Matthew Kroh

Can Diabetes Be Surgically Cured?: Long-Term Metabolic Effects of Bariatric Surgery in Obese Patients with Type 2 Diabetes Mellitus

Objective: Evaluate the long-term effects of bariatric surgery on type 2 diabetes (T2DM) remission and metabolic risk factors. Background: Although the impressive antidiabetic effects of bariatric surgery have been shown in short- and medium-term studies, the durability of these effects is uncertain. Specifically, long-term remission rates following bariatric surgery are largely unknown. Methods: Clinical outcomes of 217 patients with T2DM who underwent bariatric surgery between 2004 and 2007 and had at least 5-year follow-up were assessed. Complete remission was defined as glycated hemoglobin (A1C) less than 6% and fasting blood glucose (FBG) less than 100 mg/dL off diabetic medications. Changes in other metabolic comorbidities, including hypertension, dyslipidemia, and diabetic nephropathy, were assessed. Results: At a median follow-up of 6 years (range: 5–9) after surgery (Roux-en-Y gastric bypass, n = 162; gastric banding, n = 32; sleeve gastrectomy, n = 23), a mean excess weight loss (EWL) of 55% was associated with mean reductions in A1C from 7.5% ± 1.5% to 6.5% ± 1.2% (P < 0.001) and FBG from 155.9 ± 59.5 mg/dL to 114.8 ± 40.2 mg/dL (P < 0.001). Long-term complete and partial remission rates were 24% and 26%, respectively, whereas 34% improved (>1% decrease in A1C without remission) from baseline and 16% remained unchanged. Shorter duration of T2DM (P < 0.001) and higher long-term EWL (P = 0.006) predicted long-term remission. Recurrence of T2DM after initial remission occurred in 19% and was associated with longer duration of T2DM (P = 0.03), less EWL (P = 0.02), and weight regain (P = 0.015). Long-term control rates of low high-density lipoprotein, high low-density lipoprotein, high triglyceridemia, and hypertension were 73%, 72%, 80%, and 62%, respectively. Diabetic nephropathy regressed (53%) or stabilized (47%). Conclusions: Bariatric surgery can induce a significant and sustainable remission and improvement of T2DM and other metabolic risk factors in severely obese patients. Surgical intervention within 5 years of diagnosis is associated with a high rate of long-term remission.

Novel Robotic da Vinci Instruments for Laparoendoscopic Single-site Surgery

OBJECTIVES To describe novel robotic laparoendoscopic single-site surgery (R-LESS) instruments, and present the initial laboratory experience in urology. METHODS The VeSPA surgical instruments (Intuitive Surgical, Sunnyvale, CA) were designed to be used with the DaVinci Si surgical system. A multichannel port and curved cannulae were inserted through a single 3.5-cm umbilical incision. The port allowed 1 scope, 2 robotic instruments, and a 5- to 12-mm assistant instrument. Four pyeloplasties (right 2, left 2), 4 partial nephrectomies (right 2, left 2), and 8 nephrectomies (right 4, left 4) were performed in 4 female farm pigs (mean weight, 34.5 kg). Technical feasibility and efficiency were assessed in addition to perioperative outcomes. RESULTS All 16 R-LESS procedures were performed successfully without the addition of laparoscopic ports or open conversion. Mean total operative time was 110 minutes (range, 82-127), and mean blood loss was 20 mL (range, 10-100). Mean warm ischemia time for partial nephrectomy was 14.8 minutes (range, 12-20). There were no intraoperative complications. No robotic system failures occurred, and robotic instrument clashing was found to be minimal. One needle driver malfunctioned and assistant movement was limited. CONCLUSIONS R-LESS kidney surgery using the VeSPA instruments is feasible and efficient in the porcine model. The system offers a wide range of motion, instrument and scope stability, improved ergonomics, and minimal instrument clashing. Although preliminary experience is encouraging, further refinements are expected to optimize urological applications of this robotic technology.

Laparoscopic gastric plication for treatment of severe obesity.

BACKGROUND Current gastric restrictive procedures include either a prosthetic device or gastric resection. We present the results of a feasibility study using laparoscopic gastric plication for weight loss achieved without stapling or banding. METHODS After institutional review board approval, 2 methods were used to achieve laparoscopic gastric volume reduction. In the first group (anterior plication [AP]), the anterior gastric wall was folded inward from the fundus to the antrum using 2 rows of running sutures. The greater and lesser curvatures were approximated to create an intraluminal fold of the stomach. In the second group (greater curvature plication [GCP]), the short gastric vessels were divided, and the greater curvature was folded inward, with 2 suture lines to reduce the gastric capacity by a large intraluminal gastric fold. RESULTS The average preoperative body mass index was 43.3 kg/m(2) (range 36.9-49.0), and 3 patients were men. Of the 15 patients, 9 underwent AP. For the 9 patients who underwent AP, the 6- and 12-month endoscopic evaluations demonstrated comparable-size plications over time, except for in 1 patient, who had a partially disrupted fold. Of the 6 patients who underwent GCP, the 6- and 12-month follow-up endoscopic examinations demonstrated a durable intraluminal fold, except for in 1 patient, with a partial disruption at the distal fold owing to a broken suture. For patients completing 1 year of follow-up, the percentage of excess weight loss was 23.3% ± 24.8% in the AP group (n = 5) and 53.4% ± 22.7% in the GCP group (n = 6). No bleeding or infectious complications developed. The first patient in the GCP group required reoperation and plication reduction owing to gastric obstruction. CONCLUSION Our initial experience has suggested that a reduction in gastric capacity can be achieved by way of plication of the anterior stomach and greater curvature. The early weight loss results have been encouraging, with better weight loss in patients who underwent GCP. The use of laparoscopic GCP warrants additional investigation as a primary bariatric procedure.

Bariatric surgery in patients with liver cirrhosis

BACKGROUND Data regarding the management of bariatric patients with cirrhosis are scarce, and there is no strong evidence that supports a specific approach for this group of patients. The aim of this study was to review our experience with cirrhotic patients undergoing bariatric surgery. METHODS A prospectively maintained database was reviewed to assess the outcomes of bariatric surgery for patients with known cirrhosis and for patients with cirrhosis discovered at surgery (unknown cirrhosis). RESULTS From April 2004 to September 2011, 23 patients (12 with known cirrhosis and 11 with unknown cirrhosis) met inclusion criteria. There were 14 females and 9 males with a mean age of 51.5 ± 8.3 and a mean body mass index of 48.2 ± 8.6 kg/m2. Child-Pugh classes were A (n = 22) and B (n = 1). Patients had a high frequency of diabetes (83%), dyslipidemia (61%), and hypertension (83%). Procedures performed were laparoscopic Roux-en-Y gastric bypass (LRYGB) (n = 14), laparoscopic sleeve gastrectomy (LSG) (n = 8), and laparoscopic adjustable gastric banding (n = 1). Two patients underwent LSG successfully after transjugular intrahepatic portosystemic shunt. Mean length of hospital stay was 4.3 ± 2.7 days. Complications developed in 8 patients. One patient died of unknown cause 9 months after surgery. No patients had liver decompensation after surgery. The patients lost 67.4% ± 30.9% of their excess weight at 12 months follow-up and 67.7% ± 24.8% at 37 months follow-up. CONCLUSION LRYGB and LSG can be performed without prohibitive complication rates in carefully selected patients with cirrhosis. In our experience, bariatric patients with cirrhosis achieved excellent weight loss and improvement in obesity-related co-morbidities.

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.

Single-Port, Laparoscopic Cholecystectomy and Inguinal Hernia Repair: First Clinical Report of a New Device

OBJECTIVE To report the initial clinical cases of single-port, transumbilical cholecystectomy and inguinal hernia repair using a novel operating device. METHODS One patient each underwent single-port transumbilical cholecystectomy and transabdominal pre-peritoneal (TAPP) inguinal hernia repair using the Uni-X Single Port System (Pnavel Systems, Inc.). The device was placed through a single infraumbilical incision in both cases. Novel, specialized instruments, bowed in the shaft for triangulation, were used in addition to standard laparoscopic instrumentation. During cholecystectomy, a single stab incision was made and a laparoscopic suture passer was used for additional cephalad retraction of the gallbladder. RESULTS Both procedures were technically successful without placement of additional trocars. Operative times were 59 and 47 minutes for the cholecystectomy and inguinal hernia, respectively. Blood loss was minimal, and there were no intraoperative complications. The patient who underwent cholecystectomy had a previously placed infusion pump for chronic pain management and was kept overnight. The patient who underwent TAPP hernia repair was discharged the same day. Follow-up at three weeks postoperatively demonstrated the patients to be without complaints. CONCLUSIONS Transumbilical, single-port cholecystectomy and TAPP inguinal hernia repair are technically feasible. The first initial clinical experience with these procedures using this device is reported.

Single-port surgery: laboratory experience with the daVinci single-site platform.

This animal study demonstrates that single-port robotic surgery using the VeSPA platform can allow the performance of technically challenging procedures within acceptable operative times and without complications or insertion of additional trocars.

Safety and effectiveness of bariatric surgery in dialysis patients and kidney transplantation candidates

BACKGROUND Chronic renal disease is known to adversely affect the results of bariatric surgery. There is a paucity of literature on the safety and effectiveness of bariatric surgery on dialysis patients who are at very advanced stages in their renal disease. The objective of this study was to determine the safety and effectiveness of bariatric surgery in dialysis patients. METHODS A retrospective review of a prospectively collected database was conducted for dialysis patients who underwent bariatric surgery between January 2006 and January 2012. Age, gender, body mass index (BMI), cause of renal failure, associated co-morbidities, type of surgery, early and late complications, and mortality were collected. RESULTS Of the 3048 patients undergoing bariatric surgery during the study period, 21 dialysis patients (.7%) were identified. Eighteen patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB), 2 patients underwent laparoscopic sleeve gastrectomy, and 1 patient underwent laparoscopic adjustable gastric banding. Mean preoperative BMI was 47.1±5.5 kg/m(2), and BMI decreased to 35.3±8.4 kg/m(2) after a mean follow-up period of 27.6 months (range = 1.4-78.0 mo). Early major complications (<30 days of surgery) occurred in 2 patients (1 anastomotic leak and 1 anastomotic stricture). Four patients had a late complication, including 1 marginal ulcer with bleeding managed endoscopically, 1 small bowel obstruction requiring laparoscopic lysis of adhesions, 1 cholecystitis requiring cholecystectomy, and 1 anastomotic stricture requiring endoscopic dilation. There was 1 death in this cohort, at 45 days after LRYGB, that was unrelated to a surgery. CONCLUSIONS Chronic renal failure requiring dialysis should not be considered a contraindication to bariatric surgery. Our experience with this patient population has shown excellent medium-term weight loss and an acceptable (albeit increased) risk/benefit ratio.

Endoscopic stent management of leaks and anastomotic strictures after foregut surgery

BACKGROUND Anastomotic complications after upper gastrointestinal surgery present an arduous therapeutic challenge. Avoiding revisional surgery is desirable and might be possible with the advent of endoscopically placed stents. We reviewed our experience with endoscopic stent management of anastomotic complications after esophagogastric surgery. METHODS A prospectively maintained database at our surgical endoscopy unit was reviewed to identify patients who had undergone endoscopic stent placement after various foregut procedures. Data were obtained on patient demographics, primary surgical and endoscopic procedures, and outcome. RESULTS From January 2007 to August 2010, 18 patients (12 women, mean age 51 ± 15 yr) underwent endoscopic stent placement for anastomotic complications; 14 were bariatric patients. A total of 31 stents (21 covered metal, 5 salivary, and 5 silicone-coated polyester) were used to treat anastomotic leaks (n = 13), strictures (n = 3), and fistulas (n = 2). Symptomatic improvement occurred in all but 2 patients (89%), and early oral intake was initiated in 11 (61%). Stent treatment was successful in definitively managing the anastomotic complication in 13 (72%) of the 18 patients. Five patients required additional surgical or endoscopic intervention. Stent migration occurred in 4 cases and was amenable to endoscopic management. Two patients died, with both deaths unrelated to stent placement. CONCLUSION Endoscopic stent management of anastomotic complications after foregut surgery is effective in resolving symptoms, expediting enteral nutrition, and particularly successful for treating anastomotic leaks. In the absence of stents specifically designed for surgically altered gastrointestinal anatomy, some factors that might reduce the risk of stent migration include appropriate stent selection, anchoring the stent proximally, and regular surveillance after placement.

Laparoscopic median arcuate ligament release: are we improving symptoms?

BACKGROUND Median arcuate ligament syndrome is a rare disorder characterized by postprandial abdominal pain, weight loss, and celiac stenosis. We report our experience using a laparoscopic approach for this uncommon diagnosis. STUDY DESIGN This is an IRB-approved, prospectively collected retrospective analysis of patients treated with laparoscopic median arcuate ligament release at our institution. Data collected included patient demographics, preoperative symptoms, operative approach, and postoperative outcomes. Ultimately, patients were contacted to complete a postoperative survey aimed at assessing resolution of symptoms and overall satisfaction. RESULTS A total of 15 patients underwent laparoscopic median arcuate ligament release from March 2007 to January 2012. Mean age was 34 years (range 17 to 68 years) and 93% were female. Mean preoperative celiac velocity was 380 cm/s (range 210 to 600 cm/s). Fourteen patients had laparoscopic median arcuate ligament release and 1 patient had robotic-assisted laparoscopic release. Mean operative time was 179 minutes (range 79 to 473 minutes) and there was 1 conversion to laparotomy. Twelve of 15 patients had a postoperative celiac axis ultrasonography. Celiac occlusion occurred in 2 patients (present in 1 patient preoperatively). In the remaining 10 there was a statistically significant decrease in celiac velocity to 215 cm/s (range 135 to 306 cm/s; p = 0.005). Survey response rate was 86% at a mean follow-up of 15.4 months (range 2.8 to 32.6 months), and all but 1 patient reported having resolution of pain. CONCLUSIONS Laparoscopic release of the median arcuate ligament is a safe, feasible, and effective means of managing median arcuate ligament syndrome. Postoperative symptomatic relief is seen in the vast majority of patients undergoing this procedure.