Best practice approach for redo-surgeries after sleeve gastrectomy, an expert's modified Delphi consensus

Background: Sleeve gastrectomy (SG) is the most common metabolic and bariatric surgical (MBS) procedure worldwide. Despite the desired effect of SG on weight loss and remission of obesity-associated medical problems, there are some concerns regarding the need to do revisional/conversional surgeries after SG. This study aims to make an algorithmic clinical approach based on an expert-modified Delphi consensus regarding redo-surgeries after SG, to give bariatric and metabolic surgeons a guideline that might help for the best clinical decision. Methods: Forty-six recognized bariatric and metabolic surgeons from 25 different countries participated in this Delphi consensus study in two rounds to develop a consensus on redo-surgeries after SG. An agreement/disagreement ≥ 70.0% on statements was considered to indicate a consensus. Results: Consensus was reached for 62 of 72 statements and experts did not achieve consensus on 10 statements after two rounds of online voting. Most of the experts believed that multi-disciplinary team evaluation should be done in all redo-procedures after SG and there should be at least 12 months of medical and supportive management before performing redo-surgeries after SG for insufficient weight loss, weight regain, and gastroesophageal reflux disease (GERD). Also, experts agreed that in case of symptomatic GERD in the presence of adequate weight loss, medical treatment for at least 1 to 2 years is an acceptable option and agreed that Roux-en Y gastric bypass is an appropriate option in this situation. There was disagreement consensus on efficacy of omentopexy in rotation and efficacy of fundoplication in the presence of a dilated fundus and GERD. Conclusion: Redo-surgeries after SG is still an important issue among bariatric and metabolic surgeons. The proper time and procedure selection for redo-surgery need careful considerations. Although multi-disciplinary team evaluation plays a key role to evaluate best options in these situations, an algorithmic clinical approach based on the expert's consensus as a guideline can help for the best clinical decision-making.info:eu-repo/semantics/publishedVersio

¿Cambio de paradigma desde el bypass gástrico Roux-en-Y al (mini) bypass gástrico debido a problemas de glucosa?

El bypass gástrico Roux-en-Y funciona de la siguiente manera sobre la diabetes mellitus tipo 2: En obesos mórbidos la diabetes tipo2 inicia con la presencia de resistencia a la insulina con un incremento del péptido C, o sea incremento de las necesidades de insulina que los no obesos tienen para mantener el estado euglucemico. Cuando la secreción de insulina es insuficiente, se desarrolla la diabetes. Esta secreción de insulina está modulada por las incretinas y posiblemente por anti-incretinas producidas en duodeno y yeyuno proximal. Después del bypass, la secreción de incretinas como efecto inmediato, disminuyen la resistencia a la insulina ocasionando la desaparición de la hiperglucemia. Existe ya la insulina suficiente para la remisión de diabetes.Universidad de Málaga. Campus de Excelencia Internacional Andalucía Tec

Bypass Gástrico BII.

Hay varias técnicas de bypass gástrico para la reducción del peso, la cual se decide dependiendo de la historia, hábitos dietéticos, evaluación psicológica, estado médico, reflujo gastroesofágico, diabetes. El bypass gástrico Roux-en-Y es la única opción en 50% de los pacientes debido a reflujo, diabetes o ambas. Estos pacientes tienen ciertas características como el IMC, síndrome metabólico y diabetes. Los pacientes obesos presentan mayor resistencia a la insulina, que se encuentra regulada por las incretinas producidas en duodeno y yeyuno proximal. Después del bypass, la resistencia a la insulina desaparece y si el páncreas tiene suficiente insulina, la diabetes tipo 2 desaparece. Se mencionan los mecanismos específicos y los efectos adversos como el síndrome de dumping y la hipoglicemia posprandial y los medios para evitar esas condiciones. El nuevo procedimiento minigastric bypass se analizan sus pros y contras.Universidad de Málaga. Campus de Excelencia Internacional Andalucía Tech

Bronchial muscle peristaltic activity in the fetal rat

Aside for the potential for tonic contraction, the airway smooth muscle exhibits intermittent phasic rhythmic activity that may contribute to lung growth during fetal life. Therefore, we examined 4th generation rat 18-22 d gestation fetal, 4-6 d of age newborn and adult bronchial ring from Sprague Dawley rats to compare differences in smooth muscle function. We hypothesized that phasic contractions were greatest before birth. Bronchial muscle spontaneous rhythmic contractions were greatest in the fetus and absent in the adult. In response to KCl stimulation, the fetal bronchial smooth muscle only developed tonic force that was 3.5 +/- 0.6 and lower than measured in the newborn 9.0 +/- 0.3 and adult 13.7 +/- 1.4 mN/mm2. The thromboxane A2 analogue U46619 induced tonic and phasic muscle contractions and the amplitude and frequency of the phasic contractions were greater in the fetus as compared with the adult and increased with gestational age. The U46619-induced rhythmic contractions were abrogated by ryanodine, thapsigargin and reduction of extracellular Na+, suggesting intracellular Ca2+ dependence and involvement of the Na+/Ca2+ exchanger. The inward rectifier K+ blocker BaCl2 induced phasic contractions in unstimulated fetal, but not adult bronchial muscle of the same amplitude and frequency as for the spontaneous and U46619-induced ones. We conclude that the airway smooth muscle phasic activity is greatest in the fetus and tends to disappear post-natally with age suggesting an in utero role during lung development

Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus

Abstract Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future