John Rodriguez

Can Sleeve Gastrectomy "Cure" Diabetes? Long-term Metabolic Effects of Sleeve Gastrectomy in Patients With Type 2 Diabetes.

Objective: The aim of the study was to assess long-term metabolic effects of laparoscopic sleeve gastrectomy (LSG) in patients with type 2 diabetes (T2DM) and to identify predictive factors for long-term diabetes remission and relapse. Background: LSG has become the most common bariatric operation worldwide. Its long-term metabolic effects in patients with T2DM are, however, unknown. Methods: Outcomes of 134 patients with obesity with T2DM who underwent LSG at an academic center during 2005 to 2010 and had at least 5 years of follow-up were assessed. Results: At a median postsurgical follow-up of 6 years (range: 5–9), a mean body mass index loss of −7.8 ± 5.1 kg/m2 (total weight loss: 16.8% ± 9.7%) was associated with a reduction in mean glycated hemoglobin (HbA1c, −1.3 ± 1.8%, P < 0.001), fasting blood glucose (−37.8 ± 70.4 mg/dL, P < 0.001) and median number of diabetes medications (−1, P < 0.001). Long-term glycemic control (HbA1c <7%) was seen in 63% of patients (vs 31% at baseline, P < 0.001), diabetes remission (HbA1c <6.5% off medications) in 26%, complete remission (HbA1c <6% off medications) in 11%, and “cure” (continuous complete remission for ≥5 years) was achieved in 3%. Long-term relapse of T2DM after initial remission occurred in 44%. Among patients with relapse, 67% maintained glycemic control (HbA1c <7%). On adjusted analysis, taking 2 or more diabetes medications at baseline predicted less long-term remission (odds ratio 0.19, 95% confidence interval 0.07–0.55, P = 0.002) and more relapse of T2DM (odds ratio 8.50, 95% confidence interval: 1.40–49.20, P = 0.02). Significant improvement in triglycerides (−53.7 ± 116.4 mg/dL, P < 0.001), high-density lipoprotein (8.2 ± 12.9 mg/dL, P < 0.001), systolic (−8.9 ± 18.7 mmHg, P < 0.001) and diastolic blood pressure (−2.6 ± 14.5 mmHg, P = 0.04), and cardiovascular risk (13% relative reduction, P < 0.001) was observed. Conclusions: LSG can significantly improve cardiometabolic risk factors including glycemic status in T2DM. Long-term complete remission and “cure” of T2DM, however, occur infrequently.

The incidence of hiatal hernia and technical feasibility of repair during bariatric surgery.

PURPOSE To evaluate the incidence and outcomes of hiatal hernias (HH) that are repaired concomitantly during bariatric surgery. METHODS We identified patients who had concomitant HH repair during bariatric surgery from 2010 to 2014. Data collected included baseline demographics, perioperative parameters, type of HH repair, and postoperative outcomes. RESULTS A total of 83 underwent concomitant HH during study period. The male-to-female ratio was 1:8, mean age was 57.2 ± 10.0 years, and mean body mass index was 44.5 ± 7.9 kg/m(2). A total of 61 patients had laparoscopic Roux-en-Y gastric bypass, and 22 had laparoscopic sleeve gastrectomy. HH was diagnosed before bariatric surgery in 32 (39%) subjects, whereas 51 (61%) were diagnosed intraoperatively. Primary hernia repair was performed with anterior reconstruction in 45 (54%) patients, posterior in 21 (25%), and additional mesh placement in 7 (8%). A total of 24 early minor postoperative symptoms were reported. At 12 month follow-up, mean body mass index improved to 30.0 ± 6.2 kg/m(2), and anti-reflux medication was decreased from 84% preoperatively to 52%. Late postoperative complications were observed in 3 patients. A comparative analysis with a matched 1:1 control group displayed no significant differences in operative time (P = .07), duration of stay (P = .9), intraoperative complications, or early (P = .09) and late post-operative symptoms (P = .3). In addition, no differences were noted in terms of weight-loss outcomes. CONCLUSION The true incidence of HH may be underestimated before bariatric surgery. Combined repair of HH during bariatric surgery appears safe and feasible.

Endoscopic stents in the management of anastomotic complications after foregut surgery: new applications and techniques

BACKGROUND Anastomotic complications after foregut surgery include leaks, fistulas, and late strictures. The management of these complications can be challenging, and it may be desirable to avoid complex reoperation. OBJECTIVES We aim to describe the indications and outcomes of the use of esophageal self-expanding metal stents in the management of postoperative anastomotic complications after foregut surgery. SETTING Tertiary-referral academic medical center. METHODS We performed a retrospective review of a prospectively managed database. Data was collected on patient demographic characteristics, work-up, intraprocedure findings, and outcomes. RESULTS From October of 2009 to November of 2014, 47 patients (mean age 51.1, 36 women and 11 men) underwent endoscopic stent placement for anastomotic complications following upper gastrointestinal (UGI) surgery. The median time from index operation to endoscopic stent placement was 52 days (range 1-5280 days). Indications were sleeve leak or stenosis, gastrojejunal leak or stenosis after Roux-en-Y gastric bypass (RYGB), pouch staple-line leak after RYGB, enterocutaneous fistula, perforation after endoscopic dilation, upper gastrointestinal bleeding after peroral endoscopic myotomy (POEM), and peptic stricture after POEM. Symptomatic improvement occurred in 76.6% of patients, and early oral intake was initiated in 66% of patients. 14 patients (29.8%) went on to require definitive surgical intervention for persistent symptomatology. The average follow-up was 354.1 days (range 25-1912 days). CONCLUSION This paper describes the use of endoscopic stent therapy for a variety of pathologies after upper gastrointestinal surgery. We demonstrate that, in the appropriate setting, it is an effective and less-invasive therapeutic approach.

Paraesophageal Hernia Repair With Partial Longitudinal Gastrectomy in Obese Patients.

Background and Objectives: Treatment of gastroesophageal reflux disease (GERD) with hiatal hernia in obese patients has proven difficult, as studies demonstrate poor symptom control and high failure rates in this patient population. Recent data have shown that incorporating weight loss procedures into the treatment of reflux may improve overall outcomes. Methods: We retrospectively reviewed 28 obese and morbidly obese patients who presented from December 2007 through July 2013 with large or recurrent type 3 or 4 paraesophageal hernia. All of the patients underwent combined paraesophageal hernia repair and partial longitudinal gastrectomy. Charts were retrospectively reviewed, and the patients were contacted to determine symptomatic relief. Results: Mean preoperative body mass index was 38.1 ± 4.9 kg/m2. Anatomic failure of prior fundoplication occurred in 7 patients (25%). The remaining 21 had primary paraesophageal hernia, 3 of which were type 4. Postoperative complications included pulmonary embolism (n = 1), pulmonary decompensation (n = 2), and wound infection (n = 1). Mean hospital stay was 5 ± 3 days. Upper gastrointestinal esophagogram was performed in 21 patients with no immediate recurrence or staple line dehiscence. Mean excess weight loss was 44 ± 25%. All of the patients surveyed experienced near to total resolution of their preoperative symptoms within the first month. At 1 year, symptom scores decreased significantly. At 27 months, however, there was a mild increase in the scores. Return of severe symptoms occurred in 2 patients, both of whom underwent conversion to gastric bypass. Conclusions: Combined laparoscopic paraesophageal hernia repair with longitudinal partial gastrectomy offers a safe, feasible approach to the management of large or recurrent paraesophageal hernia in well-selected obese and morbidly obese patients. Short-term results were promising; however, intermediate results showed increasing rates of reflux symptoms that required medical therapy or conversion to gastric bypass.

Endoscopic management of post-bariatric surgery complications

Understanding the technical constructs of bariatric surgery is important to the treating endoscopist to maximize effective endoluminal therapy. Post-operative complication rates vary widely based on the complication of interest, and have been reported to be as high as 68% following adjustable gastric banding. Similarly, there is a wide range of presenting symptoms for post-operative bariatric complications, including abdominal pain, nausea and vomiting, dysphagia, gastrointestinal hemorrhage, and weight regain, all of which may provoke an endoscopic assessment. Bleeding and anastomotic leak are considered to be early (< 30 d) complications, whereas strictures, marginal ulcers, band erosions, and weight loss failure or weight recidivism are typically considered late (> 30 d) complications. Treatment of complications in the immediate post-operative period may require unique considerations. Endoluminal therapies serve as adjuncts to surgical and radiographic procedures. This review aims to summarize the spectrum and efficacy of endoscopic management of post-operative bariatric complications.

Laparoscopic resection of symptomatic gastric diverticula.

Patients with symptomatic gastric diverticula may experience successful symptom resolution after laparoscopic resection.

How I Do It: Per-Oral Pyloromyotomy (POP)

IntroductionSeveral surgical treatments exist for treatment of gastroparesis, including gastric electrical stimulation, pyloroplasty, and gastrectomy. Division of the pylorus by means of endoscopy, Per-Oral Pyloromyotomy (POP), is a newer, endoluminal therapy that may offer a less invasive, interventional treatment option.MethodsWe describe and present a video of our step by step technique for POP using a lesser curvature approach. The following are technical steps to complete the POP procedure from the lesser curve approach.ConclusionIn our experience, these methods provide promising initial results with low operative risks, although long-term outcomes remain to be determined.

Adult Idiopathic Hypertrophic Pyloric Stenosis

Introduction: Adult idiopathic hypertrophic pyloric stenosis (AIHPS) is a rare entity. The most common clinical symptom is abdominal distention relieved by vomiting. There are several treatment modalities for relief of the pyloric obstruction. Case Description/Technique: A 43-year-old woman presented with a long history of epigastric pain, nausea, vomiting, and bloating, which appeared to be caused by functional dyspepsia. She also reported severe postprandial epigastric pain that was thought to be secondary to peptic ulcer disease (PUD). She had lost 7 kg, leading to a poor nutritional status. Further investigation by upper gastrointestinal endoscopy demonstrated moderate stenosis at the pylorus. After discussion, she elected to undergo laparoscopic Heineke-Mikulicz pyloroplasty. The patient was placed supine, and entrance into the peritoneal cavity was obtained with a 5-mm optical trocar. The pylorus was clearly identified and was visibly thickened. Two 2-0 silk stay sutures were placed. Gastrotomy was made with a harmonic scalpel, and the pylorus was cut. The pylorus was reconstructed horizontally by using the Heineke-Mikulicz technique. Finally, a second layer of interrupted 2-0 silk sutures was placed. Discussion: The etiology of AIHPS remains unclear. In a case report, Zarineh et al. classified AIHPS into two main types: primary and secondary. Several factors are important in establishing the diagnosis. The approaches include endoscopic dilation, gastrojejunostomy, partial gastrectomy, and pyloromyotomy with or without pyloroplasty. Despite the technical difficulty, operative procedures such as the Heineke-Mikulicz pyloroplasty have shown favorable results. Currently, laparoscopic pyloroplasty may represent a reasonable, less invasive option for this rare condition.

Feeding the gut after revisional bariatric surgery: The fate of 126 enteral access tubes

BACKGROUND Revisional bariatric surgery (RBS) is associated with higher complication rates compared with primary bariatric surgery. Feeding tubes (FTs), including gastrostomy and jejunostomy tubes placed during RBS, may serve as a safety net to provide nutrition when oral intake is contraindicated or limited; however, FTs in this setting have not been well investigated. OBJECTIVES This study aims to determine complications, use, and duration of FTs placed during RBS. SETTING A high-volume academic medical center in the United States. METHODS Included patients underwent RBS between January 2008 and December 2016 with FTs placed at the time of RBS. RESULTS There were 126 patients identified (84.9% female, 76.2% Caucasian, mean age 53.4-±10.9 yr). Patients had previously undergone Roux-en-Y gastric bypass (34.1%), vertical banded gastroplasty (27.8%), and adjustable gastric band (14.3%). Indications for RBS included correction of complication of prior bariatric surgeries (50%), weight regain/failure to lose weight (32.3%), or both (17.3%). Most FTs were placed in the excluded stomach (89.7%), and median tube size was 18 F. FTs were used for feeding in 68.2% of patients, with feeding initiated in a median of 2 days. Leakage around the tube (32.5%) and pain (26.8%) were common complaints. Significant tube-related complications included infection (9.1%), dislodgement (5.9%), reintervention (5.8%), and reoperation (2.8%); 16.7% experienced at least 1 significant complication. FTs were removed at a median of 36 days. CONCLUSION FTs may aid in prevention of perioperative dehydration and malnutrition after RBS, but should not be considered a benign intervention. FT use should be balanced against institutional outcomes and care goals.

EUS-Guided Drainage of Post-operative Subphrenic Fluid Collection Through Gastric Pouch with a Lumen-Apposing Metal Stent in a Patient with Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass (RYGB) is one of the most common bariatric procedure in the USA. Anastomosis leak has been well described and it can present acutely or become chronic. It can lead to acute or chronic fluid collection formation, development of an abscess, peritonitis, sepsis, and death. Endoscopic drainage of these symptomatic fluid collections can be challenging, especially in patients with modified anatomy such as RYGB [1, 2]. We hereby report the first case of successful drainage of symptomatic, post-operative subphrenic fluid collection from an anastomotic leak using a lumen-apposing metal stent (LAMS) through the gastric pouch of a patient with a recent RYGB surgery. A 67-year-old woman with history of RYGB complicated by gastrojejunal anastomosis leak that was managed endoscopically with over the scope endoscopic clip (Ovesco Endoscopy GmbH, Tuebingen) presented to us with nausea, vomiting, and abdominal pain 2 months after gastric bypass. On clinical exam, she was afebrile and had epigastric tenderness. Laboratory analysis was unremarkable. Abdominal CT scan revealed a new subphrenic fluid collection (10 × 5.1 cm) compressing the gastric pouch and causing outlet obstruction (Figs. 1, 2). She underwent endoscopic ultrasound (EUS) evaluation, cystgastrostomy creation, and drainage of the post-operative fluid collection with hot Axios sys tem (Xlumena Inc. , Mounta in View, California) and placement of a 15-mm × 10-mm lumenapposing metal stent (LAMS) (Figs. 3, 4, 5, 6, 7, 8 and 9). Procedure was uneventful and the patient reported resolution of her symptoms within 24 h of LAMS placement and was discharged home. Follow-up imaging 2 months after the drainage revealed complete resolution of fluid collection. The LAMS was removed uneventfully on follow-up endoscopy at 8 weeks. There were no immediate or late post-procedure complications. The patient continues to do well and is asymptomatic at 6month follow-up. The use of LAMS for the management of post-surgical abdominal fluid collections through a Roux-en-Y gastric pouch has not been reported. LAMS are fully covered metal stents with a unique lumen-apposing capacity over its two anchoring ends. The wide proximal and distal anchoring ends limits migration of the stent. Even though LAMS have been well studied in the endoscopic drainage of pancreatic fluid collections, the use of LAMS for the drainage of other abdominal fluid collections, that are endosonographically accessible, has not been widely reported and merit further studies. LAMS usage to drain post-operative fluid collections after RYGB surgery can be performed safely and successfully in expert hands. Larger studies on endoscopic management of abdominal fluid collections related to bariatric surgery are needed. * Prabhleen Chahal chahalp@ccf.org