Laparoscopic Sleeve Gastrectomy as a Primary Operation for Morbid Obesity: Experience with 200 Patients

Introduction. Laparoscopic sleeve gastrectomy (LSG) represents a valid option for morbid obesity, either as a primary or as a staged procedure. The aim of this paper is to report the experience of a single surgeon with LSG as a standalone operation for morbid obesity. Methods. From April 2006 to April 2011, 200 patients underwent LSG for morbid obesity. Each patient record was registered and prospectively collected. In July 2011, a retrospective analysis was conducted. Results. Patients were 128 females and 72 males with a median age of 40.0 years. Median pre-operative BMI was 49.4 kg/m2. Median follow-up was 27.2 months. Median post-operative BMI was 30.4 kg/m2. Median %excess weight loss (%EWL) was 63.6%. Median post-operative hospital stay was 4.0 days in the first 84 cases and 3.0 days in the last 116 cases. Six major post-operative complications occurred (3%): two gastric stump leaks (1%), three major bleedings (1.5%) and 1 (0.5%) bowel obstruction. One case of mortality was registered (0.5%). To date only 4 patients are still in the range of morbid obesity (BMI > 35 kg/m2). Conclusions. Laparoscopic sleeve gastrectomy is a formidable operation in the short-term period. Median %EWL in this series was 63.6% at 27.2 months follow-up

Ketogenic Diet for Preoperative Weight Reduction in Bariatric Surgery: A Narrative Review

Bariatric surgery (BS) is the most effective treatment in reducing weight and the burden of comorbidities in patients with severe obesity. Despite the overall low mortality rate, intra- and post-operative complications remains quite common. Weight loss before BS reduces surgical risk, but studies are inconclusive regarding which is the best approach to apply. In this review, we summarize the current evidence on the effect of a ketogenic diet (KD) before BS. All studies agree that KD leads to considerable weight loss and important improvements in terms of surgical risk, but populations, interventions and outcomes are very heterogeneous. KD appears to be a safe and effective approach to induce weight loss before BS. However, randomized controlled trials with better-defined dietary protocols and homogeneous outcomes are necessary in order to draw firm conclusions

Palliative Laparoscopic Hepatico- and Gastrojejunostomy for Advanced Pancreatic Cancer

Only 10% to 20% of pancreatic tumors are resectable at the time of diagnosis. Patients with advanced disease have a median survival of 4.9 months. Palliation is often required for biliary or duodenal obstruction, or both, and for pain. Optimal palliation should guarantee the shortest possible hospital stay and as long a survival as possible with a good quality of life. In recent years, treatment options for palliation of biliary and duodenal obstruction due to pancreatic cancer have broadened. Endoscopic and percutaneous biliary stenting have been shown to be successful tools for safe palliation of high-risk patients. Nevertheless, fit patients with unresectable pancreatic cancer benefit from surgery, which allows long-lasting biliary and gastric drainage

Metabolic surgery for type II diabetes: an update

Bariatric operations have been documented in clinical trials to promote remission or dramatic improvement of Type II Diabetes Mellitus and related comorbidities. Herein we review randomized trials and meta-analyses published during the last 20 years on the results of bariatric/metabolic surgery in obese patients with type 2 diabetes with the aim of highlighting the scientific evidence available. Several studies and RCTs in the last 20 years have showed outstanding results of bariatric/metabolic surgery on Type II diabetes and comorbidities in patients with either BMI > 35 kg/m(2) or BMI < 35 kg/m(2). They have established that bariatric procedures are superior to non-surgical interventions for inducing weight loss and amelioration of type 2 diabetes, even in patients with a BMI between 30 and 35 kg/m(2). The physiopatologic changes that improve glucose homeostasis after bariatric surgery remain unclear but glycemic control is improved after sleeve gastrectomy, duodenal-jejunal bypass, Roux-en-Y gastric bypass, gastric banding, One Anastomosis Gastric Bypass, and biliopancreatic diversion. Nevertheless, it is suggested that the various gastrointestinal procedures may have different effects and mechanisms of action. Metabolic surgery will help integrate knowledge and multidisciplinary expertise to provide a combination of conservative and surgical treatments for Type II diabetes. These treatments must be considered as complementary options and not alternative strategies, with the same goal of controlling diabetes and achieving cure

Bariatric and metabolic surgery during COVID-19 outbreak phase 2 in Italy: why, when and how to restart

In Italy elective bariatric and metabolic surgery was cancelled on February 21,2020 at the beginning of the so-called phase 1 of the SARS-CoV-2 outbreak. Gradually it was restarted on May 4,2020 at the beginning of the so-called phase 2, when epidemiological data showed containment of the infection. Before the outbreak in eight high-volume bariatric centers 840 patients were surgically treated developing a Covid-19 infection, during phase 1, in only 5 cases (0.6%) without mortality. The post-operative complication rate was similar when compared to the 836 subjects submitted to bariatric surgery the year before. Since the high prevalence of infection in subjects with BMI. 30, it was argued that early intervention on obesity during phase 2 could help to minimize the effects of the disease in the event of a possible reversion to a SARS-CoV-2 outbreak phase 1. At the same time a prospective observational study from July 1 till the WHO declaration of the end of the pandemic has started in the eight high volume centers to monitor the post-operative outcome and its effect on SARS-CoV2 infection. (C) 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved

High-priority liver transplantation and simultaneous sleeve gastrectomy in MELD 32 end-stage liver disease: a case report with long-term follow-up

Background: Morbid obesity is a worldwide epidemic closely linked to Non-Alcoholic Fatty Liver Disease (NAFLD), an ever more relevant indication for Liver Transplantation (LT). Obesity affects an increasing number of LT recipients, but the ideal management of these patients remain unclear. Bariatric surgery (BS) in LT setting is challenging but feasible, although the debate is still open about the best timing of bariatric surgery. Herein we report a case of high-priority LT and simultaneous sleeve gastrectomy (SG) in an obese young adult.Case report: A 45 years old man with morbid obesity (BMI 46 kg/m(2)) and severe NAFLD-related end-stage liver disease (ESLD) underwent simultaneous LT and sleeve gastrectomy (SG) in an emergency setting, due to a MELD score of 32. He had substantial weight loss during long-term follow-up and enjoyed resolution of diabetes and hypertension. At 4 years follow-up, he has normal allograft function with appropriate immunosuppressant blood levels and no ultrasound evidence of steatosis.Conclusion: In selected patients, combined LT and SG present several advantages in terms of transplant outcomes, weight loss and resolution of obesity-related comorbidities. In addition, it can be performed in the high-priority setting in case of severe ESLD with good results in the short-and long-term

Mirabegron relaxes arteries from human visceral adipose tissue through antagonism of α1-adrenergic receptors

Aim: As inadequate perfusion has emerged as a key determinant of adipose tissue dysfunction in obesity, interest has grown regarding possible pharmacological interventions to prevent this process. Mirabegron has proved to improve insulin sensitivity and glucose homeostasis in obese humans via stimulation of β3-adrenoceptors which also seem to mediate endothelium-dependent vasodilation in disparate human vascular beds. We characterized, therefore, the vasomotor function of mirabegron in human adipose tissue arteries and the underlying mechanisms. Methods: Small arteries (116-734 μm) isolated from visceral adipose tissue were studied ex vivo in a wire myograph. After vessels had been contracted, changes in vascular tone in response to mirabegron were determined under different conditions. Results: Mirabegron did not elicit vasorelaxation in vessels contracted with U46619 or high-K+ (both P > 0.05). Notably, mirabegron markedly blunted the contractile effect of the α1-adrenergic receptor agonist phenylephrine (P < 0.001) either in presence or absence of the vascular endothelium. The anti-contractile action of mirabegron on phenylephrine-induced vasoconstriction was not influenced by the presence of the selective β3-adrenoceptor blocker L-748,337 (P < 0.05); lack of involvement of β3-adrenoceptors was further supported by absent vascular staining for them at immunohistochemistry. Conclusions: Mirabegron induces endothelium-independent vasorelaxation in arteries from visceral adipose tissue, likely through antagonism of α1-adrenoceptors

Bariatric Surgery Closure During COVID-19 Lockdown in Italy: The Perspective of Waiting List Candidates

Background: From the beginning of March 2020, lockdown regimens prevented patients with obesity from receiving bariatric surgery. Surgical emergencies and oncological procedures were the only operations allowed in public hospitals. Consequently, patients with morbid obesity were put in a standby situation. With the aim at exploring the viewpoint of our future bariatric surgery patients, we built a questionnaire concerning obesity and COVID-19.Method: A total of 116 bariatric surgery candidates were approached using a telephonic interview during the Italian lockdown.Results: Of the total sample, 73.8% were favorable to regular bariatric surgery execution. Forty percent were concerned about their own health status due to the COVID-19 emergency, and 61.1% were troubled by the temporary closure of the bariatric unit. The majority of the sample were eating more. Forty-five percent and the 27.5% of patients reported a worsening of the emotional state and physical health, respectively. Most of the patients (52.2%) considered themselves more vulnerable to COVID-19, especially individuals with class III obesity. Patients who reported an increased consumption of food were younger (43.44 +/- 12.16 vs. 49.18 +/- 12.66; F = 4.28, p = 0.042). No gender difference emerged.Conclusion: The lockdown had a negative result on Italian patients' psychological well-being and eating habits. The majority of patients would have proceeded with the surgery even during the COVID-19 emergency. Effective management and bariatric surgery should be restarted as soon as possible

Measuring Knowledge, Attitudes, and Barriers to Medication Adherence in Potential Bariatric Surgery Patients

Background Bariatric surgery is an effective treatment for the obesity epidemic, but the poor attendance and adherence rates of post-surgery recommendations threaten treatment effectiveness and health outcomes. Preoperatively, we investigated the unique contributions of clinical (e.g., medical and psychiatric comorbidities), sociodemographic (e.g., sex, age, and educational level), and psychopathological variables (e.g., binge eating severity, the general level of psychopathological distress, and alexithymia traits) on differing dimensions of adherence in a group of patients seeking bariatric surgery.Methods The final sample consisted of 501 patients (346 women). All participants underwent a full psychiatric interview. Self-report questionnaires were used to assess psychopathology, binge eating severity, alexithymia, and three aspects of adherence: knowledge, attitude, and barriers to medical recommendations.Results Attitude to adherence was associated with alexithymia (beta = 2.228; p < 0.001) and binge eating disorder (beta = 0.103; p = 0.047). The knowledge subscale was related to medical comorbidity (beta = 0.113; p = 0.012) and alexithymia (beta = -2.256; p < 0.001); with age (beta = 0.161; p = 0.002) and psychiatric comorbidity (beta =0.107; p = 0.021) manifesting in the barrier subscale.Conclusion We demonstrated that alexithymia and psychiatric and eating disorders impaired adherence reducing attitude and knowledge of treatment and increasing the barriers. Both patient and doctor can benefit from measuring adherence prior to surgery, with a qualitative approach shedding light on the status of adherence prior to the postsurgical phase when the damage regarding adherence is, already, done

Nutritional Status after Roux-En-Y (Rygb) and One Anastomosis Gastric Bypass (Oagb) at 6-Month Follow-Up: A Comparative Study

Introduction: Roux-en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB) are two effective bariatric surgical procedures with positive outcomes in terms of weight loss, comorbidities remission, and adverse events profiles. OAGB seems to carry a higher risk of malnutrition, but existing data are controversial. The aim of this study is to objectively evaluate and compare malnutrition in patients undergoing RYGB and OAGB. Methods: Retrospective monocentric study of obese patients undergoing RYGB or OAGB between the 15 September 2020 and the 31 May 2021. Nutritional status was assessed using the Controlling Nutritional Status (CONUT) score and compared between groups. The primary outcome was the mean CONUT score at 6 months. The secondary outcomes included the incidence of malnutrition, comorbidities, including hypertension, insulin resistance and type II diabetes mellitus, and weight loss. Results: 78 patients were included: 30 underwent RYGB and 48 underwent OAGB. At 6-Month Follow-Up there was no difference between groups in the mean CONUT score nor in incidence of malnutrition. In both groups, the nutritional status significantly worsened 6 months after surgery (preoperative and postoperative score of 0.48 +/- 0.9 and 1.38 +/- 1.5; p = 0.0066 for RYGB and of 0.86 +/- 1.5 and 1.45 +/- 1.3; p = 0.0422 for OAGB). Type II Diabetes mellitus (DMII) and hypertension remission were significant in the OAGB group with a 100% relative remission in the DMII-OAGB group (p = 0.0265), and a 67% relative remission in the hypertension-OAGB group (p = 0.0031). Conclusions: No difference in nutritional status has been detected between patients undergoing RYGB or OAGB at the 6-Month Follow-Up. Both procedures may have significant mal-absorptive effects leading to decline in nutritional status. OAGB may be more efficacious in inducing DMII and hypertension remission. Larger prospective studies dedicated specifically to nutritional status after gastric bypass are needed to confirm the impact of different bypass procedures on nutritional status