Timothy Shope

Dysphagia after vertical sleeve gastrectomy: Evaluation of risk factors and assessment of endoscopic intervention

AIM To evaluate the risks of medical conditions, evaluate gastric sleeve narrowing, and assess hydrostatic balloon dilatation to treat dysphagia after vertical sleeve gastrectomy (VSG). METHODS VSG is being performed more frequently worldwide as a treatment for medically-complicated obesity, and dysphagia is common post-operatively. We hypothesize that post-operative dysphagia is related to underlying medical conditions or narrowing of the gastric sleeve. This is a retrospective, single institution study of consecutive patients who underwent sleeve gastrectomy from 2013 to 2015. Patients with previous bariatric procedures were excluded. Narrowing of a gastric sleeve includes: inability to pass a 9.6 mm gastroscope due to stenosis or sharp angulation or spiral hindering its passage. RESULTS Of 400 consecutive patients, 352 are included; the prevalence of dysphagia is 22.7%; 33 patients (9.3%) have narrowing of the sleeve with 25 (7.1%) having sharp angulation or a spiral while 8 (2.3%) have a stenosis. All 33 patients underwent balloon dilatation of the gastric sleeve and dysphagia resolved in 13 patients (39%); 10 patients (30%) noted resolution of dysphagia after two additional dilatations. In a multivariate model, medical conditions associated with post-operative dysphagia include diabetes mellitus, symptoms of esophageal reflux, a low whole blood thiamine level, hypothyroidism, use of non-steroidal anti-inflammatory drugs, and use of opioids. CONCLUSION Narrowing of the gastric sleeve and gastric sleeve stenosis are common after VSG. Endoscopic balloon dilatations of the gastric sleeve resolves dysphagia in 69% of patients.

Breath Hydrogen as a Biomarker for Glucose Malabsorption after Roux-en-Y Gastric Bypass Surgery

Objective. Abdominal symptoms are common after bariatric surgery, and these individuals commonly have upper gut bacterial overgrowth, a known cause of malabsorption. Breath hydrogen determination after oral glucose is a safe and inexpensive test for malabsorption. This study is designed to investigate breath hydrogen levels after oral glucose in symptomatic individuals who had undergone Roux-en-Y gastric bypass surgery. Methods. This is a retrospective study of individuals (n = 63; 60 females; 3 males; mean age 49 years) who had gastric bypass surgery and then glucose breath testing to evaluate abdominal symptoms. Results. Among 63 postoperative individuals, 51 (81%) had a late rise (≥45 minutes) in breath hydrogen or methane, supporting glucose malabsorption; 46 (90%) of these 51 subjects also had an early rise (≤30 minutes) in breath hydrogen or methane supporting upper gut bacterial overgrowth. Glucose malabsorption was more frequent in subjects with upper gut bacterial overgrowth compared to subjects with no evidence for bacterial overgrowth (P < 0.001). Conclusion. These data support the presence of intestinal glucose malabsorption associated with upper gut bacterial overgrowth in individuals with abdominal symptoms after gastric bypass surgery. Breath hydrogen testing after oral glucose should be considered to evaluate potential malabsorption in symptomatic, postoperative individuals.

Development of minimally invasive techniques for management of medically-complicated obesity.

The field of bariatric surgery has been rapidly growing and evolving over the past several decades. During the period that obesity has become a worldwide epidemic, new interventions have been developed to combat this complex disorder. The development of new laparoscopic and minimally invasive treatments for medically-complicated obesity has made it essential that gastrointestinal physicians obtain a thorough understanding of past developments and possible future directions in bariatrics. New laparoscopic advancements provide patients and practitioners with a variety of options that have an improved safety profile and better efficacy without open, invasive surgery. The mechanisms of weight loss after bariatric surgery are complex and may in part be related to altered release of regulatory peptide hormones from the gut. Endoscopic techniques designed to mimic the effects of bariatric surgery and endolumenal interventions performed entirely through the gastrointestinal tract offer potential advantages. Several of these new techniques have demonstrated promising, preliminary results. We outline herein historical and current trends in the development of bariatric surgery and its transition to safer and more minimally invasive procedures designed to induce weight loss.

Case report of combined surgical oncologic and bariatric procedures

Highlights • Morbidly obese patients do get cancer and require laparotomy for resection of the malignancy.• Sleeve gastrectomy can follow a successful oncologic intervention with minimal increase in morbidity and mortality.• Doing the oncologic procedure, HIPEC, and then sleeve gastrectomy helps prevent tumor seeding at the gastric staple line.• Patient satisfaction is high with a favorable prognosis expected from a simultaneous oncologic and bariatric intervention.

Thiamine (Vitamin B1) After Weight Loss Bariatric Surgery

Bariatric surgery is a major tool for treating medically complicated obesity. Commonly utilized bariatric procedures can restrict dietary intake alone or in combination with the development of an element of malabsorption. There is growing evidence that subclinical thiamine deficiency is common in obese individuals, while thiamine stores can be depleted in as little as 2–3 weeks. Thiamine deficiency has been reported both after restrictive bariatric procedures as well as after malabsorptive bariatric procedures; thus, individuals are at risk after vertical sleeve gastrectomy. The most common clinical subtypes of thiamine deficiency after Roux-en-Y gastric bypass are cardiovascular and neuropsychiatric (neuro-psych) manifestations. Small intestinal bacterial overgrowth appears to be a major mechanism for development of symptomatic thiamine deficiency after bariatric surgery. Treatment of bacterial overgrowth with an oral antibiotic can improve oral absorption of thiamine after bariatric surgery. Wernicke’s disease is a potentially devastating complication of thiamine deficiency that should be managed with immediate intravenous infusions of high doses of thiamine.