Simon Msika

Comparison of Nutritional Status During the First Year After Sleeve Gastrectomy and Roux-en-Y Gastric Bypass

Sleeve gastrectomy (SG) is supposed to induce fewer nutritional deficiencies than gastric bypass (GBP). However, few studies have compared nutritional status after these two procedures, and the difference in weight loss (WL) between procedures may alter the results. Thus, our aim was to compare nutritional status after SG and GBP in subjects matched for postoperative weight. Forty-three subjects who underwent SG were matched for age, gender, and 6-month postoperative weight with 43 subjects who underwent GBP. Dietary intakes (DI), metabolic (MP), and nutritional parameters (NP) were recorded before and at 6 and 12xa0months after both procedures. Multivitamin supplements were systematically prescribed after surgery. Before surgery, BMI, DI, MP, and NP were similar between both groups. After surgery, LDL cholesterol, serum prealbumin, vitamin B12, urinary calcium, and vitamin D concentrations were lower after GBP than after SG, whereas WL and DI were similar after both procedures. However, the total number of deficiencies did not increase after surgery regardless of the procedure. In addition, we found a significant increase in liver enzymes and a greater decrease in C-reactive protein after GBP. In conclusion, during the first year after surgery, in patients with the same WL and following the same strategy of vitamin supplementation, global nutritional status was only slightly impaired after SG and GBP. However, some nutritional parameters were specifically altered after GBP, which could be related to malabsorption or other mechanisms, such as alterations in liver metabolism.

Impact of bariatric surgery on fetal growth restriction: experience of a perinatal and bariatric surgery center

BACKGROUNDnBariatric surgery is known to improve some pregnancy outcomes, but there is concern that it may increase the risk of small for gestational age.nnnOBJECTIVEnTo assess the impact of bariatric surgery on pregnancy outcomes and specifically of the type of bariatric surgery on the risk of fetal growth restriction.nnnSTUDY DESIGNnA single-center retrospective case-control study. The study group comprised all deliveries in women who had undergone bariatric surgery. To investigate the effects of weight loss on pregnancy outcomes, we compared the study group with a control group matched for presurgery body mass index. Secondly, to assess the specific impact of the type of surgery on the incidence of fetal growth restriction in utero, we distinguished subgroups with restrictive and malabsorptive bariatric surgery, and compared outcomes for each of these subgroups with a second control group, matched for prepregnancy body mass index.nnnRESULTSnAmong 139 patients operated, 58 had a malabsorptive procedure (gastric bypass) and 81 a purely restrictive procedure (72 a gastric banding and 9 a sleeve gastrectomy). Compared with controls matched for presurgery body mass index, the study group had a decreased rate of gestational diabetes (12% vs 23%, Pxa0= .02) and large for gestational age >90th percentile (11% vs 22%, Pxa0= .01) but an increased rate of small for gestational age <10th percentile. The incidence of small for gestational age was higher after gastric bypass (29%) than it was after restrictive surgery (9%) or in controls matched for prepregnancy body mass index (6%) (P < .01 between bypass and controls). In multivariable analysis, after adjustment for other risk factors, gastric bypass remained strongly associated with small for gestational age (adjusted odds ratio, 7.16; 95% confidence interval, 2.74-18.72).nnnCONCLUSIONnMalabsorptive bariatric surgery was associated with an increased risk of fetal growth restriction.

Comparison of the incidence of cholelithiasis after sleeve gastrectomy and Roux-en-Y gastric bypass in obese patients: a prospective study

BACKGROUNDnAlthough the risk of cholelithiasis (CL) increases in patients after Roux-en-Y gastric bypass (RYGB), no prospective study has yet assessed the incidence of CL after sleeve gastrectomy (SG).nnnOBJECTIVESnTo compare, prospectively, the incidence and predictive factors for CL after both procedures.nnnMETHODSnA postoperative abdominal ultrasound follow-up was proposed to all patients with an intact gallbladder and who underwent RYGB or SG in Hôpital Louis Mourier from 2008 onward.nnnRESULTSnAt least one ultrasound was performed on one hundred and sixty patients between 6 and 12 months postsurgery, 43 after SG and 117 after RYGB. Age, gender, initial body-mass index, co-morbidities were similar in both groups. Weight loss (WL) at 6 months was significantly lower after SG than after RYGB (26.9 ± 9.2 and 31.3 ± 7.5 kg, respectively = .001). The incidences of CL after SG and RYGB were similar (28% versus 34% respectively, P = .57). Most cases of CL occurred in the first year post surgery. During the follow-up, 12% and 13% of patients who underwent SG and RYGB, respectively, became symptomatic. WL of>30 kg at 6 months was a risk factor for CL after bariatric surgery, but we did not find any preoperative predictive factor for gallstone formation.nnnCONCLUSIONSnDespite lower WL after SG, the incidence of CL after SG and RYGB was similar at 2 years. Our results suggest that rapid WL is the main element leading to gallstone formation after both procedures.

Malabsorption and intestinal adaptation after one anastomosis gastric bypass compared with Roux-en-Y gastric bypass in rats

The technically easier one-anastomosis (mini) gastric bypass (MGB) is associated with similar metabolic improvements and weight loss as the Roux-en-Y gastric bypass (RYGB). However, MGB is controversial and suspected to result in greater malabsorption than RYGB. In this study, we compared macronutrient absorption and intestinal adaptation after MGB or RYGB in rats. Body weight and food intake were monitored and glucose tolerance tests were performed in rats subjected to MGB, RYGB, or sham surgery. Carbohydrate, protein, and lipid absorption was determined by fecal analyses. Intestinal remodeling was evaluated by histology and immunohistochemistry. Peptide and amino acid transporter mRNA levels were measured in the remodeled intestinal mucosa and those of anorexigenic and orexigenic peptides in the hypothalamus. The MGB and RYGB surgeries both resulted in a reduction of body weight and an improvement of glucose tolerance relative to sham rats. Hypothalamic orexigenic neuropeptide gene expression was higher in MGB rats than in RYGB or sham rats. Fecal losses of calories and proteins were greater after MGB than RYGB or sham surgery. Intestinal hyperplasia occurred after MGB and RYGB with increased jejunum diameter, higher villi, and deeper crypts than in sham rats. Peptidase and peptide or amino acid transporter genes were overexpressed in jejunal mucosa from MGB rats but not RYGB rats. In rats, MGB led to greater protein malabsorption and energy loss than RYGB. This malabsorption was not compensated by intestinal overgrowth and increased expression of peptide transporters in the jejunum.

Association Between Bariatric Surgery and Rates of Continuation, Discontinuation, or Initiation of Antidiabetes Treatment 6 Years Later

Importance Few large-scale long-term prospective cohort studies have assessed changes in antidiabetes treatment after bariatric surgery. Objective To describe the association between bariatric surgery and rates of continuation, discontinuation, or initiation of antidiabetes treatment 6 years after bariatric surgery compared with a matched control obese group. Design, Setting, and Participants This nationwide observational population-based cohort study extracted health care reimbursement data from the French national health insurance database from January 1, 2008, to December 31, 2015. All patients undergoing primary bariatric surgery in France between January 1 and December 31, 2009, were matched on age, sex, body mass index category, and antidiabetes treatment with control patients hospitalized for obesity in 2009 with no bariatric surgery between 2005 and 2015. Exposures Bariatric surgery, including adjustable gastric banding (AGB), gastric bypass (GBP), and sleeve gastrectomy (SG). Main Outcome and Measure Reimbursement for antidiabetes drugs. Mixed-effects logistic regression models estimated factors of discontinuation or initiation of antidiabetes treatment over a period of 6 years. Results In 2009, a total of 15 650 patients (mean [SD] age, 38.9 [11.2] years; 84.6% female; 1633 receiving antidiabetes treatment) underwent primary bariatric surgery, with 48.5% undergoing AGB, 27.7% undergoing GBP, and 22.0% undergoing SG. Among patients receiving antidiabetes treatment at baseline, the antidiabetes treatment discontinuation rate was higher 6 years after bariatric surgery than in controls (−49.9% vs −9.0%, Pu2009<u2009.001). In multivariable analysis, the main predictive factors for discontinuation were the following: GBP (odds ratio [OR], 16.7; 95% CI, 13.0-21.4), SG (OR, 7.30; 95% CI, 5.50-9.50), and AGB (OR, 4.30; 95% CI, 3.30-5.60) compared with no bariatric surgery, as well as insulin use (OR, 0.17; 95% CI, 0.13-0.22), dual therapy without insulin (OR, 0.38; 95% CI, 0.32-0.45) vs monotherapy, lipid-lowering treatment (OR, 0.76; 95% CI, 0.63-0.91), antidepressant treatment (OR, 0.67; 95% CI, 0.55-0.81), and age (OR, 0.96; 95% CI, 0.95-0.97) per year. For patients without antidiabetes treatment at baseline, the 6-year antidiabetes treatment initiation rate was much lower after bariatric surgery than in controls (1.4% vs 12.0%, Pu2009<u2009.001). In multivariable analysis, protective factors were GBP (OR, 0.06; 95% CI, 0.04-0.09), SG (OR, 0.08; 95% CI, 0.06-0.11), and AGB (OR, 0.16; 95% CI, 0.14-0.20) vs controls, and risk factors were as follows: body mass index category (OR, 2.04; 95% CI, 1.68-2.47 for ≥50.0 vs 30.0-39.9 and OR, 1.68; 95% CI, 1.49-1.90 for 40.0-49.9 vs 30.0-39.9), antihypertensive treatment (OR, 1.49; 95% CI, 1.33-1.67), low income (OR, 1.43; 95 % CI, 1.26-1.62), and age (OR, 1.04; 95 % CI, 1.03-1.05) per year. Conclusions and Relevance Bariatric surgery was associated with a significantly higher 6-year postoperative antidiabetes treatment discontinuation rate compared with baseline and with an obese control group without bariatric surgery.

Impact of Intragastric Balloon Before Laparoscopic Gastric Bypass on Patients with Super Obesity: a Randomized Multicenter Study

BackgroundSuper obese patients are recommended to lose weight before bariatric surgery. The effect of intragastric balloon (IGB)-induced weight loss before laparoscopic gastric bypass (LGBP) has not been reported. The aim of this prospective randomized multicenter study was to compare the impact of preoperative 6-month IGB with standard medical care (SMC) in LGBP patients.MethodsPatients with BMI >45xa0kg/m2 selected for LGBP were included and randomized to receive either SMC or IGB. After 6xa0months (M6), the IGB was removed and LGBP was performed in both groups. Postoperative follow-up period was 6xa0months (M12). The primary endpoint was the proportion of patients requiring ICU stay >24xa0h; secondary criteria were weight changes, operative time, hospitalization stay, and perioperative complications.ResultsOnly 115 patients were included (BMI 54.3xa0±xa08.7xa0kg/m2), of which 55 underwent IGB insertion. The proportion of patients who stayed in ICU >24xa0h was similar in both groups (Pxa0=xa00.87). At M6, weight loss was significantly greater in the IGB group than in the SMC group (Pxa0<xa00.0001). Three severe complications occurred during IGB removal. Mean operative time for LGBP was similar in both groups (Pxa0=xa00.49). Five patients had 1 or more surgical complications, all in the IGB group (Pxa0=xa00.02). Both groups had similar hospitalization stay (Pxa0=xa00.59) and weight loss at M12 (Pxa0=xa00.31).ConclusionIGB insertion before LGBP induced weight loss but did not improve the perioperative outcomes or affect postoperative weight loss.

Evaluation of incidence of cholelithiasis after bariatric surgery in subjects treated or not treated with ursodeoxycholic acid

BACKGROUNDnThe use of ursodeoxycholic acid (UDCA) to prevent gallstone formation after gastric bypass (RYGB) is still debated. Furthermore, only 1 study has assessed the effectiveness of UDCA after sleeve gastrectomy (SG) with mitigated results.nnnOBJECTIVESnTo compare the incidence of cholelithiasis (CL) between patients treated or not treated with UDCA after RYGB and SG.nnnSETTINGnUniversity hospital, France.nnnMETHODSnSince January 2008, a postoperative ultrasound monitoring was scheduled for all patients without previous cholecystectomy who underwent bariatric surgery in our institution. Patients who underwent at least 1 ultrasound in the first postoperative year (±6 months) were included. We started to systematically prescribe UDCA (500 mg/d) for 6 months postoperatively, in February 2012 for RYGB (once or twice daily) and in October 2013 for SG (once daily).nnnRESULTSnMean follow-up was 13.0±3.4 months. The incidence of CL was 32.5% in the 117 nontreated RYGB and 25.5% in the 51 nontreated SG. It was reduced to 2.4% in the 42 SG treated once daily (P = .005), to 5.7% in the 87 RYGB with 250 mg twice daily (P<.001), but only to 18.6% in the 102 RYGB with 500 mg once daily (P = .03).nnnCONCLUSIONnUDCA 500 mg once daily for 6 months is efficient to prevent CL 1 year after SG, but the twice-daily doses seem to be more effective after RYGB. The effectiveness of UDCA once daily after SG and the superiority of the twice-daily doses after RYGB should be confirmed with more patients and longer follow-up.

Gastroesophageal Reflux After Sleeve Gastrectomy: a Prospective Mechanistic Study

BackgroundEvolution of gastroesophageal reflux disease (GERD) after sleeve gastrectomy (SG) is controversial. Some authors report worsening or improvement of preoperative GERD, others the occurrence of de novo GERD between 5 and 69%.AimsThe aims of this study are to evaluate the evolution of GERD after SG by ambulatory 24-h pH monitoring (APM) and to determine pre- and postoperative clinical and manometric factors associated with its evolution.MethodsBetween 2013 and 2015, 47 patients operated in our center performed APM before and 1xa0year (14.8xa0±xa04.9xa0months) after SG. GERD was defined as a percentage of time with esophageal pHxa0<xa04 (TpHxa0<xa04)xa0>xa04.2. Among them, 30 had pre- and postoperative high-resolution esophageal manometry (HRM).ResultsThirty-one patients (66%) had no preoperative GERD (group 1), and 16 had preoperative GERD (group 2). One year after SG, mean TpHxa0<xa04 increased significantly in group 1 (5.8xa0±xa04.6 vs. 1.8xa0±xa01.1%, pxa0<xa00.01) whereas it was not modified in group 2 (7.4xa0±xa06.6 vs. 6.6xa0±xa02.6%). In group 1, 16 patients (52%) had de novo GERD whereas in group 2, 7 had no more GERD, 3 improved, and 6 worsened. Maximal intragastric pressure after swallows increased significantly at postoperative HRM only in patients with de novo GERD (49.2xa0±xa022.0 vs. 25.4xa0±xa09.4xa0mmHg, pxa0=xa00.03). No preoperative clinical or manometric parameters were predictive of postoperative GERD.ConclusionsOne year after SG, esophageal acid exposure globally worsened, mostly because of de novo GERD, whereas 63% patients with preoperative GERD improved, without preoperative predictive clinical or manometric factor.

Evaluation of interstitial cells of Cajal in patients with severe colonic inertia requiring surgery: a clinical-pathological study

Subtotal colectomy is the treatment of last resort in patients with severe colonic inertia (SCI) refractory to laxatives. Some studies have reported hypoplasia of the interstitial cells of Cajal (ICC) using a semi‐quantitative analysis. The aims of this study were first to investigate if semi‐quantitative analysis or morphometry is better at the quantification of colonic ICC and second to determine whether there is a relationship between the number of ICC and the severity of constipation.

Ileus biliaire : une cause rare d’occlusion intestinale

Gallstone ileus is an uncommon complication of cholelithiasis, with a high morbidity and mortality rate, usually related to the delayed diagnosis of intestinal obstruction. Diagnosing gallstone ileus needs a high index of suspicion. A case of a gallstone ileus is reported. The clinical presentation, radiological features, intra-operative findings, operative procedure and literature review are presented.