Soo Min Ahn

Bariatric, metabolic, and diabetes surgery: what's in a name?

Objective:This study investigated the practical clinical consequences of offering surgery for metabolic disease and diabetes as opposed to weight loss. Background:The terms “metabolic” and “diabetes surgery” indicate a surgical approach whose primary intent is the control of metabolic alterations/hyperglycemia in contrast to “bariatric surgery,” conceived as a mere weight-reduction therapy. Methods:A “metabolic surgery” program distinct from the “bariatric surgery” program was recently established at a tertiary US academic medical center. The 2 programs differ in their stated goals but offer the same procedures and use identical eligibility criteria for patients with morbid obesity. Demographics, clinical characteristics, and 30-day postoperative morbidity and mortality were assessed from a prospective database of 200 consecutive patients who underwent surgery at these units. Results:Metabolic surgery patients were older (45.8 ± 13.4 v 41.8 ± 11.7, P < 0.05), had a lower body mass index (42.4 ± 7.1 vs 48.6 ± 9.5 kg/m2; P < 0.01), and a higher prevalence of being of the male sex (42% vs 26%, P < 0.05), having diabetes (62% vs 35%; P < 0.01), hypertension (68% vs 52%; P < 0.05), dyslipidemia (48% vs 31%; P < 0.05), and cardiovascular disease (14% vs 5%; P < 0.05). Diabetes was more severe among metabolic surgery patients (higher glycated hemoglobin levels; greater percentage of insulin use). There was no mortality, and there were no differences in perioperative complications. Conclusions:Offering surgery to treat metabolic disease or diabetes rather than as a mere weight-reduction therapy changes demographical and clinical characteristics of surgical candidates. This has important and practical ramifications for clinical care and support consideration of metabolic/diabetes surgery as a novel practice distinct from traditional bariatric surgery.

Surgical control of obesity and diabetes: The role of intestinal vs. gastric mechanisms in the regulation of body weight and glucose homeostasis

To elucidate the specific role of gastric vs. intestinal manipulations in the regulation of body weight and glucose homeostasis.

Surgical control of obesity and diabetes

To elucidate the specific role of gastric vs. intestinal manipulations in the regulation of body weight and glucose homeostasis.

Metabolic surgery for type 2 diabetes.

Conventional bariatric operations, including Roux‐en‐Y gastric bypass (RYGB), laparoscopic adjustable gastric banding, and biliopancreatic diversion (BPD) appear to be a safe and effective treatment for many severely obese patients with type 2 diabetes mellitus (T2DM). These operations improve glucose homeostasis through a variety of mechanisms, however, not only due to reduced food intake and body weight. Research to elucidate the weight‐independent antidiabetic mechanisms of gastrointestinal (GI) surgery and to clarify the molecular mechanisms responsible for the benefits of GI surgery on glucose homeostasis is a compelling research objective. We review the existing knowledge regarding the clinical outcomes and of the mechanisms of GI surgery to treat T2DM.

Surgical treatment of type 2 diabetes: the surgeon perspective

Type 2 diabetes mellitus (T2DM) is a major health priority globally, having achieved pandemic status in the twenty-first century. Several gastrointestinal procedures that were primarily designed to treat morbid obesity result in dramatic remission of diabetes. Studies in experimental rodent models and humans have shown that the glycemic benefits of surgery are at least in part weight-independent and extend to non-morbidly obese subjects with T2DM. Bariatric procedures differ in their ability to ameliorate type 2 diabetes, with intestinal bypass procedures being more effective than purely restrictive procedures. Several studies have demonstrated that the benefits of bariatric surgery extend beyond amelioration of hyperglycemia and include improvement in other cardiovascular risk factors such as dyslipidemia and hypertension. The safety and cost-effectiveness of bariatric surgery are also well established by several studies. In this paper, the authors present the surgeon perspective on the management of type 2 diabetes focusing on the efficacy, safety and cost-effectiveness of metabolic surgery. The available evidence warrants the inclusion of metabolic surgery in the treatment algorithm of type 2 diabetes.

Laparoscopic Total Intracorporeal Correction of Choledochal Cyst in Pediatric Population

BACKGROUND The laparoscopic correction of the choledochal cyst is an attractive treatment option. However, even the skilled surgeons do not prefer the intracorporeal jejunojejunal anastomosis due to the technical difficulties. In this article, we present the feasibility of laparoscopic total intracorporeal correction of the choledochal cyst, including the retrocolic Roux-en-Y hepaticojejunostomy and jejunojejunostomy. METHODS A prospective review of 6 cases of consecutive laparoscopic surgery for choledochal cyst in the pediatric population from March 2007 to April 2008 was performed. All patients underwent laparoscopic excision of a choledochal cyst and total intracorporeal Roux-en-Y reconstructions. The intracoporeal jejunojejunostomy was made by introducing an endoscopic gastrointestinal anastomosis device (Endo-GIA; US Surgical, Norwalk, CT) through the umbilical port with hand-sewn reinforcement. We evaluated the patients age at the time of operation, time taken for total operation, time taken for jejunojejunostomy, and intra- and postoperative events. RESULTS All 6 cases were girls (age ranging from 4 months to 7 years). All had type I choledochal cyst. Five ports were utilized: one telescopic port at the umbilicus, one left subcostal port for liver retraction, two operating ports on the right flank and left side of the umbilicus, and one right-lower quadrant port for the assistant. The mean time for total operation was 275 + or - 58 minutes (range, 210-360). Total intracoroporeal jejunojejunostomy took 38 + or - 10 minutes (range, 25-55). All patients were symptom free during the median follow up of 3.5 months. CONCLUSION In the pediatric population with choledochal cyst, total intracorporeal Roux-en-Y hepaticojejunostomy and jejunojejunostomy during laparoscopic surgery is feasible without the need for exteriorization of the bowel.

Infantile vulvar abscess with a normal anus: a suspicious sign of rectovestibular fistula.

Purpose We investigated whether infantile vulvar abscesses are predictable features of rectovestibular fistula with a normal anus. Materials and Methods A retrospective analysis of five infants with vulvar abscesses and rectovestibular fistulae with normal anuses was performed. Results Four cases had a left vulvar abscess, and in one case the vulvar abscess was on the right side. All caregivers reported passage of stool from the vagina. The fistulae were almost uniformly located from the vestibule to the rectum above the anal dentate line, observable by visual inspection and probing under anesthesia. The first two cases were treated with division and closure of the fistulae after a diverting loop colostomy, and the remaining three cases with fistulotomy and curettage. There was no recurrence during the median follow-up period of 38 months. Conclusion This unique rectovestibular fistula should be suspected in female infants with vulvar abscesses, especially when parents report passage of stool from the vagina. Fistulotomy and curettage may be an initial treatment and effective as a temporary diverting colostomy and delayed repair of the fistula.