Timothy S. Kuwada

Duodenal- jejunal bypass sleeve: a totally endoscopic device for the treatment of morbid obesity.

Morbid obesity affects over 15 million people in the United States. Nonsurgical management produces sustained weight loss in less than 5% of patients. Despite associated comorbidities, less than 1% of obese patients seek surgical intervention. Less invasive procedures have been developed with varying success. The Endobarrier ™ (GI Dynamics™, Watertown, MA) duodenal—jejunal bypass sleeve is a totally endoscopically delivered device designed to produce weight loss in the morbidly obese. We describe the first placement of a duodenal—jejunal bypass sleeve in a patient in the United States. A blinded, randomized, prospective clinical trial was approved by the Food and Drug Administration to evaluate safety and efficacy of a novel device for weight loss in the obese. The first patient enrolled was a 36-year-old woman with body mass index of 45.2. After informed consent, endoscopic placement of the device under general anesthesia was performed using fluoroscopy to confirm positioning. The device was placed without complications. At conclusion of the 3-month study period, the device was removed endoscopically. Total weight lost by the patient was 9.09 kg. Described herein is the first deployment of the duodenal—jejunal bypass sleeve in North America. The device is delivered in a totally endoscopic manner in morbidly obese patients. In our patient, total weight loss at 3 months was 9.09 kg. Continued follow-up and enrollment is ongoing to demonstrate patient safety and efficacy. Additional studies are being performed to elucidate mechanism of weight loss and future clinical applications of this device.

Does patient compliance with preoperative bariatric office visits affect postoperative excess weight loss

BACKGROUND The amount of excess weight loss (EWL) achieved after bariatric surgery has varied considerably. Reliable preoperative predictors of the postoperative %EWL do not exist. Patient compliance with the physician recommendations has generally been believed to be important for long-term success after bariatric surgery, especially after gastric banding. We hypothesized that poor preoperative patient compliance with office visits, a likely indicator of overall compliance, would be associated with lower %EWL after bariatric surgery at a teaching hospital in the United States. METHODS We performed an institutional review board-approved review of prospectively collected data from all patients undergoing bariatric surgery from 2007 to 2009. The patients were categorized into 2 groups: those who had missed <25% of all preoperative appointments at our bariatric center and those who had missed >25%. The average %EWL at 12 months between the 2 groups was compared using the unpaired t test separately for the gastric bypass and gastric banding patients. RESULTS The gastric band patients with >25% missed appointments had lost 23% EWL at 12 months compared with 32% EWL for the gastric band patients who had missed <25% of their appointments (P = .01). No difference was found in the %EWL for the gastric bypass patients according to the missed preoperative appointments. The postoperative compliance was significantly poorer than preoperatively. CONCLUSION The patients with a greater percentage of missed preoperative appointments had a lower postoperative %EWL at 1 year after gastric banding but not after gastric bypass. This information could prove useful during patient selection or when counseling patients about the type of bariatric surgery to pursue.

Does liver appearance predict histopathologic findings: prospective analysis of routine liver biopsies during bariatric surgery

BACKGROUND Nonalcoholic fatty liver disease is associated with morbid obesity. Liver biopsy is the reference standard for the diagnosis of nonalcoholic fatty liver disease. It is unclear whether the macroscopic liver appearance correlates with the histopathologic findings. Our objective was to determine the relationship between the intraoperative liver appearance and the histopathologic findings during laparoscopic bariatric surgery at a tertiary medical center. METHODS Data were prospectively collected from 108 consecutive patients undergoing laparoscopic bariatric surgery with routine intraoperative liver biopsy. An intraoperative liver visual score was recorded according to the size, tan-speckling, and contour. The liver histologic findings were categorized into 3 groups: (1) normal; (2) bland steatosis; and (3) nonalcoholic steatohepatitis (NASH). The liver visual score was compared with the liver histologic findings. A recorded video of the liver was regraded at a later date to determine observer agreement. RESULTS The prevalence of NASH was 23% (n = 25). Of the 108 patients, 48% with NASH had normal-appearing livers and accounted for 24% (n = 12) of the 50 normal-appearing livers. A similar proportion of NASH cases was found in all 3 visual categories. Furthermore, no relationship was found between the number of abnormal visual cues and the liver histologic findings (P = .23). No complications were directly attributable to liver biopsy. The kappa values for intraobserver and interobserver agreement ranged from fair to almost perfect. CONCLUSION NASH is common in the morbidly obese population. There does not appear to be a relationship between liver appearance and the histopathologic findings. Intraoperative liver biopsy is a safe and accurate method of diagnosing liver disease and should be considered in all morbidly obese patients undergoing abdominal surgery.

Failure of mesenteric defect closure after Roux-en-Y gastric bypass

Routine closure of mesenteric defects after Roux-en-Y gastric bypass may not be an effective permanent closure.

Minimally Invasive Management of Colon Cancer

One of the most controversial issues in minimally invasive surgery has been the implementation of laparoscopic techniques for the curative resection of colorectal malignancies. Initial concerns included the potential violation of oncologic principles, the effects of carbon dioxide, and the phenomenon of port site tumor recurrence. Basic science research and large randomized controlled trials are now demonstrating that these fears were unjustified. Long-term outcomes of laparoscopic colon resection compared with open colon resection for malignancy are comparable, and there may even be a survival benefit for a subset of patients who undergo laparoscopic resection.

Thrombosis in the portal venous system after elective laporoscopic splenectomy

It was with great interest that we read the article by Pietrabissa et al. [2] on portal system thrombosis after laparoscopic splenectomy. This work, once again, described venous thrombosis as a potentially catastrophic postoperative event. We agree that vigilance, thorough investigation, and aggressive management are of paramount importance in symptomatic patients. However, we question several of their assertions. First, the influence of thrombocytosis on portal system thrombosis is not well established and was not referenced in the paper. Although it may be logical to assume that higher platelet counts would predispose a patient to hypercoagulability and thrombotic sequelae [4], this effect was not demonstrated in this report and lacks support in general. In fact, it appears that none of the patients in this series who developed a thrombosis had platelet counts >1 million. In addition, the postoperative platelet counts were not statistically different in their patients with and without portal system thrombosis. Overall, the study did not demonstrate a relationship between severe thrombocytosis and postoperative thrombosis. The authors also suggested that plasma exchange therapy is appropriate for patients with postoperative platelet counts >1 million. This assertion is not supported by evidence in their report or elsewhere in the medical literature; moreover, it is debatable whether prophylactic aspirin or other anti-platelet therapy for patients with thrombocytosis is effective or warranted [1, 4]. They recommend frequent platelet surveillance, yet they reported checking a platelet count themselves only on the 3 postoperative day. Based on the evidence provided, the need for plasma exchange, anti-platelet therapy, or frequent platelet count assessment for patients undergoing splenectomy has not been proven. The prospective nature of the study enabled the authors to establish a 22% rate of postoperative portal system thrombosis. However, the natural history of asymptomatic splenic and/or portal vein thrombosis after laparoscopic splenectomy is not known [3]. Their recommendation that an immediate anticoagulation protocol be initiated for all patients with a thrombus in any branch of the portal system appears to be rational and may be even appropriate, but it is not truly supported. Given the long history of splenectomy, both open and laparoscopic, and combining this long history with the reported 22% incidence of portal system thrombosis, why are we not seeing significant numbers of patients who present with major morbidity or die from intestinal infarction or portal hypertension? Considering as well that systemic anticoagulation therapy in the early postoperative period can carry significant morbidity (two patients in their series required reoperation for bleeding), the overall risk/benefit ratio of anticoagulating asymptomatic patients with thrombosis of the splenic vein or branches of the portal system remains unknown. Finally, the authors call for an aggressive outpatient screening program to detect silent thrombotic events in all laparoscopic splenectomy patients is not based on evidence and is premature. Only when the link between asymptomatic thrombosis of the splenic vein or portal system branches and clinical complications is established will prophylactic imaging become routine. Although we congratulate the authors on their contribution to the literature on this topic, we believe that the suggested role of plasma exchange in thrombocytosis, as well as radiographic screening and anticoagulation therapy for asymptomatic patients after laparoscopic splenectomy, is not evidence-based to date and that the resolution of these issues needs further investigation.