Gastric greater curvature plication combined with Nissen fundoplication in the treatment of gastroesophageal reflux disease and obesity

Background and aim: Established anti-reflux procedures such as fundoplications are less efficient in obese patients. The aim of this study was to investigate clinical effectiveness of the fundoplication combined with gastric greater curvature plication in the treatment of gastroesophageal reflux disease (GERD) in obese patients. Materials and methods: During the period from June 2010 to September 2014, patients operated for GERD with BMI from 30 to 39.9 kg/m2 were included into the prospective study. Laparoscopic Nissen fundoplication (LNF, n = 58) was performed until February 2013 and later laparoscopic Nissen fundoplication was combined with gastric greater curvature plication (LNFGP, n = 56). The groups were compared according to the control of GERD and weight loss. Results: In LNF group there were significantly more males, patients had lower BMI and longer duration of GERD symptoms. Duration of surgery was significantly longer in LNFGP group, 96.5 (17.3) min vs. 59.8 (16.1) min (P < 0.0001). Postoperative morbidity was similar, 3.6% and 3.4% in LNFGP and LNF groups, respectively (P = 0.9539). The average percentage of excess BMI loss after 12 months was 45.3 (5.8) in LNFGP group as compared to 18.4 (4.6) in LNF group (P < 0.0001). Significantly more patients experienced remission or improvement of type 2 diabetes mellitus (P = 0.03) and hypercholesterolemia (P = 0.0001) in LNFGP group. No significant differences between the groups in postoperative DeMeester score, GERD-HRQL mean score, overall satisfaction and healing of esophagitis were observed

Risk factors of esophagojejunal anastomosis leakage after total gastrectomy

Background/AimEsophagojejunal anastomotic leakage (EJAL) after total gastrectomy is one of the most frequent life-threatening complications. The rate of EJAL after total gastrectomy is about 2–11% worlwide. The aim of this study was to identify the independent prognostic risk factors that may predict EJAL progression for patients after total gastrectomy.Materials and methodsThis retrospective study analyzed medical records of 175 patients. All these patients had underwent radical gastrectomy due to gastric cancer. The analyzed factors were: age, gender, American Society of Anaesthesiologists (ASA) funtional class, splenectomy, anastomosis technique, operative time, cancer stage, the number of dissected lymph nodes, the number of metastatic lymph nodes, resection margins. White blood cells count, C reactive protein (CRP) value, body temperature, drain output were calculated in the early postoperative period.ResultsThe average age of the patients was 63.2 ± 11.5 years. The EJAL rate was found to be 6.3%. The mortality rate among patients who developed EJAL was 9%. Postoperative laboratory and clinical findings significantly related to EJAL were the average temperature of 4 postoperative days &gt;37.2 oC (p = 0.018), postoperative white blood cell count &gt;16.7 x 109/l (p = 0.031), postoperative CRP level &gt;160 mg/l (p = 0.001) and operative time &gt;248 min (p = 0.009), although the binary logistic regression analysis revealed that none of these variables can be used as statisticaly significant predictors for EJAL.ConclusionsThe esofagojejunal anastomotic leakage rate of 6.3% was found among patients undergoing radical gastrectomy due to gastric carcinoma. Mortality rate in case of EJAL increases up to 9%. In our study, we didn’t find any independent predictors for EJAL.Key words: gastrectomy, esophagojejunal anastomosis leakage, risk factorsEzofagojejuninės jungties nesandarumo išsivystymo rizikos veiksniai po gastrektomijosĮvadasEzofagojejuninės jungties nesandarumas (EJJN) po gastrektomijos yra viena iš didžiausią grėsmę gyvybei keliančių komplikacijų. Mokslinių tyrimų duomenimis, EJJN dažnis svyruoja nuo 2 iki 11 %. Darbo tikslas – nustatyti rizikos veiksnius,darančius įtaką ezofagojejuninės jungties nesandarumo vystymuisi po gastrektomijos dėl skrandžio vėžio, ir prognozuoti jų įtaką EJJN išsivystymui.Ligoniai ir metodaiRetrospektyviai ištirta 175 pacientų medicininė dokumentacija. Tirtiems pacientams 2006–2010 metais atlikta gastrektomija dėl skrandžio vėžio. Analizuoti veiksniai: amžius, lytis, Amerikos anesteziologų asociacijos (ASA) funkcinė klasė, splenektomija, jungties susiuvimo būdas, operacijos trukmė, naviko stadija, operacijos metu pašalintų limfmazgių skaičius, limfmazgių su mestazėmis skaičius, rezekciniai kraštai. Ankstyvuoju pooperaciniu laikotarpiu vertinta leukocitų kiekis, C reaktyviojo baltymo (CRB) koncentracija kraujyje, pooperacinė temperatūra, sekrecija pro drenus.RezultataiTirtų pacientų amžiaus vidurkis 63,2±11,5 metų. Vyrų 50,6 %, moterų 49,4 %. EJJN dažnis 6,3 %. Turėjusių EJJN pacientų mirtingumas siekė 9 %. Nustatyti rizikos veiksniai, statistiškai patikimai susiję su EJJN išsivystymu. Jų reikšmės patikslintosrandant ROC kreivės lūžio taškus: 4 parų vidutinė temperatūra 37,15oC (p=0,018), maksimalios leukocitų (11,7x109/l, p=0,031) ir C reaktyviojo baltymo reikšmės (159,95 mg/l, p=0,001), operacijos trukmė 247,5 min (p=0,009). Tačiau binarinė logistinė regresija parodė, kad šie kriterijai negali būti statistiškai patikimi prognoziniai EJJN vystymosi veiksniai.IšvadosEzofagojejuninės jungties nesandarumo dažnis po gastrektomijos dėl skrandžio vėžio yra 6,3%, šią komplikaciją turėjusių pacientų mirštamumas – 9%. Savo tyrime neradome prognostiškai reikšmingų rizikos veiksnių.Reikšminiai žodžiai: gastrektomija, ezofagojejuninės jungties nesandarumas, rizikos veiksnia

Risk factors of esophagojejunal anastomosis leakage after total gastrectomy

Background/AimEsophagojejunal anastomotic leakage (EJAL) after total gastrectomy is one of the most frequent life-threatening complications. The rate of EJAL after total gastrectomy is about 2–11% worlwide. The aim of this study was to identify the independent prognostic risk factors that may predict EJAL progression for patients after total gastrectomy.Materials and methodsThis retrospective study analyzed medical records of 175 patients. All these patients had underwent radical gastrectomy due to gastric cancer. The analyzed factors were: age, gender, American Society of Anaesthesiologists (ASA) funtional class, splenectomy, anastomosis technique, operative time, cancer stage, the number of dissected lymph nodes, the number of metastatic lymph nodes, resection margins. White blood cells count, C reactive protein (CRP) value, body temperature, drain output were calculated in the early postoperative period.ResultsThe average age of the patients was 63.2 ± 11.5 years. The EJAL rate was found to be 6.3%. The mortality rate among patients who developed EJAL was 9%. Postoperative laboratory and clinical findings significantly related to EJAL were the average temperature of 4 postoperative days &gt;37.2 oC (p = 0.018), postoperative white blood cell count &gt;16.7 x 109/l (p = 0.031), postoperative CRP level &gt;160 mg/l (p = 0.001) and operative time &gt;248 min (p = 0.009), although the binary logistic regression analysis revealed that none of these variables can be used as statisticaly significant predictors for EJAL.ConclusionsThe esofagojejunal anastomotic leakage rate of 6.3% was found among patients undergoing radical gastrectomy due to gastric carcinoma. Mortality rate in case of EJAL increases up to 9%. In our study, we didn’t find any independent predictors for EJAL.Key words: gastrectomy, esophagojejunal anastomosis leakage, risk factorsEzofagojejuninės jungties nesandarumo išsivystymo rizikos veiksniai po gastrektomijosĮvadasEzofagojejuninės jungties nesandarumas (EJJN) po gastrektomijos yra viena iš didžiausią grėsmę gyvybei keliančių komplikacijų. Mokslinių tyrimų duomenimis, EJJN dažnis svyruoja nuo 2 iki 11 %. Darbo tikslas – nustatyti rizikos veiksnius,darančius įtaką ezofagojejuninės jungties nesandarumo vystymuisi po gastrektomijos dėl skrandžio vėžio, ir prognozuoti jų įtaką EJJN išsivystymui.Ligoniai ir metodaiRetrospektyviai ištirta 175 pacientų medicininė dokumentacija. Tirtiems pacientams 2006–2010 metais atlikta gastrektomija dėl skrandžio vėžio. Analizuoti veiksniai: amžius, lytis, Amerikos anesteziologų asociacijos (ASA) funkcinė klasė, splenektomija, jungties susiuvimo būdas, operacijos trukmė, naviko stadija, operacijos metu pašalintų limfmazgių skaičius, limfmazgių su mestazėmis skaičius, rezekciniai kraštai. Ankstyvuoju pooperaciniu laikotarpiu vertinta leukocitų kiekis, C reaktyviojo baltymo (CRB) koncentracija kraujyje, pooperacinė temperatūra, sekrecija pro drenus.RezultataiTirtų pacientų amžiaus vidurkis 63,2±11,5 metų. Vyrų 50,6 %, moterų 49,4 %. EJJN dažnis 6,3 %. Turėjusių EJJN pacientų mirtingumas siekė 9 %. Nustatyti rizikos veiksniai, statistiškai patikimai susiję su EJJN išsivystymu. Jų reikšmės patikslintosrandant ROC kreivės lūžio taškus: 4 parų vidutinė temperatūra 37,15oC (p=0,018), maksimalios leukocitų (11,7x109/l, p=0,031) ir C reaktyviojo baltymo reikšmės (159,95 mg/l, p=0,001), operacijos trukmė 247,5 min (p=0,009). Tačiau binarinė logistinė regresija parodė, kad šie kriterijai negali būti statistiškai patikimi prognoziniai EJJN vystymosi veiksniai.IšvadosEzofagojejuninės jungties nesandarumo dažnis po gastrektomijos dėl skrandžio vėžio yra 6,3%, šią komplikaciją turėjusių pacientų mirštamumas – 9%. Savo tyrime neradome prognostiškai reikšmingų rizikos veiksnių.Reikšminiai žodžiai: gastrektomija, ezofagojejuninės jungties nesandarumas, rizikos veiksnia

Gastric greater curvature plication combined with Nissen fundoplication in the treatment of gastroesophageal reflux disease and obesity

Background and aim: Established anti-reflux procedures such as fundoplications are less efficient in obese patients. The aim of this study was to investigate clinical effectiveness of the fundoplication combined with gastric greater curvature plication in the treatment of gastroesophageal reflux disease (GERD) in obese patients. Materials and methods: During the period from June 2010 to September 2014, patients operated for GERD with BMI from 30 to 39.9 kg/m2 were included into the prospective study. Laparoscopic Nissen fundoplication (LNF, n = 58) was performed until February 2013 and later laparoscopic Nissen fundoplication was combined with gastric greater curvature plication (LNFGP, n = 56). The groups were compared according to the control of GERD and weight loss. Results: In LNF group there were significantly more males, patients had lower BMI and longer duration of GERD symptoms. Duration of surgery was significantly longer in LNFGP group, 96.5 (17.3) min vs. 59.8 (16.1) min (P < 0.0001). Postoperative morbidity was similar, 3.6% and 3.4% in LNFGP and LNF groups, respectively (P = 0.9539). The average percentage of excess BMI loss after 12 months was 45.3 (5.8) in LNFGP group as compared to 18.4 (4.6) in LNF group (P < 0.0001). Significantly more patients experienced remission or improvement of type 2 diabetes mellitus (P = 0.03) and hypercholesterolemia (P = 0.0001) in LNFGP group. No significant differences between the groups in postoperative DeMeester score, GERD-HRQL mean score, overall satisfaction and healing of esophagitis were observed

Mid-Term Outcomes of Laparoscopic Gastric Greater Curvature Plication versus Roux-en-Y Gastric Bypass: Weight Loss, Gastrointestinal Symptoms, and Health-Related Quality of Life

Background and Objectives: Laparoscopic gastric greater curvature plication (LGGCP) is considered to be less invasive, technically simpler, and less costly. Few studies have compared LGGCP to gastric bypass. The aim of this prospective study was to evaluate the mid-term outcomes of LGGCP such as weight loss, gastrointestinal symptoms, and health-related quality of life (HRQoL) in comparison to laparoscopic Roux-en-Y gastric bypass (LRYGB). Materials and Methods: Between 2017 April and 2018 December, 112 patients were included in the study. Fifty patients had LGGCP, and sixty-two patients underwent LRYGB. Demographics, comorbidities, complications, percentage of excess body mass index loss (%EBMIL), gastrointestinal symptoms (GSRS questionnaire), and HRQoL (EQ-5D-3L questionnaire) were analysed. Gastrointestinal symptoms and HRQoL data are presented as the mean and median with the interquartile range (25th&ndash;75th percentile). Follow-up at 1 year and 3 year was performed. Results: The follow-up rate was 96.4% and 92.9%, 1 year and 3 year after surgery, respectively. Mean (SD) %EBMIL 1 year after surgery was 59.05 (25.34) in the LGGCP group and 82.40 (19.03) in the LRYGB group (p &lt; 0.001) and 3 year after was 41.44 (26.74) and 75.59 (19.14), respectively (p &lt; 0.001). The scores of all gastrointestinal symptoms measured by the GSRS questionnaire significantly decreased 3 year after both procedures, except reflux after LGGCP. Patients 3 year after LGGCP had a significantly lower abdominal pain score as compared to patients after LRYGB (1.01; 1.0 (1.0&ndash;1.0) and 1.20; 1.0 (1.0&ndash;1.33), respectively (p &lt; 0.001); however, LGGCP resulted in significantly more GERD symptoms (1.79; 1.25 (1.0&ndash;2.5) and 1.18; 1.0 (1.0&ndash;1.0), respectively (p &lt; 0.001)). Three years after surgery, the quality of life was significantly lower in the LGGCP group (0.762; 0.779 (0.690&ndash;0.794) and 0.898; 1.000 (0.783&ndash;1.000), respectively (p &lt; 0.001)). Conclusions: Three years after surgery, LGGCP patients lost significantly less weight, had less abdominal pain and more reflux symptoms, and a lower quality of life as compared to LRYGB patients

Microbiome Changes after Type 2 Diabetes Treatment: A Systematic Review

Background and objectives: Although the role of the gut microbiome in type 2 diabetes (T2D) pathophysiology is evident, current systematic reviews and meta-analyses analyzing T2D treatment mainly focus on metabolic outcomes. The objective of this study is to evaluate the microbiome and metabolic changes after different types of treatment in T2D patients. Materials and Methods: A systematic search of PubMed, Wiley online library, Science Direct, and Cochrane library electronic databases was performed. Randomized controlled clinical trials published in the last five years that included T2D subjects and evaluated the composition of the gut microbiome alongside metabolic outcomes before and after conventional or alternative glucose lowering therapy were selected. Microbiome changes were evaluated alongside metabolic outcomes in terms of bacteria taxonomic hierarchy, intestinal flora biodiversity, and applied intervention. Results: A total of 16 eligible studies involving 1301 participants were reviewed. Four trials investigated oral glucose-lowering treatment, three studies implemented bariatric surgery, and the rest analyzed probiotic, prebiotic, or synbiotic effects. The most common alterations were increased abundance of Firmicutes and Proteobacteria parallel to improved glycemic control. Bariatric surgery, especially Roux-en-Y gastric bypass, led to the highest variety of changed bacteria phyla. Lower diversity post-treatment was the most significant biodiversity result, which was present with improved glycemic control. Conclusions: Anti-diabetic treatment induced the growth of depleted bacteria. A gut microbiome similar to healthy individuals was achieved during some trials. Further research must explore the most effective strategies to promote beneficial bacteria, lower diversity, and eventually reach a non-T2D microbiome

Role of ketamine in multimodal analgesia protocol for bariatric surgery

Background and Objectives: Acute postoperative pain is one of the most undesirable experiences for a patient in the postoperative period. Many options are available for the treatment of postoperative pain. One of the methods of multimodal analgesia is a combination of opioids and adjuvant agents, such as ketamine. The aim of this study was to evaluate the effect of a pre-incisional single injection of low-dose ketamine on postoperative pain after remifentanil infusion in patients undergoing laparoscopic gastric bypass or gastric plication surgery. Materials and Methods: The prospective, randomized, double-blinded and placebo-controlled trial took place at the Hospital of the Lithuanian University of Health sciences KaunoKlinikos in 2015–2017. A total of 32 bariatric patients (9 men and 23 women) were randomly assigned to receive a single pre-incisional injection of ketamine (0.15 mg/kg (LBM)) (ketamine, K group) or saline (placebo, S group). Standardized protocol of anesthesia and postoperative pain management was followed for all patients. Postoperative pain intensity, postoperative morphine requirements, incidence of side effects and patients’ satisfaction with postoperative analgesia were recorded. Results: Thirty-two patients undergoing bariatric surgery: 18 (56.25%; gastric bypass) and 14 (43.75%; gastric plication) were examined. Both groups did not differ in demographic values, duration of surgery and anesthesia and intraoperative drug consumption. Postoperative pain scores were similar in both groups (p=0.105–0.941). Morphine consumption was 10.0 (7.0–12.5 mg) in group S and 9.0 (3.0–15.0 mg) in group K (p=0.022). The incidence of side effects was similar in both groups (p=0.412). Both groups demonstrated very high satisfaction with postoperative analgesia. [...]

Gastrointestinal symptoms and eating behavior among morbidly obese patients undergoing Roux-en-Y gastric bypass

Background and objective: Roux-en-Y gastric bypass (RYGB) changes anatomy and physiology of the gastrointestinal tract, and is followed by gastrointestinal side effects, changes in bowel function and eating behavior. The aim of the present study was to investigate the severity of gastrointestinal symptoms and changes in eating behavior preoperatively and one year after RYGB. Materials and methods: A total of 180 morbidly obese patients who underwent RYGB were included into the prospective study. Gastrointestinal symptoms were evaluated with Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) questionnaire and Gastrointestinal Symptom Rating Scale (GSRS), eating behavior with Three-Factor Eating Questionnaire before and one year after RYGB. For all patients routine gastroscopy before surgery was performed. Results: A total of 99 patients (55%) completed one-year follow-up; 79 (43.9%) patients had no pathological findings on preoperative gastroscopy. GERD-HRQL score and GSRS scores of indigestion, constipation, abdominal pain and reflux decreased significantly after surgery. Male gender (OR = 2.47, 95% CI 1.11–5.50, P = 0.026), GERD-HRQL score (OR = 1.28, 95% CI 1.16–1.41, P < 0.001) and GSRS diarrhea score (OR = 1.89, 95% CI 1.10–3.17, P = 0.020) were significant predictors of pathological findings on gastroscopy. Eating behavior one year after RYGB changed significantly as compared to baseline. Cognitive Restraint postoperatively has increased from 42.6 to 55.9 (P < 0.001). Uncontrolled Eating and Emotional Eating one year after surgery significantly decreased (59.1 vs. 20.6, P < 0.001 and 28.2 vs. 17.2, P < 0.001, respectively). Conclusions: In morbidly obese patients endoscopic findings correlate well with gastrointestinal complain. RYGB significantly improves gastrointestinal complains and eating behavior one year postoperatively

Hernia hiatus esophagi and gastroesophageal reflux: possibilities and results of surgical treatment

In this article we analyze our experience of surgical treatment of hiatal hernia, complicated with gastroesophageal reflux. We operated 134 patients with hernia hiatus esophagi, complicated with gastroesophageal reflux, from 03.1998 till 10.2001. One hundred twenty-six Nissen and 8 Toupet laparoscopic gastrofundoplications were performed. We evaluated clinical signs of gastroesophageal reflux, performed endoscopy and esophageal biopsy with histological examination and stomach X-ray examination with barium meal before the operation. Esophagus and stomach X-ray examination with water contrast on the first day after operation were performed in order to evaluate the position and function of created wrap. We also analyzed intraoperative and postoperative complications. Long-term follow-up (12 months) was obtained by using a structured questionnaire. We evaluated heartburn, dysphagia, regurgitation and patient\u92s satisfaction of surgery. Results. Postoperative complications rate was 8.96%. Eighty-two percent of our patients completed our questionnaire. Ninety-one percent of patients had no heartburn signs, 95.5% any signs of regurgitation. Eightythree percent of our patients were satisfied with our performed laparoscopic gastrofundoplication. We performed 6 refundoplications, when gastroesophageal reflux clinical signs renewed shortly after operation. Conclusions. Laparoscopic gastrofundoplication is a safe and effective treatment of hernia hiatus esophagi, complicated with gastroesophageal reflux. Operation success was about 90% in our study. Recurrences are more frequent in elderly patients or those with long disease anamnesis. Refundoplications can be successfully done laparoscopicaly as well