Jon Gabrielsen

A Role for Fibroblast Growth Factor 19 and Bile Acids in Diabetes Remission After Roux-en-Y Gastric Bypass

OBJECTIVE Roux-en-Y gastric bypass (RYGB) in humans can remit type 2 diabetes, but the operative mechanism is not completely understood. In mice, fibroblast growth factor (FGF) 15 (FGF19 in humans) regulates hepatic bile acid (BA) production and can also resolve diabetes. In this study, we tested the hypothesis that the FGF19–BA pathway plays a role in the remission of human diabetes after RYGB surgery. RESEARCH DESIGN AND METHODS Cohorts of diabetic and nondiabetic individuals of various body weights were used. In addition, RYGB patients without diabetes (No-Diabetes), RYGB patients with diabetes who experienced remission for at least 12 months after surgery (Diabetes-R), and RYGB patients with diabetes who did not go into remission after surgery (Diabetes-NoR) were studied. Circulating FGF19 and BA levels, hepatic glycogen content, and expression levels of genes regulating the FGF19–BA pathway were compared among these groups of patients using pre- and postoperative serum samples and intraoperative liver biopsies. RESULTS Preoperatively, patients with diabetes had lower FGF19 and higher BA levels than nondiabetic patients, irrespective of body weight. In diabetic patients undergoing RYGB, lower FGF19 levels were significantly correlated with increased hepatic expression of the cholesterol 7alpha-hydroxylase 1 (CYP7A1) gene, which modulates BA production. Following RYGB surgery, however, FGF19 and BA levels (particularly cholic and deoxycholic acids) exhibited larger increases in Diabetic-R patients compared with nondiabetic and Diabetic-NoR patients. CONCLUSIONS Taken together, the baseline and postoperative data implicate the FGF19–CYP7A1–BA pathway in the etiology and remission of type 2 diabetes following RYGB surgery.

Clinical factors associated with weight loss outcomes after Roux‐en‐Y gastric bypass surgery

Gastric bypass surgery is an effective therapy for extreme obesity. However, substantial variability in weight loss outcomes exists that remains largely unexplained. Our objective was to determine whether any commonly collected preoperative clinical variables were associated with weight loss following Roux‐en‐Y gastric bypass (RYGB) surgery.

An electronic health record-enabled obesity database.

BackgroundThe effectiveness of weight loss therapies is commonly measured using body mass index and other obesity-related variables. Although these data are often stored in electronic health records (EHRs) and potentially very accessible, few studies on obesity and weight loss have used data derived from EHRs. We developed processes for obtaining data from the EHR in order to construct a database on patients undergoing Roux-en-Y gastric bypass (RYGB) surgery.MethodsClinical data obtained as part of standard of care in a bariatric surgery program at an integrated health delivery system were extracted from the EHR and deposited into a data warehouse. Data files were extracted, cleaned, and stored in research datasets. To illustrate the utility of the data, Kaplan-Meier analysis was used to estimate length of post-operative follow-up.ResultsDemographic, laboratory, medication, co-morbidity, and survey data were obtained from 2028 patients who had undergone RYGB at the same institution since 2004. Pre-and post-operative diagnostic and prescribing information were available on all patients, while survey laboratory data were available on a majority of patients. The number of patients with post-operative laboratory test results varied by test. Based on Kaplan-Meier estimates, over 74% of patients had post-operative weight data available at 4 years.ConclusionA variety of EHR-derived data related to obesity can be efficiently obtained and used to study important outcomes following RYGB.

All-Cause and Specific-Cause Mortality Risk After Roux-en-Y Gastric Bypass in Patients With and Without Diabetes

OBJECTIVE This study assessed all-cause and specific-cause mortality after Roux-en-Y gastric bypass (RYGB) and in matched control subjects, stratified by diabetes status. RESEARCH DESIGN AND METHODS RYGB patients were matched by age, BMI, sex, and diabetes status at time of surgery to nonsurgical control subjects using data from the electronic health record. Kaplan-Meier curves and Cox regression were used to assess differences in all-cause and specific-cause mortality between RYGB patients and control subjects with and without diabetes. RESULTS Of the 3,242 eligible RYGB patients enrolled from January 2004 to December 2015, control subjects were identified for 2,428 (n = 625 with diabetes and n = 1,803 without diabetes). Median postoperative follow-up was 5.8 years for patients with diabetes and 6.7 years for patients without diabetes. All-cause mortality was reduced in RYGB patients compared with control subjects only for those with diabetes at the time of surgery (adjusted hazard ratio 0.44; P < 0.0001). Mortality was not significantly improved in RYGB patients without diabetes compared with control subjects without diabetes (adjusted hazard ratio 0.84; P = 0.37). Deaths from cardiovascular diseases (P = 0.011), respiratory conditions (P = 0.017), and diabetes P = 0.011) were more frequent in control subjects with diabetes than in RYGB patients with diabetes. RYGB patients without diabetes were less likely to die of cancer (P = 0.0038) and respiratory diseases (P = 0.046) than control subjects without diabetes but were at higher risk of death from external causes (P = 0.012), including intentional self-harm (P = 0.025), than control subjects without diabetes. CONCLUSIONS All-cause mortality benefits of RYGB are driven predominantly by patients with diabetes at the time of surgery. RYGB patients with diabetes were less likely to die of cardiovascular diseases, diabetes, and respiratory conditions than their counterparts without RYGB.

Identification of novel clinical factors associated with hepatic fat accumulation in extreme obesity.

Objectives. The accumulation of lipids stored as excess triglycerides in the liver (steatosis) is highly prevalent in obesity and has been associated with several clinical characteristics, but most studies have been based on relatively small sample sizes using a limited set of variables. We sought to identify clinical factors associated with liver fat accumulation in a large cohort of patients with extreme obesity. Methods. We analyzed 2929 patients undergoing intraoperative liver biopsy during a primary bariatric surgery. Univariate and multivariate regression modeling was used to identify associations with over 200 clinical variables with the presence of any fat in the liver and with moderate to severe versus mild fat accumulation. Results. A total of 19 data elements were associated with the presence of liver fat and 11 with severity of liver fat including ALT and AST, plasma lipid, glucose, and iron metabolism variables, several medications and laboratory measures, and sleep apnea. The accuracy of a multiple logistic regression model for presence of liver fat was 81% and for severity of liver fat accumulation was 77%. Conclusions. A limited set of clinical factors can be used to model hepatic fat accumulation with moderate accuracy and may provide potential mechanistic insights in the setting of extreme obesity.

Urgent laparoscopic repair of acutely symptomatic PEH is safe and effective

BackgroundAcute incarceration of paraesophageal hernias (PEHs) requiring urgent or emergent surgery is rare. Patients are often elderly with significant comorbidities and have historically been treated with open abdominal or thoracic incisions. Our study was designed to evaluate the feasibility, safety, and efficacy of laparoscopic paraesophageal hernia repair (LPEHR) in patients with PEH and acute gastric volvulus.MethodsWe reviewed our prospectively maintained database and identified 269 patients who underwent an initial LPEHR between January 2003 and January 2012. Patients were divided into group A (acute), group B (age- and comorbidity-matched 1:3), and group C (all elective repairs). Group A included those admitted with acute symptoms related to PEH and underwent urgent repair. Patient age, Charlson score, operative time, length of stay (LOS), morbidity, mortality, and recurrence rates were compared.ResultsPatients who underwent urgent LPEHR had a higher perioperative morbidity rate than the elective and matched groups. The overall mortality rate was low and no statistical difference was found between groups A, B, and C. LOS in group A was longer than groups B and C. The need for ICU admission was also higher in group A. There was no statistical difference in recurrence rates.ConclusionsHistorically, patients presenting with acute symptoms related to PEH have required open repair, which is associated with significant morbidity and mortality. The acute group was older and sicker than our elective LPEHR patients and had more adverse events resulting in a longer LOS, even when compared with comorbidity-matched elective patients. However, the LOS remained shorter than that reported for open repair and there was no mortality. The recurrence rates in all groups were low and comparable to elective repairs.

Feasibility and Impact of an Evidence-Based Program for Gastric Bypass Surgery

BACKGROUND Health care in the United States is expensive and quality is variable. The aim of this study was to investigate whether our integrated health system, composed of academic hospitals, a practice plan, and a managed care payer, could reliably implement an evidence-based program for gastric bypass surgery. A secondary aim was to evaluate the impact of the program on clinical outcomes. STUDY DESIGN A standardized program for delivery of clinical best-practice elements for patients undergoing initial open or laparoscopic Roux-en-Y gastric bypass was implemented in 2008. Best-practice elements were embedded into the workflow. The best-practice elements were refined after reviewing failures observed during the early implementation period. The study period was divided into 3 groups: group α = year preceding program implementation (control), group β = first year of implementation (unreliable), and group Ω = 2nd to 4th years of implementation (reliable). Outcomes data were collected for all patients who had undergone Roux-en-Y gastric bypass between May 2008 and April 2012 and were compared with a control group from the preceding year using multiple logistic regression analysis. RESULTS Two thousand and sixty-one patients were studied, with no significant demographic differences between study groups. Best-practice elements delivery was 40% in group β, but was >90% for group Ω (p < 0.001). Length of stay for group α was 3.5 days and improved to 2.2 days (p < 0.001) for group Ω. Complications and readmission rates improved considerably with reliable delivery of best-practice elements. CONCLUSIONS Standardization of evidence-based care delivery for Roux-en-Y gastric bypass was feasible and reliable delivery of this pathway improved clinical outcomes.

Preoperative use of incretins is associated with increased diabetes remission after RYGB surgery among patients taking insulin: a retrospective cohort analysis.

OBJECTIVE The main goal of this study was to determine the effects of incretins on type 2 diabetes (T2D) remission after Roux-en-Y gastric bypass (RYGB) surgery for patients taking insulin. BACKGROUND Type 2 diabetes is a chronic disease with potentially debilitating consequences. RYGB surgery is one of the few interventions that can remit T2D. Preoperative use of insulin, however, predisposes to significantly lower T2D remission rates. METHODS A retrospective cohort of 690 T2D patients with at least 12 months follow-up and available electronic medical records was used to identify 37 T2D patients who were actively using a Glucagon-like peptide 1 (GLP-1) agonist in addition to another antidiabetic medication, during the preoperative period. RESULTS Here, we report that use of insulin, along with other antidiabetic medications, significantly diminished overall T2D remission rates 14 months after RYGB surgery (9%) compared with patients not taking insulin (56%). Addition of the GLP-1 agonist, however, increased significantly T2D early remission rates (22%), compared with patients not taking the GLP-1 agonist (4%). Moreover, the 6-year remission rates were also significantly higher for the former group of patients. The GLP-1 agonist did not improve the remission rates of diabetic patients not taking insulin as part of their pharmacotherapy. CONCLUSIONS Preoperative use of antidiabetic medication, coupled with an incretin agonist, could significantly improve the odds of T2D remission after RYGB surgery in patients also using insulin.

A Novel Technique for Wound Protector Deployment and Efficient Specimen Extraction Following Laparoscopic Sleeve Gastrectomy

Challenges of specimen extraction during laparoscopic sleeve gastrectomy and other resectional laparoscopic procedures can often be proven to be time consuming and frustrating, and the risk of wound infection and port site tumor implantation increases. In this paper, we discuss our experience with an efficient approach to specimen extraction utilizing a novel technique for deployment of a very small self-expanding wound protector through a 12- or 15-mm port. We also report our observations with regard to the learning curve of this technique and the influence of BMI to retractor insertion times and specimen extraction times during laparoscopic sleeve gastrectomy.

Pocket Companion to Sabiston Textbook of Surgery

This pocket companion to the 16th edition of Sabiston’s Textbook of Surgery is a very portable source of key information on the broad spectrum of topics contained in the mother text for which it is named, including the basic sciences as related to surgery and several chapters dedicated to surgical subspecialties. As stated in the preface of the book, it is intended “to provide students, residents, and working surgeons with readily available pertinent information,” a goal that it handily achieves. Over 170 tables, flow diagrams, and illustrations accompany the text to reinforce key concepts. Arranged in a bulleted, outline fashion, this book provides an easy-to-follow format. Its 71 chapters seamlessly correspond with the chapters in the main Sabiston text. The editors have done an excellent job sifting through the vast amount of material contained in the large book and have selected appropriate key concepts to include in the outline format without bogging the pages down in details nonessential to a general review of a given subject, keeping the book in line with the purpose for which it was intended. For complete coverage of a topic the reader is referred to the appropriate chapter in the textbook. The text of each chapter is double spaced and uncluttered, giving the reader an opportunity to add notes in between the lines or in the margin of the page. When used in conjunction with the main Sabiston text, or even with other major texts, this book provides an excellent supplemental means of studying for in-service or board exams and can provide an excellent review of a myriad of subjects. Recognizing the need to be concise in a text of this nature, one criticism of the book is that references for the material contained in the chapters are not listed, unlike some of the other “pocket companion” type books (i.e., WA Manual of Surgery). However, if one desires to look up these references they are easily located in the mother text. The book was priced at