Joseph Talarico

Pancreatic islet isolation after gastric bypass in a rat model: technique and initial results for a promising research tool

BACKGROUND Roux-en-Y gastric bypass (RYGB) affords a high remission rate of type 2 diabetes mellitus among morbidly obese diabetic patients. We report the use of the isolated islet technique to assess pancreatic function and glucoregulatory mechanisms after RYGB surgery. METHODS A total of 15 adult, male, Sprague Dawley diet-induced obese rats were randomly divided into 3 experimental groups: sham, RYGB, and pair-fed, with 5 rats in each group. The body weight was measured at baseline and every week for 4 weeks. Pancreatic islet function was assessed in vitro according to the amount of insulin secreted from isolated islets incubated in 2 mM and 20 mM glucose for 1 hour at 37 °C. Fasting plasma glucose, insulin, glucagon-like peptide-1, PYY3-36, and glucose-dependent insulinotropic peptide were measured at baseline and 28 days after surgery. RESULTS The baseline body weight was 917 ± 61, 831 ± 42, and 927 ± 43 g for the sham, RYGB, and pair-fed groups, respectively. The RYGB group lost 32% body weight compared with 16% for the sham and 24% for the pair-fed groups. Glucose-stimulated insulin secretion from the isolated islets in the RYGB group was greater than in the comparison groups (P = .04) at 4 weeks after surgery. Fasting plasma glucagon-like peptide-1 and PYY3-36 were significantly increased at 4 weeks in the RYGB group. CONCLUSION Islet isolation and stimulation in the present animal model was feasible, affords a direct measurement of pancreatic islet function, and might provide a useful tool to study the effects of RYGB on pancreatic function and the relationship between islet cell function and incretin production after bariatric surgery.

Pre–Lap-Band group education in Medicaid population: does it really make a difference?

BACKGROUND The effect of group education classes before a Lap-Band procedure has not been well defined. We hypothesized that in a Medicaid population, the completion of a standardized 12-week multidisciplinary preoperative program (SMPP) would significantly improve the preoperative and early postoperative weight loss. All procedures were performed at a University-affiliated community hospital from 2006 to 2007. METHODS A prospectively collected database of 292 patients who underwent Lap-Band placement was retrospectively reviewed. All patients in the study cohort were encouraged to participate in the SMPP, which included medical, psychological, and nutritional interventions. The patients were divided into 2 groups according to their participation in the SMPP program: SMPP compliant and non-SMPP compliant. The postoperative weight loss of these 2 groups was then compared using the general linear models for repeated measures statistical analysis. RESULTS No significant difference was found in the mean baseline excess body weight between the 2 groups (74 +/- 20 kg in the SMPP-compliant and 76 +/- 20 kg in the non-SMPP-compliant participants). The mean baseline body mass index (47 +/- 7 versus 48 +/- 72 kg/m(2) for the SMPP-compliant and non-SMPP-compliant participants) was also similar in the 2 groups. The postoperative follow-up rate was 94.5% at 1 month, 72.3% at 6 months, and 52.7% at 12 months. The excess weight loss was significantly greater in the SMPP compliant group than in the noncompliant group during the observed 12-month follow-up period (P = .04, by general linear models for repeated measures). CONCLUSION In a Medicaid population, implementation of an intensive preoperative SMPP resulted in a significant improvement in the short-term weight loss after Lap-Band placement.

Primary Endoluminal Techniques for Weight Loss

Though bariatric surgery remains the gold standard in the treatment and management of obesity, endoluminal approaches may offer the potential for significant weight loss with an improved safety and cost profile. Endoluminal therapies can be broadly organized by three approaches: space occupying, malabsorptive, and gastric volume reduction. These combined groups may be safer and more cost-effective compared with traditional operative approaches. For all endoluminal procedures targeted to bariatric surgery, physicians must demand clear outcome measures and well-designed prospective studies. It is imperative that gastroenterologists and bariatric surgeons work together within a multidisciplinary culture and structure to ensure safe adoption of these new techniques. Ultimately, these procedures should be performed within a bariatric program that can provide expert pre- and post-procedure evaluations of the morbidly obese patient.

457 Gastric Pacing Can Eliminate Dependency On Supplemental Nutrition and Improve Medically Refractory Gastroparesis

INTRODUCTION: Gastric stimulation has been shown to improve the symptoms of medically refractory gastroparesis. With enough symptomatic improvement, patients should be able to decrease or eliminate their dependency on supplemental nutrition (parenteral or enteral) in the post-operative period. MATERIALS AND METHODS: This is a review of a single surgeons operative experience from 9/02 to 7/08. Patients with a diagnosis of diabetic or idiopathic gastroparesis that had a gastric pacer placed were selected for analysis. Chart review included age, gender, weight, symptom improvement, and the requirement of additional nutritional supplementation at baseline, six, and 12 months. RESULTS: Fifty-two patients had interrogation and programming of the gastric pacer (Enterra) at time of implantation. As part of follow-up, patients were assessed for symptom improvement and were adjusted appropriately if no improvement was seen. Patients included eight males and 44 females. The average age was 38 years (range 20-87). Thirty-one had a pre-operative, 6 month, and 12 month weight recording. Average weight was 151.9 lbs, 153.2 lbs, and 155.1 lbs at those respective times. In 47 patients with a mean follow-up of 19 months, 34 (72%) reported improvement in symptoms, nine (19%) reported no improvement in symptoms, and four had initial resolution of symptoms but return to baseline at last followup. Preoperatively, 10 patients were receiving jejunal feeds (TF) and two were receiving total parenteral nutrition (TPN). Subsequently after device implantation, seven patients at six months and an additional three at one year were off all forms of supplementation and receiving nutrition solely by mouth. No statistically significant weight change was seen in this group. Seven patients had a jejunostomy tube placed at the time of device implantation for subsequent enteral feeds. Three patients at six months had enteral feedings stopped and the remaining four continued tube feeds at one year. No patient in this group had an infectious complication secondary to concomitant gastric stimulator and jejunal tube placement. One Enterra system was replaced due to device malfunction, two revised secondary to generator malposition, and one removed due to lead erosion. CONCLUSIONS: The majority of patients demonstrated weight stability after gastric pacer placement. 72% of patients reported improvement in symptoms. Patients receiving supplemental nutrition preoperatively showed decreased reliance on enteral feeds or TPN after gastric stimulation. Concomitant jejunal tube and gastric pacer placement did not demonstrate a higher infectious complication rate.