Moshe Rubin

Laparoscopic Sleeve Gastrectomy—Volume and Pressure Assessment

BackgroundAiming to clarify the mechanism of weight loss after the restrictive bariatric procedure of sleeve gastrectomy (LSG), the volumes and pressures of the stomach, of the removed part, and of the remaining sleeve were measured in 20 morbidly obese patients.MethodsThe technique used consisted of occlusion of the pylorus with a laparoscopic clamp and of the gastroesophageal junction with a special orogastric tube connected to a manometer. Instillation of methylene-blue-colored saline via the tube was continued until the intraluminal pressure increased sharply, or the inflated stomach reached 2,000xa0cc. After recording of measurements, LSG was performed.ResultsMean volume of the entire stomach was 1,553xa0cc (600–2,000xa0cc) and that of the sleeve 129xa0cc (90–220xa0cc), i.e., 10% (4–17%) and that of the removed stomach was 795xa0cc (400–1,500xa0cc). The mean basal intragastric pressure of the whole stomach after insufflations of the abdominal cavity with CO2 to 15xa0mmHg was 19xa0mmHg (11–26xa0mmHg); after occlusion and filling with saline it was 34xa0mmHg (21–45xa0mmHg). In the sleeved stomach, mean basal pressure was similar 18xa0mmHg (6–28xa0mmHg); when filled with saline, pressure rose to 43xa0mmHg (32–58xa0mmHg). The removed stomach had a mean pressure of 26xa0mmHg (12–47xa0mmHg). There were no postoperative complications and no mortality.ConclusionsThe notably higher pressure in the sleeve, reflecting its markedly lesser distensibility compared to that of the whole stomach and of the removed fundus, indicates that this may be an important element in the mechanism of weight loss.

Gastric Emptying is not Affected by Sleeve Gastrectomy-Scintigraphic Evaluation of Gastric Emptying after Sleeve Gastrectomy without Removal of the Gastric Antrum

BackgroundThe aim of this study is to clarify whether laparoscopic sleeve gastrectomy (LSG) to treat morbid obesity causes changes in gastric emptying.MethodsGastric emptying scintigraphy was performed before and 3xa0months after LSG, in 21 consecutive morbidly obese patients. After an overnight fast, subjects consumed a standard semi-solid meal, to which 0.5xa0mCi Tc99-labeled sulfur colloid had been added. The meal was consumed within 10xa0min. Scintigraphic imaging was performed with a gamma camera immediately after the completion of the meal as well as after 30, 60, 120, 180, and 240xa0min. Quantitative and qualitative analysis was performed by drawing a region of interest (ROI) enclosing the stomach on the anterior and the posterior images. Time 0 was considered the time of meal completion (all the ingested activity) and was defined as 100% retention. The same ROI was used on all consecutive images of the same projection for the same patient. The geometric mean of the anterior and the posterior counts for each time point is calculated and corrected for Tc99m decay. Gastric emptying curves were constructed. T 1/2 is the time interval between completion of the meal and the point at which half of the meal (by radioactivity counts) has left the stomach. Retention is expressed as the percent remaining in the stomach at each time point (half, 1, 2, 3, 4xa0h).ResultsThe mean T 1/2 raw data was 62.39u2009±u200919.83 and 56.79u2009±u200918.72xa0min (pu2009=u20090.36, tu2009=u2009−0.92, NS) before and 3xa0months after LSG, respectively. The T 1/2 linear was 103.64u2009±u20099.82 and 106.92u2009±u200914.55, (pu2009=u20090.43, tu2009=u2009−0.43, NS), and the linear fit slope 0.48u2009±u20090.04 and 0.47u2009±u20090.05 (pu2009=u20090.48, tu2009=u20090.7, NS).ConclusionsLSG with antrum preservation as performed in this series has no effect on gastric emptying.

Laparoscopic sleeve gastrectomy with minimal morbidity. Early results in 120 morbidly obese patients.

BackgroundIn recent years, laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure for the treatment of morbid obesity is becoming increasingly popular. Of continuing concern are the rate of postoperative complications and the lack of consensus as to surgical technique.MethodsA prospective study assessment was made of 120 consecutive morbidly obese patients with body mass index (BMI) of 43u2009±u20095 (30 to 63), who underwent LSG using the following technique: (1) division of the vascular supply of the greater gastric curvature and application of the linear stapler-cutter device beginning at 6–7xa0cm from the pylorus so that part of the antrum remains; (2) inversion of the staple line by placement of a seroserosal continuous suture close to the staple line; (3) use of a 48xa0Fr bougie so as to avoid possible stricture; (4) firing of the stapler parallel to the bougie to make the sleeve as narrow as possible and prevent segmental dilatation.ResultsIntraoperative difficulties were encountered in four patients. There were no postoperative complications—no hemorrhage from the staple line, no anastomotic leakage or stricture, and no mortality. In 20 patients prior to the sleeve procedure, a gastric band was removed. During a median follow-up of 11.7xa0months (range 2–31xa0months), percent of excess BMI lost reached 53u2009±u200924% and the BMI decreased from 43u2009±u20095 to 34u2009±u20095xa0kg/m2. Patient satisfaction scoring (1–4) at least 1xa0year after surgery was 3.6u2009±u20090.8.ConclusionsThe good early results obtained with the above-outlined surgical technique in 120 consecutive patients undergoing LSG indicate that it is a safe and effective procedure for morbid obesity. However, long-term results are still pending.

Laparoscopic Gastric Banding with Lap-Band® for Morbid Obesity: Two-step Technique may Improve Outcome

Background: Laparoscopic placement of an adjustable gastric band is an attractive alternative for patients who can benefit from a restrictive bariatric procedure. Creation of the retrogastric tunnel (RGT) may,however, be a considerable challenge early in the surgeons learning curve. Recent reports described up to 10% band slippage and occasional gastric perforation associated with RGT. The twostep (TS) technique involves a crural dissection towards the angle of His through a gastrohepatic ligament approach. It facilitates passage of the bands tubing posteriorly with no wide posterior gastric wall dissection. Patients and Methods: Prospective data were registered for the 109 patients (92 females, 17 males) who underwent laparoscopic adjustable gastric banding from December 1998 to May 2000. In 11 patients the standard RGT approach was used, and in 98, the TS technique.The two groups were demographically similar. Mean age was 37 years (18-59); mean preoperative weight was 120 kg (90-165). Results: All procedures were completed laparoscopically.The mean operative time was 59 minutes (31-150) and the mean hospital stay 1.2 days (1-5). Complications in the TS group were gastric wall hematoma in one patient, 3 days of intubation post-operatively in one patient, damage to a band demonstrated in a postoperative contrast study in one patient, and a port-site hernia in one patient. There was no band slippage in theTS group. Among the 11 patients undergoing RGT, there was band slippage in three (27%), immediately postoperatively in one and after 3 and 11 months in the other two. In a mean follow-up of 7 months (1-18), similar weight loss was found in both groups.The mean BMI decreased from 44 kg/m2 (36-61) preoperatively to 40, 38, 36, 34 kg/m2 at 1, 3, 6 and 9 months respectively. 52 patients required band adjustment; of these, 12 required two adjustments. Conclusion: Our experience with both the RGT andTS techniques indicates that the latter may offer better results, particularly in the early experience period. It is recommended that in their initial experience with the adjustable band, surgeons should become familiar with this approach.

Mapping of Ghrelin Gene Expression and Cell Distribution in the Stomach of Morbidly Obese Patients—a Possible Guide for Efficient Sleeve Gastrectomy Construction

BackgroundGhrelin is secreted mainly in the stomach and plays a role in food intake regulation. Morbidly obese (MO) individuals report a decline in appetite after sleeve gastrectomy (SG), presumably due, in part, to ghrelin cell removal. Ghrelin cell distribution and expression were determined in three areas of resected stomach specimens from MO patients subjected to SG.MethodsResected stomach specimens from 20 MO patients undergoing SG were analyzed. Real-time polymerase chain reaction of ghrelin mRNA and immunohistostaining for ghrelin cells in three stomach regions (fundus, body, and pre-antral areas) were performed. Body mass index (BMI) and total plasma ghrelin levels were obtained before and 3xa0months postoperatively.ResultsGhrelin mRNA was detected throughout the stomach, its expression decreasing from the fundus towards the antrum. The relative quantification for ghrelin mRNA expression was 0.043, 0.026, and 0.015 at the fundus, body, and pre-antral region, respectively (Pu2009=u20090.05, fundus vs. pre-antral region). Average ghrelin cell counts declined from 60u2009±u200940 to 45u2009±u200920 and 39u2009±u200913 cells/high power fields in the fundus, body, and pre-antral region, respectively. Three months after surgery, total plasma ghrelin levels decreased from 1,676u2009±u2009470 to 1,179u2009±u2009188xa0pg/ml (Pu2009<u20090.00001) and BMI dropped from 46u2009±u20096 to 38u2009±u20095xa0kg/m2 (Pu2009<u20090.00001).ConclusionsDistribution and expression of ghrelin-secreting cells throughout the stomach were defined, emphasizing the importance of meticulous resection of the fundus during SG for maximal ghrelin cell removal.

Gastric emptying is not prolonged in obese patients

BACKGROUNDnObesity is associated with a poor anesthetic risk, in part because of the greater aspiration rates. A greater gastric residue and lower stomach pH have been implicated. The relationship of obesity to gastric emptying is ill-defined. with contradicting reports stating shorter, similar, and longer times compared with nonobese subjects. The aim of the present study was to compare gastric emptying in obese and nonobese subjects at a university hospital.nnnMETHODSnA total of 19 obese (body mass index [BMI] >40 kg/m(2)) and 20 nonobese (BMI <30 kg/m(2)) subjects underwent a standardized scintigraphic gastric emptying study. The participants consumed a standard semisolid, technetium-99m-labeled meal. Images were acquired immediately and 1, 2, and 4 hours after meal completion. The interval to evacuate one half of the counts measured at meal completion) and retention (the percentage of counts in stomach at each measurement point) were recorded.nnnRESULTSnThe mean age and BMI was 35 years and 45 kg/m(2) in the obese and 44 years and 26 kg/m(2) in the nonobese group, respectively. No differences were found between the 2 groups regarding gastric emptying. Regression analysis showed no statistical association between the BMI and gastric emptying, including multivariate analysis, considering BMI, age, and gender.nnnCONCLUSIONnA scintigraphy test of a labeled meal was used to evaluate gastric emptying in obese and nonobese subjects. In accordance with other published data, no significant difference was found between the 2 groups. The anesthetic risks in the obese should be attributed to factors other than delayed gastric emptying (i.e., anatomic variation, increased rates of hiatal hernia and reflux).

Laparoscopic Sleeve Gastrectomy Using 42-French Versus 32-French Bougie: The First-Year Outcome

BackgroundThe optimal size of bougie in laparoscopic sleeve gastrectomy (LSG) remains controversial. The aim of this study was to evaluate the first-year outcome of LSG using two different sizes of bougies.MethodsThis study used a single institute retrospective case-control study of two groups of patients. Group A (Nu2009=u200966) underwent LSG using 42-Fr and group B (Nu2009=u200954) using 32-Fr bougies. A medication score was applied to assess the change in comorbid conditions.ResultsGroups A and Bs age (39.5u2009±u200912 vs. 43.6u2009±u200912.3xa0years), weight (119u2009±u200917 vs. 120u2009±u200920), and BMI (42.8u2009±u20093.8 vs. 43.6u2009±u20096.9xa0kg/m2), respectively, were comparable (pu2009=u2009NS). Comorbid conditions were type 2 diabetes (T2DM) in 19 (29xa0%) vs. 23 (43xa0%) patients, hypertension in 22 (33xa0%) vs. 18 (33xa0%) patients, and gastroesophageal reflux (GERD) in 28 (42xa0%) vs. 10 (19xa0%) patients, respectively. At 1xa0year, group A vs. B BMI was (29.4u2009±u20095 vs. 30u2009±u20095xa0kg/m2) and excess weight loss was 67 vs. 65xa0%, respectively (pu2009=u2009NS). Postoperatively, T2DM (79 vs. 83xa0%), hypertension (82 vs. 61xa0%), and GERD (82 vs. 60xa0%) (pu2009=u2009NS), respectively, in groups A vs. B did not require previous medications anymore. Complications were comparable.ConclusionsOur data suggest that using a 42-Fr or 32-Fr bougie does not influence LSG first-year weight loss or resolution of comorbid conditions. Long-term data is needed to conclude this issue.

THE EFFECTS OF DIETARY PHOSPHOLIPIDS ENRICHED WITH PHOSPHATIDYLETHANOLAMINE ON BILE AND RED CELL MEMBRANE LIPIDS IN HUMANS

The role of phospholipids in biliary cholesterol solubilization and crystallization has only recently begun to be appreciated. Phospholipid vesicles are believed to be the metastable carrier from which cholesterol nucleates. Cholesterol crystallization is influenced by the phospholipid species in bile. Feeding rats and hamsters with diets enriched in phospholipids or their precursors, especially ethanolamine, resulted in reduced cholesterol saturation of bile. Although whole phospholipids are normal dietary constituents, the effects and safety of phospholipid components have not been tested in humans. In the present study, we have evaluated the effects of a dietary phospholipid mixture, enriched with phosphatidylethanolamine, on human bile and red blood cell membrane lipid composition. Five ambulatory volunteers having a chronic indwelling T-tube, with an intact enterohepatic circulation, were investigated. Thirty-six grams of phospholipids (54% phosphatidylethanolamine, 54% linoleyl acyl chains) were added to their daily diet for fourteen days. Biliary nucleation time, cholesterol carriers, as well as plasma, red blood cell membrane, and bile lipid compositions, were monitored. Following phospholipid supplementation, the proportion of linoleyl chains (18:2) in biliary phospholipids increased significantly from 31.1±1.2 to 37.7±5.3%, while that of oleyl chains (18:1) decreased from 11.4±1.6 to 9.6±1.1%. These changes were accompanied by an increase of linoleate and its metabolite, arachidonate, in red cell membranes. Phospholipid feeding did not cause any side effects, and no significant changes in biliary nucleation time, cholesterol, phospholipid, or bile salt concentrations, or in the distribution of cholesterol within micelles or vesicles. We conclude that phospholipid feeding is safe, and can be effective as a vehicle for lecithin fatty acyl chain modulation of bile and lipid membranes. These findings may provide a basis for a controlled modulation of biliary phospholipids to increase cholesterol solubility in bile.

Postoperative Swallow Study as a Predictor of Intermediate Weight Loss after Sleeve Gastrectomy

BackgroundLaparoscopic sleeve gastrectomy (LSG) is an accepted bariatric procedure. Swallow studies (SS) after LSG are not uniform and display different patterns with regard to contrast passage through the gastric sleeve. The impact of immediate postoperative contrast transit time on weight loss has not been studied. The influence of immediate fluid tolerance on weight loss after LSG is herein reported.MethodsNinety-nine patients after LSG were included. There were 67 females, mean age 41 (range 17–67), mean BMI 44.4 (range 37–75). A routine SS was performed on postoperative day (POD) 1. Pattern of contrast transit was noted. Patients were followed-up in our bariatric clinic.ResultsPercent excess weight loss was significantly lower in the patients with rapid contrast passage (Group 1, nu2009=u200950) than those with delayed passage (Group 2, nu2009=u200949). Group 1 achieved 62, 58, and 53xa0% at 1, 2, and 3xa0years, respectively, while Group 2 attained 69, 74, and 75xa0% at the same time points (pu2009=u20090.05, 0.001, and 0.04, respectively). Group 1 patients displayed a negative weight loss trend after 1xa0year whereas Group 2 patients plateaued after 2xa0years.ConclusionsTolerance of fluid intake after LSG is crucial for patient recovery and discharge. Distinct radiologic appearance on POD 1 helps predict this behavior. Mid-term weight loss after LSG appears to be dependent on immediate postoperative contrast transit time, whereas patients with slow contrast passage tend to lose more weight. Long-term follow-up will reveal whether this finding will hold true.

Gastric Wall Thickness and the Choice of Linear Staples in Laparoscopic Sleeve Gastrectomy: Challenging Conventional Concepts

BackgroundLittle evidence is available on the choice of linear staple reloads in laparoscopic sleeve gastrectomy (LSG). Previous literature recommends matching closed staple height (CSH) to tissue-thickness (TT) to avoid ischemia. Our objective was to examine feasibility and safety of “tight” hemostatic (CSH/TT <1) stapling and map the entire gastric wall TT in LSG patients.MethodsProspectively collected outcomes on 202 consecutive patients who underwent LSG with tight order of staples (Ethicon Endosurgery) in this order: pre-pylorus—black (CSHxa0=xa02.3xa0mm), antrum—green (CSHxa0=xa02.0xa0mm), antrum/body—blue (CSHxa0=xa01.5xa0mm), and white (CSHxa0=xa01.0xa0mm) on the body and fundus. Measurements of entire gastric wall TT were made on the first 100 patients’ gastric specimens with an electronic-dogmatic indicator.ResultsStudy included 147 females and 55 males with a mean age of 41.5xa0±xa011.9xa0years and body mass index of 41.5xa0±xa03.8xa0kg/m2. Gastric wall measurements revealed mean CSH/TT ratio <1, decreasing from 0.7xa0±xa00.1 at pre-pylorus to 0.5xa0±xa00.1 at the fundus. There were 3.1% mechanical failures, mainly (68%) at pre-pylorus—black reloads. Post-operative bleeding occurred in 5 (2.5%) patients. There were no leaks or clinical evidence of sleeve ischemia. Stepwise regression analysis revealed that body mass index (Pxa0<xa00.001), hypertension (Pxa0<xa00.01), and male gender (Pxa0<xa00.001) were associated with increased gastric TT.ConclusionsOur study suggests that reloads with CSH/TT <1 in LSG including staples with CSH of 1xa0mm on body and fundus are safe. The results challenge the concept that tight stapling cause’s ischemia. Since tight reloads are designed to improve hemostasis, their application could have clinical benefit.