Sheilendra Mehta

Past, present, and future: Critical analysis of use of gastric bands in obese patients

Adjustable gastric banding (AGB) is quickly becoming the most popular bariatric operation performed in the United States and Canada. Patients are particularly fond of the simplicity of the tool, the relatively low morbidity of the surgery, the quick recovery, and overall results. The gastric band has evolved over its 35-year history into a very successful adjustable tool used to restrict food consumption and limit caloric intake. The percent of excessive weight loss after banding can range from 30%–60% and depends on the time out from surgery. Along with weight loss, there is good resolution of the co-morbid conditions that are associated with excess weight and improvements in quality of life demonstrated after banding. Nutrition and follow up are extremely important after banding to ensure good compliance and adequate weight loss. Failure to follow the postoperative diet, exercise regiment, or mechanical failure of the band can lead to failure to lose adequate weight. While there are particular early and late complications associated with this surgery, the safety profile of the AGB is very appealing when compared to other bariatric operations. As we continue to reduce the morbidity of the procedure, the simple adjustable band concept has a lot of potential to remain a primary technique of maintaining long term weight loss. In conclusion, AGB has and continues to play an important role in the treatment of morbid obesity. It offers reasonably good weight loss results with very little morbidity, and the future of the adjustable band is bright.

Synergistic endocrine induction by GLP-1 and TGF-β in the developing pancreas

Objectives: Glucagon-like peptide-1 (GLP-1) is known to stimulate glucose-dependent insulin production and secretion by pancreatic β-cells. Preliminary evidence suggests that GLP-1 may also influence endocrine differentiation from pancreatic progenitor cells. Additionally, TGF-β signaling can also control endocrine differentiation by both inhibiting proliferation and enhancing differentiation of endocrine progenitor cells to become mature β-cells. Here we document synergy of these two signaling pathways in the differentiation of endocrine cells in the developing pancreas. Methods: Embryonic pancreas was harvested from mice at day 11.5 and cultured for six days with GLP-1 agonist, exendin-4, and/or TGF-β1 ligand. Also, a pan-neutralizing TGF-β isoform antibody was used alone or with exendin-4 to study TGF-β inhibition in this system. Pancreatic cultures were processed for immunohistochemistry. Results: Exogenous TGF-β1 and exendin-4 each individually enhanced both insulin and glucagon differentiation dose-dependently. However, when combined there was an additive effect to a 4.5-fold increase in insulin-positive differentiation. We also saw suppression of amylase-positive differentiation. Surprisingly, TGF-β pan-neutralizing antibody also gave an augmentation of endocrine differentiation by 1.5 to 2-fold, but no synergistic effect was seen with exendin-4. Conclusion: We conclude that TGF-β isoforms have a specific synergistic role with GLP-1 pathway signaling in early pancreatic development, toward endocrine differentiation and away from acinar differentiation.

A Randomized Trial Comparing Reflux Symptoms in Sleeve Gastrectomy Patients with or without Hiatal Hernia Repair

BACKGROUND The effect of laparoscopic sleeve gastrectomy (SG) on reflux symptoms is unclear. Many surgeons offer SG only to patients with minor or no reflux symptoms, fearing that patients with severe reflux symptoms will experience worsening of their condition after SG. Many also advocate crural repair at the time of SG to prevent de novo or worsening reflux symptoms. These decisions are made without suitable data to form such conclusions. OBJECTIVE To determine the effect of SG with or without hiatal hernia repair on reflux symptoms. SETTING University of Texas Health Sciences Center in Houston. METHODS The Gastrointestinal Symptom Rating Scale (GSRS) was administered to 100 consecutive, preoperative SG patients who were then randomly assigned into a crural repair group or nonrepair group in a parallel design. The patients were subsequently followed-up every 3 months for 1 year. We compared reflux symptoms of the 2 groups on the basis of demographic characteristics, body mass index, weight loss, presence and size of hiatal hernia, and GSRS for 12 months. RESULTS At 1 year, with 78% follow-up, the data demonstrated a significant decrease in the GSRS for both groups (P<.001); however, there was no difference between the groups (P = .35). Age, starting body mass index, percent excessive weight loss, and hiatal hernia size did not correlate with change in the GSRS score. The only variable that affected outcome was the preoperative GSRS. At 12 months, 38% of patients with a preoperative GSRS score less than the median score of the study population experienced worsening of their symptoms compared with only 2% of patients who had a preoperative GSRS score greater than the median. Overall, 19% experienced worsening reflux (5% de novo), 14% had no change, and 66% reported an improvement in symptoms. CONCLUSION These data suggest that a crural repair at the time of SG does not significantly reduce reflux symptoms compared with SG alone. Preoperative patients with significant reflux symptoms experienced a more significant improvement in symptoms after surgery compared with those who did not report significant reflux symptoms before surgery. The high incidence of reflux after SG observed in the current literature may be a result of a specific patient subpopulation who undergoes SG because of surgeon bias rather than an inherent property of SG itself or the presence of a hiatal hernia.

Words of Caution Regarding Adjustable Gastric Band Tubing

Introduction: With the decreasing popularity of adjustable gastric band (AGB) placement and the increase in explants of the devices, for erosion, slips, or inadequate weight loss, in performing revisional surgery, it is of vital importance for surgeons to understand the problems that may arise during removal. This case involved an uncommonly reported complication of fractured band tubing resulting in incomplete removal of the tubing during revisional bariatric surgery, with reoperation necessary for complete removal. In the course of the procedure, a small-bowel tumor was identified. Case Description: We present a 35-year-old woman who underwent conversion of a laparoscopic AGB to a sleeve gastrectomy. Failure to recognize a fracture in the band tubing resulted in retained tubing and readmission secondary to abdominal pain. During reoperation to remove the retained tubing, a small-bowel gastrointestinal stromal tumor (GIST) was incidentally identified and resected. Discussion: This case highlights a rarely reported complication of fractured gastric band tubing, resulting in incomplete removal of the tubing during revisional surgery, with the incidental discovery of a GIST in the small bowel.

Bone morphogenetic protein expression patterns in human esophageal atresia with tracheoesophageal fistula

The organogenesis of esophageal atresia with tracheoesophageal fistula (EA/TEF) remains unknown. The fistula tract appears to develop from a non-branching trifurcation of the embryonic lung bud. The non-branching growth of the fistula differs from the other lung buds and suggests a deficiency in bone morphogenetic protein (BMP) signaling, since BMPs are critical to proper lung development and branching. With IRB approval, portions of newborn human proximal esophageal pouch and distal fistula samples were recovered at the time of surgical repair of EA/TEF. The tissues were processed for immunohistochemistry. Commercially available fetal tissues were used as controls. In control tissues, BMP ligands (BMP 2, 4, and 7) were all present in the esophagus but absent in the trachea. BMPRIA was absent in both tissues. BMPRIB was detected in trachea but not in esophagus and BMPRII was detected in esophagus but not in trachea. In the EA/TEF specimens, all BMP ligands were present in the proximal esophageal pouch but absent in the fistula tract. BMPRIA and BMPRIB were not detected in either tissue. However, BMPRII was found in both fistula tract and proximal pouch. The submucosa of the fistula appears to maintain a mixed (identical neither to lung, esophagus, or trachea) BMP signaling pattern, providing one mechanism which could potentially explain the esophageal dismotility and lack of lung branching seen in the fistula/distal esophagus.

Retained Gastric Band Tubing Resulting in Large Bowel Obstruction

Introduction: Complications due to retained gastric band tubing are rarely reported and frequently include disconnections of the tubing requiring operative revision. Obstruction from adjustable gastric band tubing is an infrequently reported event. Case Description: The patient presented to us 1 month after removal of a presumed isolated infected port performed at an outside facility. The wound was left open, but the intra-abdominal tubing and band were left in place. Abdominal distention, pain, and peritonitis developed, and the patient was taken to the operating room because of concern regarding an acute intra-abdominal process. Intraoperatively, he was noted to have a sigmoid obstruction from the retained gastric band tubing. Discussion: Although obstruction from adjustable gastric band tubing is infrequently reported in the literature, it poses a potentially devastating complication. We review the relevant literature and potential issues when dealing with band-related tubing.

Bouveret syndrome: current management strategies

Bouveret syndrome is a rare complication of cholelithiasis that usually presents with signs and symptoms of gastric outlet obstruction. Given the relative rarity of this condition, there are no standardized guidelines for the management of this condition. In this paper, we review the diagnosis and management options (endoscopic, laparoscopic, and open approaches) of patients with Bouveret syndrome, including a report of one case to illustrate some of the endoscopic and surgical principles of management.