Differences in cerebral response to esophageal acid stimuli and psychological anticipation in GERD subtypes - An fMRI study

<p>Abstract</p> <p>Background</p> <p>To evaluate whether there are differences in the cerebral response to intraesophageal acid and psychological anticipation stimuli among subtypes of gastroesophageal reflux disease (GERD).</p> <p>Methods</p> <p>Thirty nine patients with GERD and 11 healthy controls were enrolled in this study after gastroscopy and 24 hr pH monitoring. GERD subjects were divided into four subgroups: RE (reflux esophagitis), NERD+ (non-erosive reflux disease with excessive acid reflux), NERD-SI+ (normal acid exposure and positive symptom index) and NERD-SI+ (normal acid exposure and negative symptom index, but responded to proton pump inhibitor trial). Cerebral responses to intraesophageal acid and psychological anticipation were evaluated with fMRI.</p> <p>Results</p> <p>During intraesophageal acid stimulation, the prefrontal cortex (PFC) region was significantly activated in all subgroups of GERD; the insular cortex (IC) region was also activated in RE, NERD+ and NERD-SI- groups; the anterior cingulated cortex (ACC) region was activated only in RE and NERD-SI- groups. The RE subgroup had the shortest peak time in the PFC region after acid was infused, and presented the greatest change in fMRI signals in the PFC and ACC region (<it>P </it>= 0.008 and <it>P </it>= 0.001, respectively). During psychological anticipation, the PFC was significantly activated in both the control and GERD groups. Activation of the IC region was found in the RE, NERD-SI+ and NERD-SI- subgroups. The ACC was activated only in the NERD-SI+ and NERD-SI- subgroups. In the PFC region, the NERD-SI- subgroup had the shortest onset time (<it>P </it>= 0.008) and peak time (<it>P </it>< 0.001). Compared with actual acid infusion, ACC in RE and IC in NERD+ were deactivated while additional areas including the IC and ACC were activated in the NERD-SI+ group; and in NERD-SI- group, onset-time and peak time in the PFC and IC areas were obviously shorter in induced anticipation than in actual acid infusion.</p> <p>Conclusions</p> <p>The four subgroups of GERD patients and controls showed distinctly different activation patterns and we therefore conclude GERD patients have different patterns of visceral perception and psychological anticipation. Psychological factors play a more important role in NERD-SI+ and NERD-SI- groups than in RE and NERD+ groups.</p

Quality of life after bariatric surgery - a comparative study of laparoscopic banding vs. bypass

: Laparoscopic gastric banding and Roux-en-Y gastric bypass are widely used for the treatment of morbid obesity. The impact of these two procedures on health-related quality of life has not been analyzed in comparative studies. METHODS: A matched-pair analysis of a prospectively collected database was performed. Fifty-two consecutive patients with laparoscopic gastric bypass were randomly matched to fifty-two patients with laparoscopic gastric banding according to age, BMI, and gender. Quality of life was assessed using two standardized questionnaires (SF 36 and Moorehead-Ardelt II). RESULTS: Mean preoperative BMI was 45.7 kg/m(2) for the bypass patients and 45.3 kg/m(2) for the banding patients. Mean BMI after 3 years follow-up of was 30.4 kg/m(2) and 33.1 kg/m(2) (p = 0.036). In the SF 36 questionnaire, gastric bypass patients yielded a mean total score of 613 versus 607 points in the gastric banding group (p = 0.543), which is comparable to the normal population in Europe. In the Moorhead-Ardelt II questionnaire, the gastric bypass patients scored a mean total of 1.35 points and the gastric banding patients 1.28 points (p = 0.747). Of the patients, 97% with a gastric bypass and 83% with a gastric banding were satisfied with the result of the operation (p = 0.145). CONCLUSION: The patients after laparoscopic gastric bypass and laparoscopic gastric banding have a high level of satisfaction 3 years after the operation and have similar quality of life scores compared to the normal population. Quality of life indexes were not different between the two procedures and were independent of weight loss in successfully operated patients

Three-trocar laparoscopic duodenal switch after sleeve gastrectomy

Laparoscopic duodenal switch is a recognized bariatric procedure, which can be performed in one step or as a second step after laparoscopic sleeve gastrectomy (LSG). Mainly, indications as primary surgery are super-obese or super super-obese patients, and after LSG indications are the presence of insufficient weight loss or weight regain, associated with morbid obesity co-morbidities, without gastroesophageal reflux. In this video, the authors report the technique of reduced port laparoscopic duodenal switch after LSG. The procedure is performed using a 12-mm trocar in the umbilicus, a 5-mm trocar in the right flank, and a 5-mm trocar in the left flank. One or more temporary percutaneous sutures are passed into the hepatic ligaments to increase the exposure of the first duodenum. The optical system is switched from 10 mm to 5 mm and introduced in the left 5-mm flank trocar at the step of the linear stapler insertion through the umbilical trocar. Classic construction with 150-cm alimentary limb and 100-cm common limb is performed. The duodeno-jejunostomy is fashioned in an end-to-side handsewn technique and the jejuno-ileostomy in the side-to-side semimechanical linear stapler technique. Both Petersen and mesenteric defects are closed. The umbilical access is finally meticulously closed, avoiding incisional hernia. Reduced port laparoscopic duodenal switch after LSG is a safe and feasible technique. Besides the enhanced cosmetic outcomes, this surgery is associated with a reduced use of painkillers, fewer trocar complications, and quick patient convalescence.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Should metabolic surgery be offered in morbidly obese patients with type I diabetes?

International audienceBACKGROUND: Bariatric surgery has recently been endorsed as an effective treatment of type 2 diabetes (T2D) in severely obese patients. Little is known about its metabolic effects in type 1 diabetes (T1D). The objectives were to assess bariatric surgery outcomes in T1D obese patients who underwent either a biliopancreatic diversion (BPD) or a sleeve gastrectomy (SG) and who were matched with T2D obese patients requiring insulin therapy. The study setting was at a university-affiliated tertiary care center. METHODS: Through retrospective analysis of prospectively collected data, ten patients with T1D (7 BPD, 3 SG) were matched with 20 patients with T2D (14 BPD, 6 SG) according to age, gender, type of surgery, initial Body Mass Index and insulin requirements (1:2 matching). Weight loss, diabetes control, and remission of co-morbidities were compared. RESULTS: Mean follow-up was 55.1 months. Mean Excess BMI Loss% tended to be greater in T1D patients compared to T2D (77.1% versus 68.3%, P = .14). The remission and improvement rates of T2D were 55% and 45% versus 0% and 90% for T1D. The remission rate of T2D was significantly greater after BPD (71.43%) compared to SG (16.67%, P = .04). Insulin requirements were significantly reduced in both groups after surgery (T1D: .44 +/-.24 versus 1.09 +/-.7 units/kg/d, P = 0.03, T2D: .03 +/-.12 versus .89 +/-.77 units/kg/d, P = .0001). Remission rates of hypertension and dyslipidemia were similar for T1D and T2D (66.7% versus 62.5%, P = .63 and 88.9% versus 75%, P = .23). CONCLUSIONS: Even if metabolic surgery has limited effect on glycemic control in T1D, it improves insulin sensitivity and other co-morbidities. It should be considered as a therapeutic option in selected obese patients with metabolic syndrome and high cardio-vascular risk

Laparoscopic harvesting of small bowel graft for small bowel transplantation

Background: Small bowel transplantation represents a valid therapeutic option for patients with intestinal failure, obviating the need for long-term total parenteral nutrition. Recently, reports have shown the feasibility of performing living related intestinal transplantation using segmental small bowel grafts. The limitations of this technique include inadequate harvested small bowel lengths, as compared with the lengths obtained in cadaveric small bowel harvests, and large incisions for the donor. In this pilot study, we evaluated the feasibility of laparoscopically harvesting long segments of proximal jejunum for small bowel transplantation using a porcine model. The results can be used to evaluate the potential for applying this technique in human cases.Methods: For this study 10 yorkshire pigs were used. Under general anesthesia, each pig underwent laparoscopic segmental resection of 200 cm of proximal jejunum on a vascular pedicle. The harvested graft then was autoreimplanted using an open technique by anastomosing the vascular pedicle to the superior mesenteric vessels. Success was determined 2 hours after anastomosis by visually identifying a pink graft with viable-appearing mucosa, an artery with a strong thrill, and palpable venous flow. The animals were then sacrificed.Results: The mean operation time required to laparoscopically harvest the small bowel graft was 80 min (range, 35-120 min), and the mean length of harvested graft was 220 cm (range, 200-260 cm). The mean length of the graft's vascular pedicle was 4.5 cm (range, 4 5 cm). All 10 grafts were successfully harvested laparoscopically and then reimplanted using an open technique. All the grafts maintained good vascular flow, and showed no evidence of mucosal necrosis at necropsy. Obviously, further studies would be required to examine the long-term results of reimplanting a laparoscopically harvested small bowel graft, but proposals for such studies is beyond the scope of this report.Conclusion.-Minimally invasive techniques can be used to harvest proximal small bowel grafts for living related small bowel transplantation