Nestor de la Cruz-Muñoz

Closure of mesenteric defect can lead to decrease in internal hernias after Roux-en-Y gastric bypass

BACKGROUND Although most surgeons believe that internal hernia (IH) defects should be closed, no general consensus has yet been reached. The published studies have reported conflicting obstruction incidence estimates and variations in location. Some have also argued that closed hernia sites recur. METHODS A retrospective review of 2079 Roux-en-Y gastric bypass procedures performed by 1 surgeon from 2001 to 2009 was conducted. Chi-square analysis compared those performed from 2001 to August 2003 (group 1) with those from September 2003 to 2009 (group 2) for the incidence of IH. Since September 2003, the jejunojejunal anastomotic mesenteric defect has been closed with a running, permanent suture. In contrast, before September 2003, the defect was not closed. RESULTS A total of 37 patients presented with symptomatic IH from 2001 to 2009. A significant difference was found in the proportion of those patients who experienced IH in group 1 (n = 36) compared with those who did so in group 2 (n = 1; P <.001). Group 1 developed 35 IHs (10%) at the jejunojejunal anastomotic mesenteric defect and 6 (1.7%) at Petersens defect. The median interval to presentation was 20 months (range 5-34). Of the 35 patients, 5 (1.4%) presented acutely with pain or bowel obstruction. Group 2 developed no IHs at the mesenteric defect (0%) and 1 at Petersens defect (.1%). The interval to presentation was 9 months. CONCLUSION The incidence of IH after laparoscopic Roux-en-Y gastric bypass can be reduced with closure of mesenteric defects. IHs can present either acutely with pain and obstructive symptoms or chronically with vague, intermittent postprandial pain.

Changes in weight and co-morbidities among adolescents undergoing bariatric surgery: 1-year results from the Bariatric Outcomes Longitudinal Database.

BACKGROUND Bariatric surgery is 1 of the few effective treatments of morbid obesity. However, the weight loss and other health-related outcomes for this procedure in large, diverse adolescent patient populations have not been well characterized. Our objective was to analyze the prospective Bariatric Outcomes Longitudinal Database (BOLD) to determine the weight loss and health related outcomes in adolescents. The BOLD data are collected from 423 surgeons at 360 facilities in the United States. METHODS The main outcome measures included the anthropometric and co-morbidity status at baseline (n = 890) and at 3 (n = 786), 6 (n = 541), and 12 (n = 259) months after surgery. Adolescents (75% female; 68% non-Hispanic white, 14% Hispanic, 11% non-Hispanic black, and 6% other) aged 11 to 19 years were included in the present analyses. RESULTS The overall 1-year mean weight loss for those who underwent gastric bypass surgery was more than twice that of those who underwent adjustable gastric band surgery (48.6 versus 20 kg, P < .001). Similar results were found for all other anthropometric changes and comparisons within 1 year between surgery types (P < .001). In general, the gastric bypass patients reported more improvement than the adjustable gastric band patients in co-morbidities at 1 year after surgery. A total of 45 readmissions occurred among gastric bypass patients and 10 among adjustable gastric band patients, with 29 and 8 reoperations required, respectively. CONCLUSIONS The weight loss at 3, 6, and 12 months after surgery is approximately double in adolescent males and females who underwent gastric bypass surgery versus those who underwent adjustable gastric band surgery. Bariatric surgery can safely and substantially reduce weight and related co-morbidities in morbidly obese adolescents for ≥1 year.

Bariatric Surgery Significantly Decreases the Prevalence of Type 2 Diabetes Mellitus and Pre-Diabetes among Morbidly Obese Multiethnic Adults: Long-Term Results

BACKGROUND Type 2 diabetes (T2DM) and obesity are codependent epidemics that disproportionately affect ethnic minorities. Recent studies have shown that in non-Hispanic whites, bariatric surgical procedures successfully reverse or improve abnormal glucose metabolism, yet little is known about the results of bariatric surgery in Hispanic and other ethnic minority adults with T2DM. STUDY DESIGN A retrospective analysis of 1,603 adults (77% female, 66% Hispanic, mean age at surgery 45.1 years [SD 11.6 years]) who underwent bariatric surgery from 2002 to 2010 was conducted. A total of 377 subjects had diagnosed T2DM, 107 had fasting plasma glucose (FPG) ≥126 mg/dL but were not on T2DM medication, 276 were pre-diabetic (FPG = 100 to 125 mg/dL), and 843 had normal FPG. Pre-surgery and 6, 12, 24, and 36 months post-surgery comparative-means analyses of weight, body mass index, estimated weight loss, hemoglobin A1c, and FPG were conducted via repeated-measures analysis. RESULTS By 1 year and through 3 years post-surgery, all groups had normal FPG. Patients with undiagnosed diabetes had a 43% FPG decrease followed by diagnosed diabetics (33%). Patients with diagnosed diabetes showed a slightly greater loss in hemoglobin A1c (2.30%) versus undiagnosed diabetics (2.13%). Patients with pre-diabetes saw the most dramatic loss in weight (47.00 kg), followed by patients with undiagnosed diabetes (46.62 kg), normal FPG (43.14 kg), and patients with diagnosed diabetes (41.39 kg) (p < 0.0001 for all up to 24 months). CONCLUSIONS Bariatric surgery results in significant long-term weight loss and improvement in FPG levels among ethnically diverse adults. Bariatric surgery has the potential to be an effective treatment option for weight loss and chronic disease risk improvements in this demographic.

Four-year weight outcomes of laparoscopic gastric bypass surgery and adjustable gastric banding among multiethnic adolescents

BACKGROUND Extreme obesity among U.S. adolescents is a serious problem and has disproportionally affected ethnic minorities. Recently, surgical intervention for morbid obesity in adolescents has gained increasing support. Little information is available on the long-term effectiveness of bariatric surgery among ethnic minority adolescents. We have reported the weight and body mass index (BMI) results for a large cohort of predominantly Hispanic adolescents who underwent bariatric surgery in a private practice setting. METHODS A retrospective medical chart analysis of 78 adolescents (77% Hispanic, 19% non-Hispanic white, 1% non-Hispanic black, and 3% other; 77% female; 16-19 years old), who had undergone gastric bypass or banding surgery from 2002 to 2009, was conducted. All patients had met the National Institutes of Health criteria for bariatric surgery. Repeated measures mixed linear modeling was used to assess the changes in weight/BMI from baseline to 4 years after surgery. RESULTS Non-Hispanic whites had lost 104.81 lb and 17.29 BMI units at 1 year after surgery (P <.001 for both). Hispanics had lost 91.55 lb and 15.06 BMI units at 1 year after surgery (P <.001 for both). The non-Hispanic whites had lost 18.56 BMI units and Hispanics 16.15 units during the 4 year postoperative period. A weight loss plateau occurred at 12 months for the non-Hispanic whites and at 18 months for the Hispanics; both groups had maintained their weight loss at 4 years after surgery. CONCLUSION Bariatric surgery resulted in significant weight loss that was maintained at 4 years postoperatively among obese ethnic minority adolescents. Our results have shown that bariatric surgery is a safe and effective treatment option for permanent weight improvements in this demographic.

Randomized sham-controlled trial evaluating efficacy and safety of endoscopic gastric plication for primary obesity: The ESSENTIAL trial

Evaluate safety and efficacy of the pose™ procedure for obesity treatment.

Leptin deficiency-induced obesity affects the density of mast cells in abdominal fat depots and lymph nodes in mice

BackgroundMast cells are implicated in the pathogenesis of obesity and insulin resistance. Here, we explored the effects of leptin deficiency-induced obesity on the density of mast cells in metabolic (abdominal fat depots, skeletal muscle, and liver) and lymphatic (abdominal lymph nodes, spleen, and thymus) organs. Fourteen-week-old male leptin-deficient ob/ob mice and their controls fed a standard chow were studied. Tissue sections were stained with toluidine blue to determine the density of mast cells. CD117/c-kit protein expression analysis was also carried out. Furthermore, mast cells containing immunoreactive tumor necrosis factor-α (TNF-α), a proinflammatory cytokine involved in obesity-linked insulin resistance, were identified by immunostaining.Resultsob/ob mice demonstrated adiposity and insulin resistance. In abdominal fat depots, mast cells were distributed differentially. While most prevalent in subcutaneous fat in controls, mast cells were most abundant in epididymal fat in ob/ob mice. Leptin deficiency-induced obesity was accompanied by a 20-fold increase in the density of mast cells in epididymal fat, but a 13-fold decrease in subcutaneous fat. This finding was confirmed by CD117/c-kit protein expression analysis. Furthermore, we found that a subset of mast cells in epididymal and subcutaneous fat were immunoreactive for TNF-α. The proportion of mast cells immunoreactive for TNF-α was higher in epididymal than in subcutaneous fat in both ob/ob and control mice. Mast cells were also distributed differentially in retroperitoneal, mesenteric, and inguinal lymph nodes. In both ob/ob mice and lean controls, mast cells were more prevalent in retroperitoneal than in mesenteric and inguinal lymph nodes. Leptin deficiency-induced obesity was accompanied by increased mast cell density in all lymph node stations examined. No significant difference in the density of mast cells in skeletal muscle, liver, spleen, and thymus was noted between ob/ob and control mice.ConclusionsThis study demonstrates that leptin deficiency-induced obesity is accompanied by alterations in the density of mast cells in abdominal fat depots. The divergent distribution of mast cells in subcutaneous versus visceral fat might partially account for their differential biological behavior. Mast cells might also play a role in adaptive immune response occurring in regional lymph nodes in obesity.

Cardiometabolic health among gastric bypass surgery patients with polycystic ovarian syndrome

AIM To examine the effect of gastric bypass surgery on cardiometabolic health among women with polycystic ovarian syndrome (PCOS). METHODS Retrospective medical chart review identified women (n = 389) with PCOS who underwent Roux-en-Y gastric bypass surgery from 2001-2009 in one surgical practice. Separate repeated measures linear mixed models were fit using the MIXED procedure to assess mean change in cardiometabolic disease risk factors from before to 1-year after surgery and were evaluated by ethnicity [Hispanic, non-Hispanic black (NHB) and white (NHW)]. RESULTS The majority of the sample was Hispanic (66%, 25% NHB, 9% NHW). Mean body mass index significantly improved 1 year post-surgery for all ethnic groups (45.5 to 35.5 kg/m(2) for Hispanics, 46.8 to 37.7 kg/m(2) for NHB and 45.7 to 36.7 kg/m(2) for NHW, P < 0.001). Among Hispanic women mean total cholesterol (198.1 to 160.2 mg/dL), low-density lipoproteins (LDL) cholesterol (120.9 to 91.0 mg/dL), triglycerides (148.6 to 104.8 mg/dL), hemoglobin A1c (6.2% to 5.6%), alanine aminotransferase (28.1 to 23.0 U/L) and aspartate aminotransferase (23.5 to 21.6 U/L) decreased significantly (P < 0.001). Among NHB, mean total cholesterol (184.5 to 154.7 mg/dL), LDL cholesterol (111.7 to 88.9 mg/dL) and triglycerides (99.7 to 70.0 mg/dL) decreased significantly (P < 0.05). Among NHW, mean total cholesterol (200.9 to 172.8 mg/dL) and LDL cholesterol (124.2 to 96.6 mg/dL), decreased significantly (P < 0.05). Pairwise ethnic group comparisons of all cardiometabolic outcomes adjusted for age and type of surgery before and 1 year after surgery showed no statistical difference between the three groups for any outcome. CONCLUSION Cardiometabolic disease risk improvements vary by ethnicity and obesity may impact glucose tolerance and liver function changes more in Hispanic women with PCOS vs non-Hispanic women.

Review of family-based approaches to improve postoperative outcomes among bariatric surgery patients

BACKGROUND Bariatric surgery must be partnered with postoperative lifestyle modifications for enduring weight loss and related health effects to be fully appreciated. Little is known about how these lifestyle modifications may be affected by the involvement of other family members living in the household; therefore, this review describes current family-based approaches to improving postoperative outcomes in bariatric surgery patients and their families. METHODS A MEDLINE search of publications from 1999 to 2014 was conducted in January 2014. Retrieved titles and abstracts were assessed by 2 authors to determine relevance to the topic surrounding family-based approaches to improve postbariatric surgery outcomes. All study designs except case studies were considered if they included some aspect of family as a predictor in relation to improved health outcomes after surgery. RESULTS Initial searches yielded 650 publications (bariatric surgery+family, n = 193; bariatric surgery+child, n = 338; bariatric surgery+spouse, n = 4; bariatric surgery+social support, n = 115). Two studies met criteria for a family-based approach to improving metabolic outcomes in bariatric patients. Seven studies discussed the impact of bariatric surgery on families. All other studies were excluded for not discussing family-based approaches. CONCLUSION Despite limited documentation of family-based approaches on improving health outcomes in patients who underwent bariatric surgery, evidence suggests that such an approach may be advantageous if planned a priori to occur before, during, and after bariatric surgery. Future studies could test the combination of bariatric surgery and a family-based approach for improved metabolic outcomes in both the patient and involved family member(s).

Laparoscopic pancreatoduodenectomy after laparoscopic gastric bypass

Laparoscopic pancreatoduodenectomy (LPD) was first reported in 1994. LPD has not been widely accepted [1], with only 146 cases reported as of 2008, owing to the technical difficulty in performing the procedure [2]. However, LPD can be done safely and with acceptable complication rates [2–4]. This is the first case reported of a patient who had undergone laparoscopic Roux-en-Y gastric bypass (RYGB), with the procedure subsequently converted LPD.

Postoperative marijuana use and disordered eating among bariatric surgery patients

BACKGROUND Current literature is scarce in documenting marijuana use after bariatric weight loss surgery (WLS). OBJECTIVES The objective of this study was to explore the association among marijuana use patterns, disordered eating, and food addiction behaviors in patients 2 years after WLS. SETTING A university hospital in the United States. METHODS Participants (N = 50, mean age 28 y, standard deviation = 5.8) were administered a structured assessment that included the Addiction Severity Index, Yale Food Addiction Scale, Eating Disorder Examination Questionnaire, and Disordered Eating Questionnaire. Marijuana use was defined based on the Addiction Severity Index as current use (within 30 d), recent use (use in last year), and increased use (increased use since surgery). Data were analyzed using Fishers exact tests and linear regression methods adjusting for age, gender, race/ethnicity, time since surgery, and change in body mass index. RESULTS The majority of the sample was female (76%) and underwent Roux-en-Y gastric bypass (62%). Eighteen percent (18%) of the sample reported current marijuana use; 38% reported recent use; and 21.4% reported increased use post-WLS. A loss of controlled food intake was associated with current (P = .02) and increased post-WLS use (P = .01). Increased use and/or regular marijuana use predicted higher scores on eating disorder subscales compared with respective counterparts (P<.05). Current use did not significantly predict higher scores on the Yale Food Addiction Scale. CONCLUSIONS Findings indicated marijuana use in post-WLS patients despite recommendations against use. A subgroup of WLS patients may be at risk for disordered eating post-WLS, particularly those who used marijuana before surgery, and should be closely monitored for several years post-WLS.