Saravana Kumar

The effect of surgically induced weight loss on nonalcoholic fatty liver disease in morbidly obese Indians: “NASHOST” prospective observational trial

BACKGROUND Surgically induced weight loss improves nonalcoholic fatty liver disease (NAFLD) in morbidly obese Caucasian patients. Similar data are lacking from India. OBJECTIVE To compare the histologic features of NAFLD in morbidly obese Indian patients before and 6 months after bariatric surgery. Histologic changes were also separately assessed according to the type of bariatric intervention. SETTING Teaching institution, India; private practice. METHODS All patients undergoing bariatric surgery from July 2012 to July 2013 underwent a routine liver biopsy at the time of bariatric surgery. If the biopsy specimen indicated NAFLD, patients were asked to undergo a second biopsy after 6 months. Baseline anthropometry, clinical data, biochemistry, and pathology were recorded and repeated at follow-up. RESULTS Eighty-eight of 134 index biopsy specimens indicated NAFLD. Thirty patients had paired liver biopsies. Steatosis was present in all, 14 had lobular inflammation, 10 had ballooning degeneration, and 14 had fibrosis. Mean time between the biopsies was 7.1 months (range 6-8 months). At the second biopsy, steatosis had resolution in 19 and improvement in 11, lobular inflammation had resolution in 12 and improvement in 2, ballooning had resolution in 9 and improvement in 1 and fibrosis had resolution in 11 and improvement in 3 (P<0.05 for all). Improvement was greater among those who underwent a sleeve gastrectomy in comparison to a Roux-en-Y gastric bypass, although this difference was not statistically significant. None had worsening of liver histologic results. CONCLUSIONS Surgically induced weight loss significantly and rapidly improves liver histology in morbidly obese Indians with NAFLD.

Comparison of weight loss outcomes 1 year after sleeve gastrectomy and Roux-en-Y gastric bypass in patients aged above 50 years

Introduction: Safe, effective weight loss with resolution of comorbidities has been convincingly demonstrated with bariatric surgery in the aged obese. They, however, lose less weight than younger individuals. It is not known if degree of weight loss is influenced by the choice of bariatric procedure. The aim of this study was to compare the degree of weight loss between laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in patients above the age of 50 years at 1 year after surgery. Materials and Methods: A retrospective analysis was performed of all patients more than 50 years of age who underwent LSG or LRYGB between February 2012 and July 2013 with at least 1 year of follow-up. Data evaluated at 1 year included age, sex, weight, body mass index (BMI), mean operative time, percentage of weight loss and excess weight loss, resolution/remission of diabetes, morbidity and mortality. Results: Of a total of 86 patients, 54 underwent LSG and 32 underwent LRYGB. The mean percentage of excess weight loss at the end of 1 year was 60.19 ± 17.45 % after LSG and 82.76 ± 34.26 % after LRYGB (P = 0.021). One patient developed a sleeve leak after LSG, and 2 developed iron deficiency anaemia after LRYGB. The remission/improvement in diabetes mellitus and biochemistry was similar. Conclusion: LRYGB may offer better results than LSG in terms of weight loss in patients over 50 years of age.

Role of routine pre-operative screening venous duplex ultrasound in morbidly obese patients undergoing bariatric surgery

Background/Aims: It is well established that obesity is a strongly associated risk factor for post-operative deep vein thrombosis (DVT). Physical effects and pro-thrombotic, pro-inflammatory and hypofibrinolytic effects of severe obesity may predispose to idiopathic DVT (pre-operatively) because of which bariatric patients are routinely screened before surgery. The aim of this study was to audit the use of routine screening venous duplex ultrasound in morbidly obese patients before undergoing bariatric surgery. Methods: We retrospectively reviewed 180 patients who underwent bariatric surgery from August 2013 to August 2014 who had undergone pre-operative screening bilateral lower-extremity venous duplex ultrasound for DVT. Data were collected on patients demographics, history of venous thromboembolism, prior surgeries and duplex ultrasound details of the status of the deep veins and superficial veins of the lower limbs. Results: No patients had symptoms or signs of DVT pre-operatively. No patient gave history of DVT. No patient was found to have iliac, femoral or popliteal vein thrombosis. Superficial venous disease was found in 17 (8%). One patient had a right lower limb venous ulcer. Conclusion: Thromboembolic problems in the morbidly obese before bariatric surgery are infrequent, and screening venous duplex ultrasound can be done in high-risk patients only.

Evolution and Standardisation of Techniques in Single-Incision Laparoscopic Bariatric Surgery

Bariatric surgery has proven benefits for morbid obesity and its associated comorbidities. Laparoscopic approach is well established for bariatric surgery. Single-incision laparoscopic surgery (SILS) offers even more minimally invasive approach for the same with the added advantage of better cosmesis. We have developed and standardised the SILS approach at our institute. We share our experience and technical “tips” and modifications which we have learnt over the years. Technical details of performing sleeve gastrectomy and Roux-en-Y gastric bypass with special attention to liver retraction, techniques of dissection in difficult areas, creation of anastomoses and suturing have all been described. In our experience and in experience of others, single-incision bariatric surgery is feasible. Use of conventional laparoscopic instruments makes single-incision approach practical for day-to-day practice. Supervised training is essential to learn these techniques.

Preoperative Predictors of Diabetes Remission Following Bariatric Surgery

Obesity is one of the greatest public health problems today with more than 400 million adults as being obese [1]. The worldwide prevalence of type 2 diabetes mellitus (T2DM) is also rising alongside obesity with more than 300 million people suffering from T2DM of which more than 60 % of patients with T2DM are obese [3]. This has been commonly referred as ‘diabesity’. Hence the prevention and treatment of diabesity is an important public health priority.

Preoperative Evaluation and Contraindications to Bariatric Surgery

Bariatric surgery is the most effective treatment option for the morbidly obese patients who fail weight loss by lifestyle interventions [1]. In addition to weight loss, it results in resolution or improvement of obesity associated co-morbidities of diabetes, hypertension, dyslipidemia, obstructive sleep apnea, gastro-esophageal reflux etc. Improvement in long-term survival and overall quality of life has been demonstrated in several studies. It has been shown that morbidly obese patients are high risk candidates for any surgical intervention [2, 3]. They can have several potential perioperative and long term complications after surgical intervention. Hence any patient who needs to be subjected to bariatric surgery should be thoroughly evaluated and accordingly optimized prior to surgery.

Concomitant intraperitoneal onlay mesh repair with endoscopic component separation and sleeve gastrectomy.

Bariatric surgery can be safely combined with laparoscopic intraperitoneal onlay mesh (IPOM) repair. In case of large ventral hernias, laparoendoscopic component separation can also be combined to achieve tension-free closure of the defect. Concomitant bariatric surgery and hernia repair also offer the additional benefit of reduction in recurrence of hernias as obesity, one of the risk factors, is treated in the process. We present a case of 60-year-old man with a body mass index of 45.3 kg/m2 with a large recurrent ventral hernia. We performed a lap sleeve gastrectomy with laparoendoscopic anterior component separation with IPOM. The operative steps included hernia contents reduction, conventional sleeve gastrectomy, anterior component separation on either side, intra-corporeal closure of hernia defect and placement of a composite mesh. Patient recovery was uneventful. Concomitant bariatric surgery with laparoendoscopic component separation with IPOM may be safe, but more studies are required.

Non-alcoholic steatohepatitis (NASH) and metabolic surgery in Asia

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide, as well as, in Asia. The incidence of NAFLD has been reported to range from 65% to 95% in patients undergoing bariatric surgery. Spectrum of NAFLD ranges from simple steatosis to non-alcoholic steatohepatitis (NASH) to fibrosis and cirrhosis. Liver biopsy is the gold standard for diagnosis of NAFLD. Other investigations including imaging of abdomen and liver function tests (LFTs) are not diagnostic per se but play a role in management. Treatment strategies include lifestyle modifications, pharmacotherapy and bariatric surgery. Bariatric surgery has shown promising results worldwide as well as in Asian patients. Asian literature shows that there is significant improvement in NAFLD after both restrictive and mal-absorptive procedures. Reversal of all features of NAFLD, NASH and fibrosis are reported after bariatric surgery. In conclusion, improvement of obesity associated NAFLD after bariatric surgery is well documented. Both restrictive as well as malabsorptive procedures are effective but NAFLD per se is not an indication for surgery.

Primary epiploic appendagitis: Laparoscopic diagnosis and treatment

Sir, The diagnosis of primary epiploic appendagitis was rarely made preoperatively, but nowadays, with improved imaging, this is possible in many cases. We read with interest the article “Primary epiploic appendagitis: Reconciling CT and clinical challenges” published in your Journal [1]. The authors describe 15 cases of primary epiploic appendagitis which were diagnosed on CT scan, treated conservatively and advised for follow up. Only 10 patients completed the advised follow up schedule of a CT scan at 2 weeks, 3 months and 6 months to look for resolution. Complete resolution was noted in three patients at 2 weeks, in six patients at 3 months and in one patient at 6 months. We at our institution treat epiploic appendagitis surgically by the laparoscopic method. The optimum treatment for this condition is still a matter of controversy. Most authors state that if diagnosed preoperatively, it should be managed conservatively with antibiotics and analgesics. We wish to point out several issues in clinical practice with this approach. This condition is relatively rare with a possibility of misdiagnosis especially if there is significant colonic wall thickening on imaging in spite of its characteristic imaging features. Symptoms resolve slowly in 7–10 days with imaging resolution taking even up to 6 months as was also noted in this study. The latter adds to diagnostic confusion and makes it necessary that the patient be subjected to the anxiety and expense of several follow up imagings lest a more alarming diagnosis is missed out. Many patients are lost to follow up. On the other hand, laparoscopic diagnosis and treatment offers an excellent option. It confirms the diagnosis without the morbidity of open surgery and allows for surgical removal with subsequent rapid recovery. Histopathological confirmation is made, and there is no need for follow up. Laparoscopy should be strongly considered as a primary treatment option for primary epiploic appendagitis.

Prevention of migration of endotracheal tubes used for aided nasogastric tube placement in anaesthetized patients.

Sir, During bariatric surgery procedures, the anaesthesiologists help facilitate proper placement of nasogastric tubes (NGTs) and bougies to size the gastric pouch. They help perform leak tests with saline, methylene blue or air to ensure staple-line or anastomotic integrity. They ensure complete removal of all gastric tubes before gastric division to avoid unplanned stapling and transection of these tubes. After the surgery is performed, they re-insert the NGT tube under vision watching the monitor carefully while the tube is advanced to avoid disruption of the anastomosis. NGT insertion in an anaesthetised patient is however a very cumbersome procedure for the anaesthesiologist with the need to burrow under sterile drapes to approach the oral cavity and the need to use a laryngoscope and Magills forceps to advance the tube 1–2 cms at a time to avoid coiling in the oropharynx because of the flexibility and slippery nature of a lubricated NGT through the compromised lumen of the oesophagus secondary to the inflated endotracheal bulb.[1] Several techniques to simplify this procedure have been recommended in the literature.[2,3,4,5,6,7] Of these a quick and easy way often adopted intra-operatively by many anaesthesiologists is to pass a paediatric endotracheal tube (ETT) nasally and a NGT is passed down this tube directly to the oesophagus without coiling or trauma.[2,3,4] The ETT can be then be removed from around the NGT without displacement of the tube. Correct position of NGT is confirmed by injection of air and auscultation over the epigastrium, aspiration of gastric contents or direct visualisation/palpation at surgery. An ETT is preferred over a nasopharyngeal airway as guide for NGT insertion because of its length. We would like to share our experience of a possible undesired event associated with this manoeuvre to create awareness and for adoption of necessary precautions. We recently encountered three patients undergoing bariatric procedures for treatment of their morbid obesity spread over three different centres that were complicated by intra-operative migration of the guiding nasal ETT into the oesophagus after dislodgement of the tube from its connector by this manoeuvre [Figure ​[Figure1a1a and ​andb].b]. In all three cases unaware of tube dislodgment (as the connector was the only visible portion), the NGT was threaded pushing the tube further downwards. In all three cases, the tube could not be readily accessed for removal through the mouth and were managed by endoscopic retrieval in two and retrieval through a gastrostomy in one [Figure ​[Figure2a2a and ​andbb]. Figure 1 (a) Endoscopic image of the proximal end of migrated nasal endotracheal tube in the oesophagus after displacement of the tube connector, (b) Endoscopic image of the body of the migrated nasal endotracheal tube in the oesophagus after displacement of the ... Figure 2 (a) Endoscopic image of the visualization and grasping of the migrated nasal endotracheal tube in the oesophagus, (b) Endoscopic image of the retrieval of the migrated nasal endotracheal tube from the oesophagus Portex® ETT connectors easily get separated from the tube if attached shallowly resulting in dislodgement of the tube. The simplest precaution to prevent dislodgement is to encircle a 1-cm wide tape at the proximal end of tube and secure it to the connector or use a one-size larger tracheal tube connector, which can be easily and snugly fit into the proximal end of the tube.[8] Furthermore, the Portex® ETTs used should be larger than the NGT as a snugly fitting NGT can easily carry the ETT also with it. Precautionary measures should always be implemented to avoid this unnecessary intra-operative complication.