Samer G. Mattar

Effect of Laparoscopic Roux-En Y Gastric Bypass on Type 2 Diabetes Mellitus

Objective: To evaluate pre- and postoperative clinical parameters associated with improvement of diabetes up to 4 years after laparoscopic Roux-en-Y gastric bypass (LRYGBP) in patients with type 2 diabetes mellitus (T2DM). Summary Background Data: The surgical treatment of morbid obesity leads to dramatic improvement in the comorbidity status of most patients with T2DM. However, little is known concerning what preoperative clinical factors are associated with postoperative long-term improvement in diabetes in the morbidly obese patient with diabetes. Methods: We evaluated pre- and postoperative data, including demographics, duration of diabetes, metabolic parameters, and clinical outcomes, in all patients with impaired fasting glucose (IFG) and type T2DM undergoing LRYGBP from July 1997 to May 2002. Results: During this 5-year period, 1160 patients underwent LRYGBP and 240 (21%) had IFG or T2DM. Follow up was possible in 191 of 240 patients (80%). There were 144 females (75%) with a mean preoperative age of 48 years (range, 26–67 years). After surgery, weight and body mass index decreased from 308 lbs and 50.1 kg/m2 to 211 lbs and 34 kg/m2 for a mean weight loss of 97 lbs and mean excess weight loss of 60%. Fasting plasma glucose and glycosylated hemoglobin concentrations returned to normal levels (83%) or markedly improved (17%) in all patients. A significant reduction in use of oral antidiabetic agents (80%) and insulin (79%) followed surgical treatment. Patients with the shortest duration (<5 years), the mildest form of T2DM (diet controlled), and the greatest weight loss after surgery were most likely to achieve complete resolution of T2DM. Conclusion: LRYGBP resulted in significant weight loss (60% percent of excess body weight loss) and resolution (83%) of T2DM. Patients with the shortest duration and mildest form of T2DM had a higher rate of T2DM resolution after surgery, suggesting that early surgical intervention is warranted to increase the likelihood of rendering patients euglycemic.

Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity

BackgroundThe surgical treatment of obesity in the high-risk, high-body-mass-index (BMI) (>60) patient remains a challenge. Major morbidity and mortality in these patients can approach 38% and 6%, respectively. In an effort to achieve more favorable outcomes, we have employed a two-stage approach to such high-risk patients. This study evaluates our initial outcomes with this technique.MethodsIn this study, patients underwent laparoscopic sleeve gastrectomy (LSG) as a first stage during the period January 2002–February 2004. After achieving significant weight loss and reduction in co-morbidities, these patients then proceeded with the second stage, laparoscopic Roux-en-Y gastric bypass (LRYGBP).ResultsDuring this time, 126 patients underwent LSG (53% female). The mean age was 49.5 ± 0.9 years, and the mean BMI was 65.3 ± 0.8 (range 45–91). Operative risk assessment determined that 42% were American Society of Anesthesiologists physical status score (ASA) III and 52% were ASA IV. The mean number of co-morbid conditions per patient was 9.3 ± 0.3 with a median of 10 (range 3–17). There was one distant mortality and the incidence of major complications was 13%. Mean excess weight after LSG at 1 year was 46%. Thirty-six patients with a mean BMI of 49.1 ± 1.3 (excess weight loss, EWL, 38%) had the second-stage LRYGBP. The mean number of co-morbidities in this group was 6.4 ± 0.1 (reduced from 9). The ASA class of the majority of patients had been downstaged at the time of LRYGB. The mean time interval between the first and second stages was 12.6 ± 0.8 months. The mean and median hospital stays were 3 ± 1.7 and 2.5 (range 2–7) days, respectively. There were no deaths, and the incidence of major complications was 8%.ConclusionThe staging concept of LSG followed by LRYGBP is a safe and effective surgical approach for high-risk patients seeking bariatric surgery.

The Chronic Inflammatory Hypothesis for the Morbidity Associated with Morbid Obesity: Implications and Effects of Weight Loss

Background: Obesity is a worldwide pandemic that causes a multitude of co-morbid conditions.However, there has been slow progress in understanding the basic pathophysiology that underlies co-morbid conditions associated with obesity. Recently, there has been intense interest in the role of inflammation in obesity. Using the inflammatory hypothesis, many of the mechanisms by which co-morbid conditions are associated with obesity are being elucidated. Methods: We searched the literature and reviewed all relevant articles. We focused on hormones and cytokines that have been associated with other inflammatory conditions such as sepsis and systemic inflammatory response syndrome. Findings: Angiotensinogen (AGT), transforming growth factor beta (TGFβ), tumor necrosis factor alpha (TNFα), and interleukin six (IL-6) are all elevated in obesity and correlate with several markers of adipocyte mass. These mediators have detrimental effects on hypertension, diabetes, dyslipidemia, thromboembolic phenomena, infections, and cancer. Weight loss results in a reduction of inflammatory mediators and a diminution of the associated co-morbid conditions. Conclusions: The success of weight loss surgery in treating the complications associated with obesity is most probably related to the reduction of inflammatory mediators. While some aspects of bariatric physiology remain unclear, there appears to be a strong association between obesity and inflammation, thereby rendering obesity a chronic inflammatory state. A clearer understanding of the physiology of obesity will allow physicians who treat the obese to develop better strategies to promote weight loss and improve the well-being of millions of individuals.

General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors.

Objective:To assess readiness of general surgery graduate trainees entering accredited surgical subspecialty fellowships in North America. Methods:A multidomain, global assessment survey designed by the Fellowship Council research committee was electronically sent to all subspecialty program directors. Respondents spanned minimally invasive surgery, bariatric, colorectal, hepatobiliary, and thoracic specialties. There were 46 quantitative questions distributed across 5 domains and 1 or more reflective qualitative questions/domains. Results:There was a 63% response rate (n = 91/145). Of respondent program directors, 21% felt that new fellows arrived unprepared for the operating room, 38% demonstrated lack of patient ownership, 30% could not independently perform a laparoscopic cholecystectomy, and 66% were deemed unable to operate for 30 unsupervised minutes of a major procedure. With regard to laparoscopic skills, 30% could not atraumatically manipulate tissue, 26% could not recognize anatomical planes, and 56% could not suture. Furthermore, 28% of fellows were not familiar with therapeutic options and 24% were unable to recognize early signs of complications. Finally, it was felt that the majority of new fellows were unable to conceive, design, and conduct research/academic projects. Thematic clustering of qualitative data revealed deficits in domains of operative autonomy, progressive responsibility, longitudinal follow-up, and scholarly focus after general surgery education.

Surgically-induced Weight Loss Significantly Improves Nonalcoholic Fatty Liver Disease and the Metabolic Syndrome

Objective:To evaluate the effects of surgical weight loss on fatty liver disease in severely obese patients. Summary Background Data:Nonalcoholic fatty liver disease (NAFLD), a spectrum that extends to liver fibrosis and cirrhosis, is rising at an alarming rate. This increase is occurring in conjunction with the rise of severe obesity and is probably mediated in part by metabolic syndrome (MS). Surgical weight loss operations, probably by reversing MS, have been shown to result in improvement in liver histology. Methods:Patients who underwent laparoscopic surgical weight loss operations from March 1999 through August 2004, and who agreed to have an intraoperative liver biopsy followed by at least one postoperative liver biopsy, were included. Results:There were 70 patients who were eligible. All patients underwent laparoscopic operations, the majority being laparoscopic Roux-en-Y gastric bypass. The mean excess body weight loss at time of second biopsy was 59% ± 22% and the time interval between biopsies was 15 ± 9 months. There was a reduction in prevalence of metabolic syndrome, from 70% to 14% (P < 0.001), and a marked improvement in liver steatosis (from 88% to 8%), inflammation (from 23% to 2%), and fibrosis (from 31% to 13%; all P < 0.001). Inflammation and fibrosis resolved in 37% and 20% of patients, respectively, corresponding to improvement of 82% (P < 0.001) in grade and 39% (P < 0.001) in stage of liver disease. Conclusion:Surgical weight loss results in significant improvement of liver morphology in severely obese patients. These beneficial changes may be associated with a significant reduction in the prevalence of the metabolic syndrome.

The management of splenic artery aneurysms: Experience with 23 cases

BACKGROUND Splenic artery aneurysms (SAA) are rare clinical entities that carry the risk of rupture and fatal hemorrhage. They are being detected with increased frequency and often cause a clinical dilemma, particularly when small lesions occur in compromised patients. This paper relates our experience in the management of SAA over a 14-year period. PATIENTS AND METHODS We analyzed data from the medical charts and radiological images of all patients diagnosed with SAA at Emory University Hospital from December 1979 to January 1993. RESULTS A search of medical records discovered 23 patients who experienced 44 SAAs during the time period under study. Twelve patients had multiple SAAs, most of them in the distal third of the artery. Seven had SAAs > 2 cm in diameter. Modalities used to diagnose SAA included Doppler ultrasound in 9 patients, computerized tomography in 10, and arteriography in 21. Sixteen patients had portal hypertension. Splenomegaly was present in 13 of those with portal hypertension. Aneurysm excision and splenectomy were carried out emergently on 2 patients and electively on 1. Aneurysm ligation was performed on 3 patients. One patient underwent embolization of the lesion. Sixteen asymptomatic patients whose aneurysms were < 2 cm in diameter were treated expectantly for a mean period of 3 years. One patient who received active treatment died. There were no documented deaths attributable to SAA among patients treated by observation. Six patients in this group died of unrelated causes. The longest follow-up was 7 years. CONCLUSIONS We support current criteria that call for active treatment of symptomatic or enlarging SAAs, with particular emphasis on treating women anticipating pregnancy and patients undergoing orthotopic liver transplantations. For most other cases, expectant treatment is acceptable.

Long-term outcome of laparoscopic repair of paraesophageal hernia

BackgroundIt has been reported that the laparoscopic repair of paraesophageal hernias is associated with higher complication and recurrence rates than the open methods of repair.MethodsWe identified 136 consecutive patients who underwent laparoscopic repair of a paraesophageal hernia between 1993 and 1999. Patient demographics and symptom scores for regurgitation, heartburn, chest pain, and dysphagia at presentation and at last follow-up were recorded (0=none, 1=mild, 2=moderate, 3=severe). The operative records were reviewed, and early and late complications were noted. Only patients with a follow-up of 1 were included in the analysis.ResultsThe median age was 64 years, and there was a female preponderance (1.8∶1). Most patients had some medical comorbidity; the American Society of Anesthesiologists (ASA) scores were <2 in eight patients and ≥2 in 117 patients. Three laparoscopic operations were converted to open procedures. There were nine intraoperative complications, five early complications, and three related deaths (morbidity and mortality rates of 10.2% and 2.2%, respectively). Follow-up data were available for 83 patients (66%), and the mean follow-up time was 40 months (range, 12–82). The percentage of patients experiencing chest pain, dysphagia, heartburn, and regurgitation in the moderate to severe range dropped from a range of 34–47% to 5–7% (p<0.05). Three patients underwent repeat laparoscopic repair for symptomatic recurrence.ConclusionThe laparoscopic repair of paraesophageal hernias provides excellent long-term symptomatic relief in the majority of patients and has a low rate of symptomatic recurrence. The complication and death rates may be related in part to the higher incidence of comorbidities in this somewhat elderly patient population.

Laparoscopic sleeve gastrectomy for super obese patients: forty-eight percent excess weight loss after 6 to 8 years with 93% follow-up.

Objectives:In this study, we report long-term outcomes of high-risk, high-BMI (body mass index) patients who underwent laparoscopic sleeve gastrectomy (LSG). Background:Short- and medium-term data appear to support the effectiveness of LSG, but long-term data to support its durability are sparse. Methods:A prospective database was reviewed on all high-risk patients who underwent LSG as part of a staged approach for surgical treatment of severe obesity between January 2002 and February 2004. We included only patients who did not proceed to second-stage surgery (gastric bypass). Analyzed data included demographics, BMI, comorbidities, and surgical outcomes. All partial gastrectomies were performed using a 50F bougie. Results:Seventy-four patients underwent LSG, and follow-up data were available on 69 of 74 patients (93%). The mean age was 50 years (25–78) and the mean number of co-morbidities was 9.6. Perioperative mortality (<30 days) was zero, and the incidence of short- and long-term postoperative complications was 15%. The mean overall follow-up time period was 73 months (38–95). Mean excess weight loss (EWL) at 72, 84, and 96 months after LSG was 52%, 43%, and 46%, respectively, with an overall EWL of 48%. The mean BMI decreased from 66 kg/m2(43–90) to 46 kg/m2 (22–73). Seventy-seven percent of the diabetic patients showed improvement or remission of the disease. Conclusions:This study reports the longest follow-up of LSG patients thus far and supports the effectiveness, safety, and durability of laparoscopic sleeve gastrectomy as a definitive therapeutic option for severe obesity, even in high-risk, high-BMI patients.

Results of Laparoscopic Gastric Bypass in Patients with Cirrhosis

Background: The safety and efficacy of bariatric surgery in patients with cirrhosis has not been well studied. Methods: A retrospective review was conducted of patients with cirrhosis who underwent weight-loss surgery at a single institution. Results: Out of a total of 2,119 patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP), 30 patients (1.4%) with cirrhosis were identified.When compared with the entire cohort, patients with cirrhosis were significantly more prone to be heavier (BMI 53 vs 48), older in years (age 50 vs 45), more likely to be male (RR=1.3), and have a higher incidence of diabetes (70% vs 21%) and hypertension (67% vs 21%), P<0.05. The diagnosis of cirrhosis was made intra-operatively in 90% of patients. There were no perioperative deaths, conversions to laparotomy, or liver-related complications. Early complications occurred in 9 patients and included anastomotic leak (1), acute tubular necrosis (4), prolonged intubation (2), ileus (1), and blood transfusion (2). Mean length of hospital stay was 4 days (2-18). There was one late unrelated death and one patient with prolonged nausea and protein malnutrition. The average follow-up time was 16 months (1-48). For patients >12 months postoperatively (n=15), the average percent excess weight loss was 63±15%. Conclusion: Laparoscopic RYGBP in the cirrhotic patient has an acceptable complication rate and achieves satisfactory early weight loss. Patients tend to be heavier, older, male and more likely to have diabetes and hypertension. Long-term studies are necessary to examine how weight loss impacts established cirrhosis.

Medium-term follow-up confirms the safety and durability of laparoscopic ventral hernia repair with PTFE

BACKGROUND Ventral abdominal wall hernias are common lesions and may be associated with life-threatening complications. The application of laparoscopic principles to the treatment of ventral hernias has reduced recurrence rates from a range of 25% to 52% to a range of 3.4% to 9%. In this study, we review our experience and assess the clinical outcome of patients who have undergone laparoscopic repair of ventral hernias. METHODS We reviewed the outcome of 79 patients with more than 1 year of follow-up who underwent laparoscopic ventral hernia repair between March 1996 and December 2001. Patient demographics, hernia characteristics, operative parameters, and clinical outcomes were evaluated. RESULTS Of the 79 patients, 37 were males. Mean age was 55.8 years (range 28-81). Sixty-eight patients had incisional hernias, including 17 with recurrent hernias. Eleven patients had primary ventral hernias. The mean defect size was 103 cm(2) (range 4-510); incarceration was present in 22 patients (27.8%), and multiple (Swiss-cheese) defects in 20 (25.3%). Laparoscopic expanded polytetrafluoroethylene mesh repair by the modified Rives-Stoppa technique was completed in 78 (98.7%). One conversion occurred because of bowel injury. The mean operating time was 110 minutes (range 45-210) and mean hospital stay was 1.7 days (range 0-20), with 46 patients (58.2%) being discharged within 24 hours of surgery. Complications included seroma formation (3), chronic pain (3), prolonged ileus (1), hematoma formation (1), and missed bowel injury (1) for a complication rate of (11.4%). There were no deaths. After a follow-up of up to 6 years (a mean of 34 months), there were 4 recurrences (5%). CONCLUSION The laparoscopic repair of ventral hernias is safe, effective, and durable with minimal morbidity. It is particularly successful in patients with recurrent lesions. The laparoscopic approach to ventral hernia repair should be considered the standard of care.