Giovanni Casella

Effectiveness of Laparoscopic Sleeve Gastrectomy (First Stage of Biliopancreatic Diversion with Duodenal Switch) on Co-Morbidities in Super-Obese High-Risk Patients

Background: We evaluated laparoscopic sleeve gastrectomy (LSG) on major co-morbidities (hypertension, type 2 diabetes / impaired glucose tolerance, obstructive sleep apnea syndrome (OSAS) and on American Society of Anesthesiologists (ASA) operative risk score in high-risk super-obese patients undergoing two-stage laparoscopic biliopancreatic diversion with duodenal switch (LBPD-DS). Methods: 41 super-obese high-risk patients (mean BMI 57.3±6.5 kg/m2, age 44.6±9.7 years) were entered into a prospective study (BMI ≥60, or BMI ≥50 with at least two severe co-morbidities, no Prader-Willi syndrome, no conversion, minimum follow-up 12 months). 9 patients had BMI ≥60. 17 patients (41.4%) had OSAS on C-PAP therapy. In 10 patients, at least one intragastric balloon had been positioned and 4 had undergone laparoscopic adjustable gastric banding, all with unsatisfactory results. At surgery, 41.5% were classified ASA 4 and 58.5% as ASA 3 (mean ASA score 3.4±0.5). Patients underwent evaluation every 3 months postoperatively and were restaged at 12 months and/or before the second step. Results: 60% of major co-morbidities were cured and 24% improved. Average BMI after 6 and 12 months was 44.5±8.1 and 40.8±8.5 respectively (mean follow-up 22.2±7.1 months). After 12 months, 57.8% of the patients were co-morbidity-free and 31.5% had only one major co-morbid condition. At restaging, 20% of patients were still classified as ASA score 4 (OSAS on C-PAP therapy). 3 patients showed BMI <30 and were co-morbidity-free 12 months after LSG. Conclusions: LSG represents a safe and effective procedure to achieve marked weight loss as well as significant reduction of major obesity-related co-morbidities. The procedure reduced the operative risk (ASA score) in super-obese patients undergoing two-stage LBPD-DS.

Long-term effects of laparoscopic sleeve gastrectomy, gastric bypass, and adjustable gastric banding on type 2 diabetes

BackgroundThis study aimed to compare the efficacy of laparoscopic sleeve gastrectomy (SG) with that of laparoscopic gastric bypass (GBP) and laparoscopic adjustable gastric banding (AGB) for glucose homeostasis in morbidly obese subjects with type 2 diabetes mellitus (T2DM) at a 3-year follow-up assessment and to elucidate the role of weight loss in the T2DM resolution after SG.MethodsFor this study, 60 morbidly obese T2DM patients (44 females and 16 males) who underwent AGB (24 patients), GBP (16 patients), or SG (20 patients) between 1996 and 2008 were retrospectively analyzed. Age, sex, body mass index (BMI), estimated weight loss (EWL), fasting glycemia, HbA1c, euglycemic hyperinsulinemic clamp, discontinuation of diabetes treatment, and time until interruption of therapy were evaluated.ResultsIn the study, 54 patients received oral hypoglycemic agents for at least 12xa0months before surgery, and 6 patients received insulin. The mean follow-up period was 36xa0months. The resolution rate was 60.8% for the AGB patients, 81.2% for the GBP patients, and 80.9% for the SG patients. The postoperative time until interruption of therapy was 12.6xa0months for the AGB patients, 3.2xa0months for the GBP patients, and 3.3xa0months for the SG patients. The hyperinsulinemic euglycemic clamp test was performed 12xa0months after surgery for the cured patients. Insulin resistance was restored to normal values in all the patients. The greatest improvement from preoperative values occurred in the SG group. For the not-cured GBP and SG patients, an improvement of 120xa0mg/dl in fasting plasma glucose was observed 3xa0months after the surgery, suggesting an enhancement in insulin sensitivity, which determines better medical control. The resolution rate remained constant at the 36-month follow-up evaluation in both the GBP and SG groups.ConclusionsAll three bariatric procedures are effective in treating diabetes, with a 3-year follow-up evaluation showing an effect that lasts. The AGB procedure was the least effective. The antidiabetic effect was similarly precocious after GBP and SG compared with AGB. This difference may indicate that a hormonal mechanism may be involved, independent of weight loss.

Nonsurgical treatment of staple line leaks after laparoscopic sleeve gastrectomy.

BackgroundLaparoscopic sleeve gastrectomy (LSG) is gaining popularity as a “per se” bariatric procedure due to its effectiveness on weight loss and comorbidity resolution. The most feared and life-threatening complication after LSG is the staple line leak and its management is still a debated issue. Aim of this paper is to analyze the incidence of leak and the treatment solutions adopted in a consecutive series of 200 LSG.MethodsFrom October 2002 to November 2008, 200 patients underwent LSG. Nineteen patients (9.5%) had a body mass index (BMI) of >60xa0kg/m2. A 48-Fr bougie is used to obtain an 80–120-ml gastric pouch. An oversewing running suture to reinforce the staple line was performed in the last 100 cases. The technique adopted to reinforce the staple line is a running suture taken through and through the complete stomach wall.ResultsStaple line leaks occurred in six patients (mean BMI 52.5; mean age 41.6xa0years). Leak presentation was early in three cases (first, second, and third postoperative (PO) day), late in the remaining three cases (11th, 22nd, and 30th PO day). The most common leak location was at the esophagogastric junction (five cases). Mortality was nihil. Nonoperative management (total parenteral nutrition, proton pump inhibitor, and antibiotics) was adopted in all cases. Percutaneous abdominal drainage was placed in five patients. In one case, a small fistula was successfully treated by endoscopic injection of fibrin glue only. Self-expandable covered stent was used in three cases. Complete healing of leaks was obtained in all patients (mean healing time 71xa0days).ConclusionNonoperative treatment (percutaneous drainage, endoscopy, stent) is feasible, safe, and effective for staple line leaks in patients undergoing LSG; furthermore, it may avoid more mutilating procedures such as total gastrectomy.

First-phase insulin secretion, insulin sensitivity, ghrelin, GLP-1, and PYY changes 72 h after sleeve gastrectomy in obese diabetic patients: The gastric hypothesis

BackgroundThe aim of this study was to evaluate the possible role of sleeve gastrectomy (SG) per se in the reversibility of diabetes.MethodsInsulin secretion and peripheral insulin sensitivity using the intravenous glucose tolerance test (IVGTT) were assessed in 18 obese type 2 diabetic patients and in 10 nondiabetic obese patients before and 3xa0days after SG, before any food intake and any weight change occurrence. At the same time, ghrelin, GLP-1, and PYY levels were determined.ResultsIn diabetic patients who had the disease less than 10.5xa0years, the first phase of insulin secretion promptly improved after SG. The early insulin area under the curve (AUC) significantly increased at the postoperative IVGTT, indicating an increased glucose-induced insulin secretion. The second phase of insulin secretion (late AUC) significantly decreased after SG in all groups, indicating an improved insulin peripheral sensitivity. In all groups, pre- and postoperatively, intravenous glucose stimulation determined a decrease in ghrelin values and an increase in GLP-1 and PYY values. However, in the group of patients with disease duration >10.5xa0years, the differences were not significant except for the late insulin AUC. Postoperative basal and intravenous glucose-stimulated ghrelin levels were lower than preoperative levels in all groups of patients. Basal and intravenous stimulated GLP-1 and PYY postoperative values were higher than preoperative levels in all groups.ConclusionsRestoration of the first phase of insulin secretion and improved insulin sensitivity in diabetic obese patients immediately after SG, before any food passage through the gastrointestinal tract and before any weight loss, seem to be related to ghrelin, GLP-1, and PYY hormonal changes of possible gastric origin and was neither meal- nor weight-change-related. Duration of the disease up to 10.5xa0years seems to be a major cut off in the pathophysiological changes induced by SG. A “gastric” hypothesis may be put forward to explain the antidiabetes effect of SG.

Sleeve gastrectomy and crural repair in obese patients with gastroesophageal reflux disease and/or hiatal hernia

BACKGROUNDnGastroesophageal reflux disease (GERD) with or without hiatal hernia (HH) is now recognized as an obesity-related co-morbidity. Roux-en-Y gastric bypass has been proved to be the most effective bariatric procedure for the treatment of morbidly obese patients with GERD and/or HH. In contrast, the indication for laparoscopic sleeve gastrectomy (SG) in these patients is still debated. Our objective was to report our experience with 97 patients who underwent SG and HH repair (HHR). The setting was a university hospital in Italy.nnnMETHODSnFrom July 2009 to December 2011, 378 patients underwent a preoperative workup for SG. In 97 patients, SG was performed with HHR. The clinical outcome was evaluated considering GERD symptom resolution or improvement, interruption of antireflux medications, and radiographic evidence of HH recurrence.nnnRESULTSnBefore surgery, symptomatic GERD was present in 60 patients (15.8%), and HH was diagnosed in 42 patients (11.1%). In 55 patients (14.5%), HH was diagnosed intraoperatively. The mean follow-up was 18 months. GERD remission occurred in 44 patients (73.3%). In the remaining 16 patients, antireflux medications were diminished, with complete control of symptoms in 5 patients. No HH recurrences developed. De novo GERD symptoms developed in 22.9% of the patients undergoing SG alone compared with 0% of patients undergoing SG plus HHR.nnnCONCLUSIONnSG with HHR is feasible and safe, providing good management of GERD in obese patients with reflux symptoms. Small hiatal defects could be underdiagnosed at preoperative endoscopy and/or upper gastrointestinal contrast study. Thus, a careful examination of the crura is always recommended intraoperatively.

Early postoperative insulin-resistance changes after sleeve gastrectomy.

IntroductionBiliopancreatic diversion and Gastric bypass are associated with a rapid improvement in insulin resistance few days after surgery. The purpose of this study was to evaluate the short-term effects in insulin resistance following sleeve gastrectomy (SG).Materials and methodsBetween December 2007 and September 2008, 17 consecutive obese type 2 diabetes mellitus patients (three men, mean age 51.1xa0years, mean BMI 44.7xa0kg/m2) were submitted to laparoscopic SG. Fasting serum glucose, insulin concentration, and homeostatic model assessment for insulin resistance (HOMA IR) were drawn preoperatively and at 5, 15, 30, and 60 postoperative days. In seven of these patients insulin sensitivity was evaluated on postoperative days 1, 2, 3, and 4. Moreover a control group of three overweight and diabetic patients (one man, mean age 52.1xa0years and mean BMI 26.8 kg/m2) submitted to laparoscopic cholecystectomy and undergoing the same diet protocol was studied.ResultsIn all obese patients, a sharp (5xa0days) and significant reduction of serum glucose and insulin concentration and HOMA IR values was observed after SG. In seven patients, serum glucose and insulin concentration and HOMA IR values were significantly lower at third postoperative day. At the 15th postoperative day both serum glucose and insulin concentration and HOMA IR remained significantly lower in the absence of significant weight modifications. At 30 and 60 postoperative days, these values remained substantially unchanged in spite of a greater weight loss. In the cholecystectomy patients group, at postoperative day 5, only the serum glucose concentrations were significantly reduced although with the higher values than normal in respect to the preoperative values.ConclusionsAfter SG the improvement of insulin action occurred rapidly and independently of EWL. The results of the present study confirm that a hormonal mechanism may contribute to changes in insulin resistance following SG.

Laparoscopic sleeve gastrectomy as first stage or definitive intent in 300 consecutive cases

BackgroundLaparoscopic sleeve gastrectomy (SG) was originally used as a bridge to definitive surgery in high-risk patients. Recently it has been considered as a stand-alone procedure due to its effectiveness on weight loss and comorbidities resolution. This study was designed to evaluate the results of SG on complications, body mass index (BMI), and comorbidities resolution in 300 consecutive obese patients and to analyze the lesson learned from this experience.MethodsFrom October 2002 to November 2009, 300 patients underwent SG. In the first 100 cases (group 1: mean BMI, 54.4xa0±xa09.3), SG was intended as a first stage of biliopancreatic diversion with duodenal switch in high risk super-obese patients. In the last 200 cases (group 2: mean BMI, 45.5xa0±xa07.3), SG was intended as a definitive procedure. No routine reinforcement was performed in group 1. In group 2, oversewn reinforcement was performed routinely. SG was redo surgery in 21 patients (7%).ResultsMean operative time was 119xa0±xa048.6xa0min in group 1 and 72xa0±xa033.8 in group 2. Conversion rate was 0.6% (massive hepatomegaly). Mortality was 0.6%. Major postoperative complications were registered in 15 patients in group 1 and 11 in group 2. In 3 cases, a reoperation was needed. The mean BMI in group 1 was 46, 43, 39, and 31 at 6, 12, 24, and 36xa0months, respectively. In group 2, the mean BMI was 32.9, 30.6, and 31.7 at 6, 12, and 18xa0months. At 12xa0months, the diabetes, hypertension, and OSAS were cured on 69%, 62%, and 50% in group 1 and 88%, 57%, and 58% in group 2. In group 2, no patient required second stage.ConclusionsSG is a safe and effective treatment for morbid obesity at mid-term follow-up. SG is effective for comorbidities resolution, especially for the treatment of diabetes. Suture line reinforcement allows a significant reduction of bleeding.

Initial Experience with Laparoscopic Crural Closure in the Management of Hiatal Hernia in Obese Patients Undergoing Sleeve Gastrectomy

BackgroundThe prevalence of gastroesophageal reflux disease (GERD) and/or hiatal hernia (HH) is significantly increased in morbidly obese patients. Laparoscopic bariatric procedures such as gastric banding (LGB) and Roux-en-Y gastric bypass have been shown to improve both obesity and reflux symptoms. The aim of this paper is to evaluate the effectiveness of laparoscopic sleeve gastrectomy (LSG) and hiatal hernia repair (HHR) for the treatment of obesity complicated by HH.MethodsFrom October 2008, six patients underwent HHR in addition to LSG. Clinical outcomes have been evaluated in terms of GERD symptoms improvement or resolution, interruption of antireflux medication, and X-ray evidence of HH recurrence.ResultsSymptomatic HH was diagnosed preoperatively in four patients. In two additional patients, HH was asymptomatic and it was diagnosed intraoperatively. Prosthetic reinforcement of crural closure was performed in two symptomatic cases with a HH >5xa0cm. Mortality was nil and no complications occurred. After a mean follow-up of 4xa0months, GERD symptoms resolution occurred in three patients, while the other patient reported an improvement of reflux. Body mass index had fallen from 43.4 to 36.2xa0kg/m2. A small recurrence in the patient with persistence of reflux symptoms has been radiologically reported.ConclusionsLaparoscopic crural closure in addition to LSG could represent a valuable option for the synchronous management of morbid obesity and HH, providing good outcomes in terms of weight loss and GERD symptoms control.

Long-term remission of type 2 diabetes in morbidly obese patients after sleeve gastrectomy

BACKGROUNDnThe aim of this study was to evaluate the long-term effects of laparoscopic sleeve gastrectomy (LSG) on type 2 diabetes mellitus (T2DM) and other related co-morbidities in severely obese patients.nnnMETHODSnFrom May 2003 to July 2008, 33 morbidly obese diabetic patients (20 with body mass index [BMI]>50 kg/m(2)) underwent LSG. A total of 23 females and 10 males participated, with a mean age of 49.3±8 years, mean preoperative BMI of 52.1±8.5 kg/m(2), mean fasting plasma glucose (FPG) of 143.2±47.9 mg/dL, mean glycosylated hemoglobin (HbA1c) of 7.3%±1.4%, and a mean T2DM duration of 7 years. All patients had a 36-month follow-up, and 13 had a 60-month follow-up.nnnRESULTSnTwenty-nine patients (87.8%) discontinued antidiabetic medications 3 months after LSG, (mean BMI of 42.8±7.8 kg/m(2); FPG of 104.5±22.1 mg/dL; HbA1c of 5.3%±.4%). At 36 months, 22 of 26 LSG patients (84.6%) had normal FPG and HbA1c values without antidiabetic therapy. At the 60-month follow-up, 10 of 13 patients (76.9%) had normal FPG and HbA1c values without antidiabetic therapy. The Framingham risk score decreased significantly from 9.7% preoperatively to 4.7% postoperatively. No new diabetic retinopathy occurred during the whole period of observation.nnnCONCLUSIONSnThis study confirms the efficacy of LSG in the treatment of T2DM and indicates that, at both 36- and 60-month follow-ups, LSG can provide a significant percentage of treated patients with a prolonged remission of T2DM, with diminished cardiac risk factors and no development of diabetic retinopathy. These results compare favorably with those reported after standard medical therapy.

Two-stage laparoscopic biliopancreatic diversion with duodenal switch as treatment of high-risk super-obese patients: analysis of complications

IntroductionThe aim of this study is to retrospectively analyze the incidence of complications after two-stage laparoscopic biliopancreatic diversion with duodenal switch (Lap BPD-DS) in high-risk super-obese patients and explore the possible predictive factors of specific complications after laparoscopic sleeve gastrectomy (SG).MethodsHigh-risk patients—body mass index (BMI)xa0>xa050xa0kg/m2 with at least two major comorbidities: type 2 diabetes, obstructive sleep apnea syndrome (OSAS), hypertension—undergoing two-stage laparoscopic BPD-DS were retrospectively analysed. The SG pouch volume was 100–150xa0ml; in the second stage, the common channel and the alimentary loop were 100xa0cm and 150xa0cm, respectively.ResultsEighty-seven patients (50 female, 57.5%) underwent SG (two open). The mean age was 41.8xa0±xa010.22xa0years with BMI of 55.2xa0±xa06.69xa0kg/m2. Four patients had Prader–Willy syndrome. Fourteen (16.46%) patients (6 female, 42.8%) had postoperative complications such as bleeding, fistula, pulmonary embolism, transitory acute renal failure, and abdominal abscess. One patient died at postoperative day 5 of pulmonary embolism. One patient was reoperated for hemoperitoneum by laparoscopy. The risk of complications after SG was lower in patients where reinforcement of the suture line was used (0.492), while it was higher in men (1.780). Neither difference was statistically significant [pxa0=xa0not significant (NS)]. After 9–24xa0months, 27 patients (BMI 43xa0±xa08xa0kg/m2) underwent a second stage of BPD-DS (two open). Major postoperative complications were registered in eight patients (29.6%): three bleeding, four duodeno-ileal stenosis and one rhabdomyolysis. Two cases of internal hernia required laparoscopic reoperation. The reoperation rate was 1/85 (1.2%) after SG and 2/27 (7.4%) after second stage.ConclusionsComplications after SG greatly decrease after the learning curve period and can be successfully managed without need of reoperation. Suture-line reinforcement, at least selectively in the middle-upper portion of the staple line and in super-super-obese patients, is recommended to decrease the incidence of specific complications.