWL was >50% in all BPD patients compared to 88.7% in the RYGBP patients at 2-year follow-up. No statistically significant differences were observed between the 2 groups in early and late non-metabolic complications. Hypoalbuminemia occurred in only 1 patient (1.5%) after RYGBP and in 6 patients after BPD (9.2%). Only 1 patient from each group was hospitalized and received total parenteral nutrition. Glucose intolerance, hypercholesterolemia, hypertriglyceridemia and sleep apnea completely resolved in all patients in both groups, although mean total cholesterol level was significantly lower in BPD patients at the second year follow-up (t-test, P<0.0001). Diabetes completely resolved in all BPD patients and in 7 of the 10 diabetic RYGBP patients. Conclusion: Both RYGBP and BPD were safe and effective procedures when offered to non-superobese patients. Weight loss after BPD was consistently better than that after RYGBP, as was the resolution of diabetes and hypercholesterolemia. Because the nutritional deficiencies that occurred following this type of BPD were not severe and were not significantly different between the 2 operations, both may be offered to non-superobese patients, keeping in mind the severity and type of preoperative co-morbidities as well as the desired weight loss.

Significance of bile leaks complicating conservative surgery for liver hydatidosis.

Hepatic hydatidosis presents a challenge in liver surgery, and there is still controversy regarding the appropriate surgical technique. A high incidence of postoperative bile leaks is reported as a significant disadvantage of conservative surgical procedures. The purpose of this study was to examine the incidence and clinical importance of bile leakage in patients being treated exclusively by a conservative surgical technique. From January 1985 to November 2000 a total of 187 patients were operated on at our department for hepatic hydatidosis. They were subjected to the standard conservative surgical technique (wide unroofing and cyst drainage). A total of 18 complications were related to bile leakage (10%), 3 of them bile abscesses (1 drained surgically and 2 percutaneously), 1 case of bile peritonitis due to an accessory bile duct in the gallbladder bed (treated surgically), and 14 fistulas (1 bronchobiliary and 13 biliocutaneous). Five of the fistulas, including the bronchobiliary one, were treated successfully by endoscopy; and the remaining nine healed after conservative treatment. Bile leakage, representing a significant complication following conservative operations for hepatic hydatidosis, can be effectively treated conservatively or endoscopically, not justifying more aggressive surgical approaches.RésuméL’hydatitose hépatique représente un véritable challenge en chirurgie hépatique, alors que la meilleure technique chirurgicale est toujours controversée. L’incidence de fistules biliaires postopératoires est élevée: elles représentent l’inconvénient majeur des procédés chirurgicaux conservateurs. Le but de cette étude a été d’analyser l’incidence et l’importance clinique des fuites biliaires chez les patients traités exclusivement par une technique chirurgicale conservatrice. Entre janvier 1985 et novembre 2000, 187 patients ont été opérés dans notre département pour hydatitose hépatique: le procédé chirurgical, standardisé, était conservateur (résection large du dôme saillant et drainage du kyste). Il y avait au total 18 complications en rapport avec une fuite biliaire (10%), trois abcès biliaires (un drainé chirurgicalement et deux par voie percutanée), une péritonite biliaire en rapport avec un canal biliaire accessoire du lit vésiculaire (traitée chirurgicalement), et 14 fistules (une fistule biliobronchique et 13 biliocutanées). Cinq des fistules, y compris la fistule biliobronchique ont été traitées avec succès par voie endoscopique, alors que les neuf autres ont guéri par un traitement conservateur. La fuite biliaire, une des complications possibles après intervention conservatrice pour hydatose hépatique, peut être traitée efficacement de façon conservatrice et endoscopiquement, et ne justifie pas une approche chirurgicale, plus agressive.ResumenLa hidatidosis hepática constituye un desafío en el campo de la cirugía del hígado y todavía se mantiene la controversia acerca de cuál es la técnica quirúrgica más apropiada. Se informa una elevada tasa de fuga biliar postoperatoria como una desventaja significativa de los procedimientos quirúrgicos conservadores. El propósito del presente estudio fue determinar la incidencia y la importancia clínica de la fuga biliar en pacientes manejados con técnica quirúrgica conservadora exclusivamente. Entre enero de 1985 y noviembre de 2000 se operaron 187 pacientes con hidatidosis hepática en nuestro Departamento utilizando una técnica quirúrgica conservadora estandarizada (destechamiento amplio y drenaje del quiste). Se registraron 18 complicaciones relacionadas con fuga biliar (10%), tres de ellas fueron absceso (uno drenado quirúrgicamente y dos en forma percutánea), una peritonitis biliar debida a un conducto biliar accesorio en el lecho de la vesícula biliar (tratado quirúrgicamente) y 14 fístulas (una broncobiliar y 13 biliocutáneas). Cinco de las fístulas, incluyendo la bronchobiliar, fueron manejadas exitosamente mediante endoscopia, en tanto que las nueve restantes cicatrizaron con tratamiento conservador. Las fugas biliares, que representan una complicación significante de las operaciones conservadoras en la hidatidosis hepática, pueden ser efectivamente tratadas con manejo conservador o endoscópico, y no se justifican conductas quirúrgicas más agresivas.

Prospective evaluation of biliopancreatic diversion with Roux-en-Y gastric bypass in the super obese

The aim of this study was to determine prospectively the efficacy and safety of the biliopancreatic diversion with Roux-en-Y gastric bypass (BPD with RYGBP) procedure used as the primary bariatric procedure in super obese patients. The main characteristics of the BPD with RYGBP procedure were a gastric pouch of 15 ± 5 ml, biliopancreatic limb of 200 cm, common limb of 100 cm, and alimentary limb of the remainder of the small intestine. From June 1994 through July 2003, 132 super obese patients (body mass index [BMI]: 57 ± 7), with an incidence of comorbidities 6 ± 2 per patient, underwent BPD with RYGBP and subsequent follow-up. Mean follow-up time was 29 ± 14 months. Maximum weight loss was achieved at 18 months postoperative with average excess weight loss (EWL) 65%, average initial weight loss (IWL) 39%, and average BMI 35 kg/m2. Thereafter, a decline was observed with EWL stabilizing at around 50%, IWL at around 30%, and BMI at around 40 kg/m2, respectively, by the end of the study period. The majority of preexisting comorbidities were permanently resolved by the 6-month follow-up visit. Early mortality was 1% and early morbidity was 11%. Late morbidity was 27%, half of which was due to incisional hernia. Deficiencies of microelements were mild and successfully treated with additional oral supplementation. The incidence of hypoalbuminemia was 3% and there were no hepatic complications. We conclude that BPD with RYGBP is a safe and effective procedure for the super obese with few metabolic complications.

Effects of bariatric surgery on HDL structure and functionality: results from a prospective trial

BACKGROUND In addition to high-density lipoprotein cholesterol (HDL-C) levels, HDL quality appears also very important for atheroprotection. Obese patients with metabolic syndrome have significantly reduced HDL-C levels and are usually at increased risk for coronary heart disease. Despite that weight loss benefits these patients, its effects on HDL quality and functionality is currently poorly studied. OBJECTIVES We investigated how rapid weight loss affects HDL structure and its antioxidant potential in patients undergoing a malabsorptive bariatric procedure. METHODS Fasting plasma samples were collected the day before and 6 months after the bariatric procedure from 20 morbidly obese patients with body mass index >50, then HDL was isolated and analyzed by biochemical techniques. RESULTS We report a dramatic alteration in the apolipoprotein ratio of HDL that was accompanied by the presence of more mature HDL subspecies and a concomitant increase in the antioxidant potential of HDL. Interestingly, our obese cohort could be distinguished into 2 subgroups. In 35% of patients (n = 7), HDL before surgery had barely detectable apolipoprotein (apo) A-I and apoCIII, and the vast majority of their HDL cholesterol was packed in apoE-containing HDL particles. In the remaining 65% of patients (n = 13), HDL before surgery contained high levels of apoA-I and apoCIII, in addition to apoE. In both subgroups, surgical weight loss resulted in a switch from apoE to apoA-I-containing HDL. CONCLUSIONS Rapid weight loss exerts a significant improvement in HDL structure and functionality that may contribute to the documented beneficial effect of malabsorptive bariatric procedures on cardiovascular health.

Unusual Presentation of Pancreatic Mucinous Cystadenocarcinoma by Spontaneous Splenic Rupture

Background: Mucinous cystic neoplasms of the pancreas are uncommon tumors with varying potential for malignancy. Although traumatic splenic rupture is common, spontaneous rupture is a rare event. Case Report: We present an unusual case of spontaneous splenic rupture, due to an otherwise asymptomatic mucinous cystadenocarcinoma of the tail of the pancreas. Conclusion: A tumor of the tail of the pancreas may uncommonly present as spontaneous splenic rupture, probably due to venous congestion and infiltration of the spleen, requiring emergency surgical treatment.