James M. Swain

Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial.

IMPORTANCE Controlling glycemia, blood pressure, and cholesterol is important for patients with diabetes. How best to achieve this goal is unknown. OBJECTIVE To compare Roux-en-Y gastric bypass with lifestyle and intensive medical management to achieve control of comorbid risk factors. DESIGN, SETTING, AND PARTICIPANTS A 12-month, 2-group unblinded randomized trial at 4 teaching hospitals in the United States and Taiwan involving 120 participants who had a hemoglobin A1c (HbA1c) level of 8.0% or higher, body mass index (BMI) between 30.0 and 39.9, C peptide level of more than 1.0 ng/mL, and type 2 diabetes for at least 6 months. The study began in April 2008. INTERVENTIONS Lifestyle-intensive medical management intervention and Roux-en-Y gastric bypass surgery. Medications for hyperglycemia, hypertension, and dyslipidemia were prescribed according to protocol and surgical techniques that were standardized. MAIN OUTCOMES AND MEASURES Composite goal of HbA1c less than 7.0%, low-density lipoprotein cholesterol less than 100 mg/dL, and systolic blood pressure less than 130 mm Hg. RESULTS All 120 patients received the intensive lifestyle-medical management protocol and 60 were randomly assigned to undergo Roux-en-Y gastric bypass. After 12-months, 28 participants (49%; 95% CI, 36%-63%) in the gastric bypass group and 11 (19%; 95% CI, 10%-32%) in the lifestyle-medical management group achieved the primary end points (odds ratio [OR], 4.8; 95% CI, 1.9-11.7). Participants in the gastric bypass group required 3.0 fewer medications (mean, 1.7 vs 4.8; 95% CI for the difference, 2.3-3.6) and lost 26.1% vs 7.9% of their initial body weigh compared with the lifestyle-medical management group (difference, 17.5%; 95% CI, 14.2%-20.7%). Regression analyses indicated that achieving the composite end point was primarily attributable to weight loss. There were 22 serious adverse events in the gastric bypass group, including 1 cardiovascular event, and 15 in the lifestyle-medical management group. There were 4 perioperative complications and 6 late postoperative complications. The gastric bypass group experienced more nutritional deficiency than the lifestyle-medical management group. CONCLUSIONS AND RELEVANCE In mild to moderately obese patients with type 2 diabetes, adding gastric bypass surgery to lifestyle and medical management was associated with a greater likelihood of achieving the composite goal. Potential benefits of adding gastric bypass surgery to the best lifestyle and medical management strategies of diabetes must be weighed against the risk of serious adverse events. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00641251.

Combined Liver Transplantation and Gastric Sleeve Resection for Patients With Medically Complicated Obesity and End‐Stage Liver Disease

Obesity is increasingly common before and after liver transplantation (LT), yet optimal management remains unclear. Our aim was to analyze the effectiveness of a multidisciplinary protocol for obese patients requiring LT, including a noninvasive pretransplant weight loss program, and a combined LT plus sleeve gastrectomy (SG) for obese patients who failed to lose weight prior to LT. Since 2006, all patients referred LT with a BMI > 35 were enrolled. There were 37 patients who achieved weight loss and underwent LT alone, and 7 who underwent LT combined with SG. In those who received LT alone, weight gain to BMI > 35 was seen in 21/34, post‐LT diabetes (DM) in 12/34, steatosis in 7/34, with 3 deaths plus 3 grafts losses. In patients undergoing the combined procedure, there were no deaths or graft losses. One patient developed a leak from the gastric staple line, and one had excess weight loss. No patients developed post‐LT DM or steatosis, and all had substantial weight loss (mean BMI = 29). Noninvasive pretransplant weight loss was achieved by a majority, though weight gain post‐LT was common. Combined LT plus SG resulted in effective weight loss and was associated with fewer post‐LT metabolic complications. Long‐term follow‐up is needed.

Gastrointestinal and nutritional complications after bariatric surgery

The prevalence of obesity has increased to epidemic proportions, making obesity and its comorbid conditions a major public health concern. Bariatric surgery is the most effective treatment, but it carries substantial morbidity. The subsequent gastrointestinal and nutritional complications are often not recognized or properly managed. As part of the multidisciplinary team taking care of obese patients, gastroenterologists should be familiar with the types of bariatric surgery and their associated complications. We review the most common gastrointestinal and nutritional complications after bariatric procedures and examine how gastroenterologists may best prevent, investigate, and treat them.

Changes in Functional Walking Distance and Health-Related Quality of Life After Gastric Bypass Surgery

Background and Purpose: Early physical functional changes after gastric bypass surgery (GBS) are unclear, and the relationship between these changes and health-related quality of life (HR-QOL) has not been reported. We measured distances from a 6-minute walk test (6MWT) and scores on the 36-Item Short-Form Health Survey (SF-36) before and after GBS. Subjects and Methods: Twenty-five people undergoing GBS completed the SF-36 and 6MWT presurgically and at the 3-month and 6-month follow-up visits. Ratings of perceived exertion (RPE) were measured during 6MWTs. Results: Presurgical walking distance (X̄±SD; 414.1±103.7 m) was 55%±14% of normative values. Distances increased significantly at 3 months (505.2±98.0 m) and at 6 months (551.5±101.2 m). Final RPEs decreased significantly, and HR-QOL improved significantly. Both physical and mental health components of the SF-36 improved significantly. Distance was inversely correlated with body mass throughout the study and positively correlated with the SF-36 Physical Component Summary change from 3 to 6 months. Discussion and Conclusions: Improved functional capacity was associated with enhanced HR-QOL. At 6 months, walking distances remained 75% of those for age-matched peers who had normal weight.

Adipocyte Mitochondrial Function Is Reduced in Human Obesity Independent of Fat Cell Size

CONTEXT It has been suggested that mitochondrial dysfunction in adipocytes contributes to obesity-related metabolic complications. However, obesity results in adipocyte hypertrophy, and large and small adipocytes from the same depot have different characteristics, raising the possibility that obesity-related mitochondrial defects are an inherent function of large adipocytes. OBJECTIVE Our goal was to examine whether obesity, independent of fat cell size and fat depot, is associated with mitochondria dysfunction. DESIGN We compared adipocyte mitochondrial function using a cross-sectional comparison study design. SETTING The studies were performed at Mayo Clinic, an academic medical center. PATIENTS OR OTHER PARTICIPANTS Omental and/or abdominal subcutaneous adipose samples were collected from 20 age-matched obese and nonobese nondiabetic men and women undergoing either elective abdominal surgery or research needle biopsy. INTERVENTION Interventions were not conducted as part of these studies. MAIN OUTCOME MEASURES We measured mitochondrial DNA abundance, oxygen consumption rates, and citrate synthase activity from populations of large and small adipocytes (separated with differential floatation). RESULTS For both omental and subcutaneous adipocytes, at the cell and organelle level, oxygen consumption rates and citrate synthase activity were significantly reduced in cells from obese compared with nonobese volunteers, even when matched for cell size by comparing large adipocytes from nonobese and small adipocytes from obese. Adipocyte mitochondrial content was not significantly different between obese and nonobese volunteers. Mitochondrial function and content parameters were not different between small and large cells, omental, and subcutaneous adipocytes from the same person. CONCLUSION Adipocyte mitochondrial oxidative capacity is reduced in obese compared with nonobese adults and this difference is not due to cell size differences. Adipocyte mitochondrial dysfunction in obesity is therefore related to overall adiposity rather than adipocyte hypertrophy.

Primary Care Perspective on Bariatric Surgery

The role of primary care physicians in identifying potential candidates for bariatric surgery and providing them with long-term postoperative care is gaining rapidly in importance. With the increased use of surgical procedures as treatment options for obesity, a knowledge of bariatric surgery is essential for providing optimal care. During the past decade, the number of bariatric procedures has increased, and refinements of these procedures have made them safer and more effective. Primary care physicians should know how to Identify appropriate surgical candidates and be familiar with available procedures, aware of potential complications and benefits, and able to provide lifelong monitoring and follow-up care. Thus, the primary care physician must be informed about surgical criteria, types of procedures, outcomes, complications, and the long-term monitoring needs of these patients.

Congenital diaphragmatic hernia in adults.

Congenital diaphragmatic hernia is rarely seen in adults. A review of the literature is presented, and 2 additional cases of Morgagni and Bochdalek hernias are presented. They were both repaired with the laparoscopic approach. Copyright

Randomized sham-controlled trial evaluating efficacy and safety of endoscopic gastric plication for primary obesity: The ESSENTIAL trial

Evaluate safety and efficacy of the pose™ procedure for obesity treatment.

Laparoscopic antireflux surgery for supraesophageal complications of gastroesophageal reflux disease

Gastroesophageal reflux disease can result in such supraesophageal complications as hoarseness, sore throat, cough, bronchitis, asthma, recurrent pneumonia, intermittent choking, chest pain, and ear pain. Appropriate patient care involves careful evaluation to decide on medical or surgical therapy. Preoperative testing must include endoscopy, 24-hour esophageal pH monitoring, and esophageal manometry. Additional evaluations, such as barium swallow, chest x-ray, bronchoscopy, and sinus radiographs, may be required. Medical treatment improves gastroesophageal reflux and supraesophageal symptoms. However, surgical therapy seems to provide better long-term results. A profile that predicts the best response to medical therapy has not been identified, although the best results with surgery are achieved in patients with nocturnal asthma, onset of reflux before pulmonary symptoms, laryngeal inflammation, and a good response to medical treatment.

Refractory strictures after Roux-en-Y gastric bypass: operative management

BACKGROUND Stricture of the gastrojejunostomy after Roux-en-Y gastric bypass (RYGB) is common in the early postoperative period, with a reported incidence of 3-27%. Late recalcitrant strictures are much less common. Treatment has varied from endoscopic therapy to operative revision of the gastrojejunostomy with or without additional anatomic revisions. The origin of the late strictures varies, with the most common causes being excessive acid, aspirin, or nonsteroidal anti-inflammatory drug use, postoperative anastomotic leak, or, as some have maintained, smoking. We sought to identify the predictors of gastrojejunostomy strictures that require operative management after RYGB and to evaluate the clinical outcomes of patients requiring operative revision of the gastrojejunostomy stricture after failed nonoperative therapy at an academic institution. METHODS A retrospective review was performed of all patients undergoing operative intervention for gastrojejunostomy stricture from 1990 to 2009 after having undergone RYGB for medically complicated obesity. RESULTS A total of 24 patients required revision of their gastrojejunostomy stricture after multiple attempts at nonoperative therapy. The mean interval from RYGB to reoperation was 4.3 years (range .5-25). The interval to operative revision for anastomotic stricture was substantially less in patients with active anastomotic ulcers (n = 6), those who had had a gastrojejunostomy leak after RYGB (n = 5), and those with gastrogastric fistulas (n = 7; 20, 23, and 44 months, respectively). Of the 24 patients, 23 experienced relief of their symptoms. The postoperative morbidity rate was 21%, and the mortality rate was 0%. CONCLUSION Operative revision of strictured gastrojejunostomy is a safe and effective procedure for those patients in whom endoscopic therapy has failed. Most refractory anastomotic strictures have been secondary to excessive acid (too large a proximal pouch), chronic ulceration, or postoperative anastomotic leak.