Bariatric surgery and long-term nutritional issues

Bariatric surgery is recognized as a highly effective therapy for obesity since it accomplishes sustained weight loss, reduction of obesity-related comorbidities and mortality, and improvement of quality of life. Overall, bariatric surgery is associated with a 42% reduction of the cardiovascular risk and 30% reduction of all-cause mortality. This review focuses on some nutritional consequences that can occur in bariatric patients that could potentially hinder the clinical benefits of this therapeutic option. All bariatric procedures, to variable degrees, alter the anatomy and physiology of the gastrointestinal tract; this alteration makes these patients more susceptible to developing nutritional complications, namely, deficiencies of macro-and micro-nutrients, which could lead to disabling diseases such as anemia, osteoporosis, protein malnutrition. Of note is the evidence that most obese patients present a number of nutritional deficits already prior to surgery, the most important being vitamin D and iron deficiencies. This finding prompts the need for a complete nutritional assessment and, eventually, an adequate correction of pre-existing deficits before surgery. Another critical issue that follows bariatric surgery is post-operative weight regain, which is commonly associated with the relapse of obesity-related comorbidities. Nu-tritional complications associated with bariatric surgery can be prevented by life-long nutritional monitoring with the administration of multivitamins and mineral supplements according to the patient's needs.

2型糖尿病大鼠胃肠手术模型的建立

目的:利用糖尿病大鼠建立手术治疗糖尿病的实验动物模型。方法:SPF级SD大鼠60只,所有动物给予8周的高脂高糖饮食,随后予以腹腔注射链脲佐菌素(40mg/kg)制备糖尿病大鼠模型。造模成功一周后行手术,选取24只随机分为2组,分别为十二指肠空肠旁路手术组(DJB,n=12)、Roux-en-y旁路手术组(RYGB,n=12)。结果:术后大鼠的总生存率达到83.3%,术后第8周,两组大鼠均存活10只。结论:胃肠道手术的2型糖尿病大鼠模型是可行的,可用于长期观察及检测研究,有助于临床评估相关手术的远期效果。

肝总管空肠微创吻合手术效果研究

目的探讨肝总管空肠微创吻合手术(Roux-en-Y吻合术)的临床效果,为其研究应用提供可参考依据。方法回顾性分析46例入住该院行腹腔镜肝总管空肠Roux-en-Y吻合术的患者作为观察组,选择38例开腹行肝总管空肠Roux-en-Y吻合术的患者作为对照组,比较两组围手术期差异及并发症发生情况。结果观察组患者术中出血量、切口长度、术后胃肠道恢复时间及住院时间均明显低于对照组,而手术时间高于对照组,差异有统计学意义(P<0.05)。术后观察组患者C反应蛋白(CRP)、白细胞介素-6(IL-6)、肿瘤坏死因子-α(TNF-α)水平低于对照组,差异有统计学意义(P<0.05)。观察组切口感染发生率明显低于对照组,差异有统计学意义(P<0.05)。结论腹腔镜下肝总管空肠Roux-en-Y吻合术有较好的疗效及安全性,值得临床推广应用。

Initial experience of single-incision plus one port left-side approach totally laparoscopic distal gastrectomy with uncut Roux-en-Y reconstruction

BACKGROUND Single incision plus one port left-side approach(SILS+1/L)totally laparoscopic distal gastrectomy(TLDG)is an emerging technique for the treatment of gastric cancer.Reduced port laparoscopic gastrectomy has a number of potential advantages for patients compared with conventional laparoscopic gastrectomy:relieving postoperative pain,shortening hospital stay and offering a better cosmetic outcome.Nevertheless,there are no previous reports on the use of SILS+1/L TLDG with uncut Roux-en-Y(uncut R-Y)reconstruction.AIM To investigate the initial feasibility of SILS+1/L TLDG with uncut Roux-en-Y digestive tract reconstruction(uncut R-Y reconstruction)to treat distal gastric cancer.METHODS A total of 21 patients who underwent SILS+1/L TLDG with uncut R-Y reconstruction for gastric cancer were enrolled.All patients were treated at The Second Hospital of Shandong University.Reconstructions were performed intracorporeally with 60 mm endoscopic linear stapler and 45 mm no-knife stapler.The clinicopathological characteristics,surgical details,postoperative short-term outcomes,postoperative follow-up upper gastrointestinal radiography findings and endoscopy results were analyzed retrospectively.RESULTS All SILS+1/L operations were performed by SILS+1/L TLDG successfully.The patient population included 13 men and 8 women with a mean age of 48.2 years(ranged from 40 years to 70 years)and median body mass index of 22.8 kg/m^2.There were no conversions to open laparotomy,and no other port was placed.The mean operation time was 146 min(ranged 130-180 min),and the estimated mean blood loss was 54 mL(ranged 20-110 mL).The mean duration to flatus and discharge was 2.3(ranged 1-3.5)and 7.3(ranged 6-9)d,respectively.The mean number of retrieved lymph nodes was 42(ranged 30-47).Two patients experienced mild postoperative complications,including surgical site infection(wound at the navel incision)and mild postoperative pancreatic fistula(grade A).Follow-up upper gastrointestinal radiography and endoscopy were carried out at 3 mo postoperatively.No patients experienced moderate or severe food stasis,alkaline gastritis or bile reflux during the follow-up period.No recanalization of the biliopancreatic limb was found.CONCLUSION SILS+1/L TLDG with uncut R-Y reconstruction could be safely performed as a reduced port surgery.

Laparoscopic gastric bypass vs sleeve gastrectomy in obese Korean patients

AIM: To compare the mid-term outcomes of lapa-roscopic sleeve gastrectomy(LSG) and laparoscopic Roux-en-Y gastric bypass(LRYGB) in obese Korean patients. METHODS: All consecutive patients who underwent either LSG or LRYGB with primary to treat morbid obesity between January 2011 and December 2012 were retrospectively reviewed. Patients with a body mass index(BMI) ≥ 30 kg/m2 with inadequately controlled obesity-related comorbidities(e.g., diabetes, obstructive sleep apnea, hypertension, or obesityrelated arthropathy) or BMI ≥ 35 kg/m2 were considered for bariatric surgery according to the International Federation for the Surgery of Obesity-Asia Pacific Chapter Consensus statements in 2011. The decision regarding the procedure type was made on an individual basis following extensive discussion with the patient about the specific risks associated with each procedure. All operative procedures were performed laparoscopically by a single surgeon experienced in upper gastrointestinal surgeries. Baseline demographics, perioperative surgical outcomes, and postoperative anthropometric data from a prospectively established database were thoroughly reviewed and compared between the two surgical approaches.RESULTS: One hundred four patients underwent LSG, and 236 underwent LRYGB. Preoperative BMI in the LSG group was significantly higher than that of the LRYGB group(38.6 kg/m2 vs 37.2 kg/m2, P = 0.024). Patients with diabetes were more prevalent in the LRYGB group(18.3% vs 35.6%, P = 0.001). Operating time and hospital stay were significantly shorter in the LSG group compared with the LRYGB group(100 min vs 130 min, P < 0.001; 1 d vs 2 d, P = 0.003), but the incidence of perioperative complications was similar between the groups(P = 0.351). The mean percentage of excess weight loss(%EWL) was 71.2% for LRYGB, while it was 63.5% for LSG, at mean follow-up periods of 18.0 and 21.0 mo, respectively(P = 0.073). The %EWL at 1, 3, 6, 12, 18, 24, and 36 mo was equivalentbetween the groups. Four patients required surgical revision after LSG(4.8%), while revision was only required in one case following LRYGB(0.4%; P = 0.011).CONCLUSION: Both LSG and LRYGB are effective procedures that induce comparable weight loss in the mid-term and similar surgical risks, except for the higher revision rate after LSG.

Spontaneous rupture of a mucinous cystic neoplasm of the liver resulting in a huge biloma in a pregnant woman:A case report

BACKGROUND Mucinous cystic neoplasm of the liver(MCN-L)and intraductal papillary neoplasm of the bile duct(IPN-B)are two different types of mucin-producing bile duct tumour that may complicate the course of pregnancy.To the best of our knowledge,we describe herein the first case of MCN-L with spontaneous rupture during pregnancy necessitating complex surgical treatment.CASE SUMMARY A 24-year-old woman was initially admitted to another hospital in October 2018 with signs of jaundice(serum bilirubin level 12 mg/dL)and upper abdominal pain radiating to the left shoulder.Initial magnetic resonance imaging(MRI)of the abdominal cavity revealed a multilocular cystic tumour of the liver hilum(37 mm×40 mm in diameter)located between segments 3 and 4 of the left liver lobe.Six weeks later(December 2018),the patient was found to be 12 wk pregnant and was referred to our institution for further diagnostics and treatment.At admission,a soft,palpable,and tender mass in the left upper abdomen was found.It was determined via MRI(with no intravenous contrast in view of the first-trimester pregnancy)to be a large collection of fluid(19 cm×17 cm×10 cm)located close to the liver hilum and below the left liver lobe.The patient did not undergo any diagnostic or therapeutic procedures nor did they have any abdominal trauma in the preceding weeks.The fluid collection proved to be of biliary origin following percutaneous drainage.Therefore,we concluded this was a spontaneous rupture of an MCN-L with the formation of a biloma.The MRI study also revealed the previously found cystic tumour of the liver hilum communicating with the left hepatic duct,which,together with left hepatic duct dilatation,suggested the diagnosis of IPN-B.The follow-up MRI with intravenous gadolinium contrast performed in the second trimester of pregnancy(week 14)showed,in turn,some features of MCN-L,including enhancement of the internal septations within the cystic liver mass.A precise preoperative differential diagnosis between IPN-B and MCN-L was therefore not possible.The patient was submitted to surgery in the second trimester of pregnancy(week 18).Surgery included a cholecystectomy,left hepatectomy,and concomitant resection of the extrahepatic bile ducts followed by anastomosis of the right hepatic duct with the Roux limb of the jejunum.The post-operative period was uneventful and the patient was discharged 8 days after surgery.The histopathological examination of the resected specimen revealed a final diagnosis of MCN-L with low-grade dysplasia and epithelium surrounded by ovarian-type stromal tissue.The patient delivered a healthy baby girl and both remain well at present,after 2 years of follow-up since surgery.CONCLUSION The differential diagnosis and management of MCN-L and IPN-B may be very challenging,particularly in the setting of pregnancy.When indications for surgery are obvious,the final diagnosis is based on histopathological examination,with ovarian-type stroma being pathognomonic for MCN-L.We believe that the growth of this subepithelial stroma secondary to the high levels of sex hormones produced during pregnancy might have been the main causative factor leading to the tumour rupture with the formation of a biloma in our patient.

Treatment of afferent loop syndrome using fluoroscopic-guided nasointestinal tube placement: Two case reports

BACKGROUND Afferent loop syndrome(ALS)is a rare mechanical complication that occurs after reconstruction of the stomach or esophagus to the jejunum,such as Billroth II gastrojejunostomy,Roux-en-Y gastrojejunostomy,or Roux-en-Y esophagojejunostomy.Traditionally,an operation is the first choice for benign causes.However,for patients in poor physical condition who experience ALS soon after R0 resection,the type of treatment remains controversial.Here,we present an efficient conservative method to treat ALS.CASE SUMMARY Case 1 was a 69-year-old male patient who underwent total gastrectomy with Roux-en-Y jejunojejunostomy.On postoperative day(POD)10 he developed symptoms of ALS that persisted and increased over 1 wk.Case 2 was a 59-yearold male patient who underwent distal gastrectomy with Billroth II gastrojejunostomy.On postoperative day POD 9 he developed symptoms of ALS that persisted for 2 wk.Both patients underwent fluoroscopic-guided nasointestinal tube placement with maintenance of continuous negative pressure suction.Approximately 20 d after the procedure,both patients had recovered well and were discharged from hospital after removal of the tube.At 3-mo follow-up,there were no signs of ALS in these two patients.CONCLUSION This is the first report of treating postoperative ALS by fluoroscopic-guided nasointestinal tube placement.Our cases demonstrate that this procedure is an effective and safe method to treat ALS that relieves patients’symptoms and avoids complications caused by other invasive procedures.

Roux-en-Y versus BillrothⅠreconstruction after distal gastrectomy for gastric cancer:A meta-analysis

AIM: To conduct a meta-analysis to compare Roux-en-Y (R-Y) gastrojejunostomy with gastroduodenal Billroth?I?(B-I) anastomosis after distal gastrectomy (DG) for gastric cancer.METHODS: A literature search was performed to identify studies comparing R-Y with B-I?after DG for gastric cancer from January 1990 to November 2012 in Medline, Embase, Science Citation Index Expanded and the Cochrane Central Register of Controlled Trials in The Cochrane Library. Pooled odds ratios (OR) or weighted mean differences (WMD) with 95%CI were calculated using either ?xed or random effects model. Operative outcomes such as operation time, intraoperative blood loss and postoperative outcomes such as anastomotic leakage and stricture, bile re?ux, remnant gastritis, re?ux esophagitis, dumping symptoms, delayed gastric emptying and hospital stay were the main outcomes assessed. Meta-analyses were performed using RevMan 5.0 software (Cochrane library).RESULTS: Four randomized controlled trials (RCTs) and 9 non-randomized observational clinical studies (OCS) involving 478 and 1402 patients respectively were included. Meta-analysis of RCTs revealed that R-Y reconstruction was associated with a reduced bile re?ux (OR 0.04, 95%CI: 0.01, 0.14; P < 0.00?001) and remnant gastritis (OR 0.43, 95%CI: 0.28, 0.66; P = 0.0001), however needing a longer operation time (WMD 40.02, 95%CI: 13.93, 66.11; P = 0.003). Meta-analysis of OCS also revealed R-Y reconstruction had a lower incidence of bile re?ux (OR 0.21, 95%CI: 0.08, 0.54; P = 0.001), remnant gastritis (OR 0.18, 95%CI: 0.11, 0.29; P < 0.00?001) and re?ux esophagitis (OR 0.48, 95%CI: 0.26, 0.89; P = 0.02). However, this reconstruction method was found to be associated with a longer operation time (WMD 31.30, 95%CI: 12.99, 49.60; P = 0.0008).CONCLUSION: This systematic review point towards some clinical advantages that are rendered by R-Y compared to B-I?reconstruction post DG. However there is a need for further adequately powered, well-designed RCTs comparing the same.

Mirizzi综合征的临床诊治

目的 探讨Mirizzi综合征的临床特点和外科手术治疗方式。方法 回顾性总结分析 2 1例Mi rizzi综合征病人的临床资料。结果 2 1例病人分别行胆囊切除或部分胆囊切除、直接瘘口修补或胆囊壁修补及Rouxen Y式肝总管十二指肠吻合术或空肠吻合术 ,所有病人均痊愈出院。结论 术前明确诊断可减少Mirizzi综合征术后胆道损伤的发生率 ,ERCP、B超是术前明确诊断的主要手段 。