Bariatric surgery in old age:a comparative study of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in an Asia centre of excellence

Bariatric surgery has been proved to be the safest and efficient procedure in treating morbid obese patients,but data is still lacking in the elderly population.The aim of our study was to compare the safety and efficacy of laparoscopic Roux-en-Y gastric bypass（LRYGB） and sleeve gastrectomy（LSG） in patients aged more than 55 years.We performed2 a retrospective review of a prospectively collected database.All patients with body mass index（BMI） §32 kg/mand aged more than 55 years undergoing LRYGB or LSG in BMI Surgery Centre,E-Da Hospital between January 2008 and December 2011 with at least one year of follow up were included for the analysis.Demography,peri-operative data,weight loss and surgical complications were all recorded and analyzed.Mean age and BMI of these 68 patients22（22 males and 46 female） were 58.8 years（55-79 years） and 39.5 kg/m（32.00-60.40 kg/m）.LRYGB was performed in 44 patients and LSG in 24 patients.The two groups were comparable in their preoperative BMI,American Society of Anaesthesia（ASA） score and gender distribution.LSG patients were significantly older than patients receiving LRYGB.The proportion of type 2 diabetes preoperatively was significantly higher in LRYGB patients as compared to LSG patients（88.63% vs.50%; P,0.01）.The prevalence of other co-morbidities was similar and comparable2 between the groups.Mean BMI in the LRYGB and LSG groups at the end of 1 year were 28.8 kg/mand228.2 kg/m,respectively,and there was no statistically significant difference in mean percentage of excess weight loss（%EWL） at 1 year.The percentage of resolution of diabetes was significantly higher in LRYGB（69.2%） as compared to LSG（33.3%）.On the other hand,there was no statistical difference in the percentage of resolution of hypertension,hyperlipidemia and fatty liver hepatitis.The overall morbidity and re-operation rate was higher in LRYGB patients.In morbidly elderly patients,both surgeries achieved good weight loss and resolution of comorbidities.LRYGB is superior to LSG in terms of diabetes remission but carries higher complication rates even at high volume centres.

Predicting short-term thromboembolic risk following Roux-en-Y gastric bypass using supervised machine learning

BACKGROUND Roux-en-Y gastric bypass(RYGB)is a widely recognized bariatric procedure that is particularly beneficial for patients with class III obesity.It aids in significant weight loss and improves obesity-related medical conditions.Despite its effectiveness,postoperative care still has challenges.Clinical evidence shows that venous thromboembolism(VTE)is a leading cause of 30-d morbidity and mortality after RYGB.Therefore,a clear unmet need exists for a tailored risk assessment tool for VTE in RYGB candidates.AIM To develop and internally validate a scoring system determining the individualized risk of 30-d VTE in patients undergoing RYGB.METHODS Using the 2016–2021 Metabolic and Bariatric Surgery Accreditation Quality Improvement Program,data from 6526 patients(body mass index≥40 kg/m^(2))who underwent RYGB were analyzed.A backward elimination multivariate analysis identified predictors of VTE characterized by pulmonary embolism and/or deep venous thrombosis within 30 d of RYGB.The resultant risk scores were derived from the coefficients of statistically significant variables.The performance of the model was evaluated using receiver operating curves through 5-fold cross-validation.RESULTS Of the 26 initial variables,six predictors were identified.These included a history of chronic obstructive pulmonary disease with a regression coefficient(Coef)of 2.54(P<0.001),length of stay(Coef 0.08,P<0.001),prior deep venous thrombosis(Coef 1.61,P<0.001),hemoglobin A1c>7%(Coef 1.19,P<0.001),venous stasis history(Coef 1.43,P<0.001),and preoperative anticoagulation use(Coef 1.24,P<0.001).These variables were weighted according to their regression coefficients in an algorithm that was generated for the model predicting 30-d VTE risk post-RYGB.The risk model's area under the curve(AUC)was 0.79[95%confidence interval(CI):0.63-0.81],showing good discriminatory power,achieving a sensitivity of 0.60 and a specificity of 0.91.Without training,the same model performed satisfactorily in patients with laparoscopic sleeve gastrectomy with an AUC of 0.63(95%CI:0.62-0.64)and endoscopic sleeve gastroplasty with an AUC of 0.76(95%CI:0.75-0.78).CONCLUSION This simple risk model uses only six variables to assist clinicians in the preoperative risk stratification of RYGB patients,offering insights into factors that heighten the risk of VTE events.

Functional Roux-en-Y Gastric Bypass (F-RYGB), with Preservation of Duodenal Access: Report of Two Revisional Cases of Sleeve Gastrectomy

Objective: This case report aimed to demonstrate a possible neuromuscular effect of Latarjet nerves transection or truncal vagotomy, in association with sleeve gastrectomy plus antrojejunostomy, in order to reproduce a Roux-en-Y gastric bypass (RYGB) mechanistic principles, in patients with previous Sleeve Gastrectomy (SG) who had had weight regain, with or without concomitant gastroesophageal reflux disease (GERD). Background: Sleeve gastrectomy (SG) is one of the most frequently performed bariatric operations worldwide. Nevertheless, weight regain and gastroesophageal reflux disease (GERD) have been consistently demonstrated, in association with this technique, which may require a revisional procedure. RYGB is an option in such a situation but, implies in gastrointestinal exclusions, which represents a shortcoming of this revision. Surpassing this inconvenient would be of great value for the patients. Methods: We describe herein two cases of SG revision for weight regain and GERD, with a follow-up of one year. Gastroesophageal reflux disease was evaluated by validated questionnaire, upper endoscopy, seriography, high resolution manometry (HRM) and impedance pHmetry (I-pHmetry), in the pre and postoperative periods. A re-Sleeve Gastrectomy with antrojejunal anastomosis was done in both cases, after informed consents. The Latarjet nerves were transected in one case, due to a bleeding in the left gastric vessels and a truncal vagotomy was required in the other, to appropriately treat an associated hiatal hernia. Results: In the postoperative evaluation it was observed a pyloric spasm in both cases, during seriography and endoscopy, kept until the one-year follow-up. There was unidirectional contrast flow to the gastrointestinal anastomosis, filling the jejunal limb, in radiologic contrast study. No contrast passed through the pylorus. Nonetheless, the duodenum was kept endoscopically accessible. In the one-year evaluation, weight loss was adequate and GERD resolution was obtained in both cases, confirmed by endoscopic and functional esophageal assessment, together with symptoms questionnaire. Conclusion: The association of Latarjet nerves sectioning or truncal vagotomy with re-sleeve gastrectomy plus gastrointestinal anastomosis (antrojejunal), in a revision for a failed sleeve, can represent a technical approach, to reproduce RYGB results, without exclusions and with duodenum endoscopic accessibility maintenance. It maybe could be applied for primary surgeries. Additional studies are necessary to confirm this hypothesis.

Comparative study of outcomes following laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in morbidly obese patients: A case control study

To compare the impact of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) on weight loss and obesity related comorbidities over two year follow-up via case control study design. METHODSForty patients undergoing LRYGB, who completed their two year follow-up were matched with 40 patients undergoing LSG for age, gender, body mass index and presence of type 2 diabetes mellitus (T2DM). Data of these patients was retrospectively reviewed to compare the outcome in terms of weight loss and improvement in comorbidities, i.e., T2DM, hypertension (HTN), obstructive sleep apnea syndrome (OSAS), hypothyroidism and gastroesophageal reflux disease (GERD). RESULTSPercentage excess weight loss (EWL%) was similar in LRYGB and LSG groups at one year follow-up (70.5% vs 66.5%, P = 0.36) while it was significantly greater for LRYGB group after two years as compared to LSG group (76.5% vs 67.9%, P = 0.04). The complication rate after LRYGB and LSG was similar (10% vs 7.5%, P = 0.99). The median duration of T2DM and mean number of oral hypoglycemic agents were higher in LRYGB group than LSG group (7 years vs 5 years and 2.2 vs 1.8 respectively, P < 0.05). Both LRYGB and LSG had significant but similar improvement in T2DM, HTN, OSAS and hypothyroidism. However, GERD resolved in all patients undergoing LRYGB while it resolved in only 50% cases with LSG. Eight point three percent patients developed new-onset GERD after LSG. CONCLUSIONLRYGB has better outcomes in terms of weight loss two years after surgery as compared to LSG. The impact of LRYGB and LSG on T2DM, HTN, OSAS and hypothyroidism is similar. However, LRYGB has significant resolution of GERD as compared to LSG.

Two case reports of acute upper gastrointestinal bleeding from duodenal ulcers after Roux-en-Y gastric bypass surgery: Endoscopic diagnosis and therapy by single balloon or push enteroscopy after missed diagnosis by standard esophagogastroduodenoscopy

The diagnosis and opportunity for endoscopic therapy of gastric or duodenal lesions may be missed at esophagogastroduodenoscopy(EGD) because of technical difficulty in intubating at EGD the postoperatively excluded stomach and proximal duodenum in patients status post Roux-en-Y gastric bypass(RYGB). Two cases are reported of acute upper gastrointestinal bleeding 10 or 11 years status postRYGB, performed for morbid obesity, in which the EGD was non-diagnostic due to failure to intubate the excluded stomach and proximal duodenum, whereas subsequent push enteroscopy or single balloon enteroscopy were diagnostic and revealed 4-cm-wide or 5-mm-wide bulbar ulcers and even permitted application of endoscopic therapy. These case reports suggest consideration of push enteroscopy, or single balloon enteroscopy, where available, in the endoscopic evaluation of acute UGI bleeding in patients status post RYGB surgery when the EGD was non-diagnostic because of failure to intubate these excluded segments.

Effect of Roux-en-Y gastric bypass surgery on intestinal Akkermansia muciniphila

AIM: To investigated changes in intestinal Akkermansia muciniphila(A. muciniphila) and explored the mechanism underlying the therapeutic effects of Roux-en-Y gastric bypass(RYGB) surgery on type 2 diabetes in diabetic Goto-Kakizaki(GK) rats. METHODS: Male diabetic GK rats(n = 12) aged 8 wk were randomly assigned to the surgery group(GK-RYGB) or sham surgery group(GK-Sham)(n = 6 per group), and another 6 male Wistar rats aged 8 wk served as controls(WS-Sham). In the surgery group, RYGB surgery was conducted, and a sham operation was performed in both sham groups. Fasting blood glucose(FBG) levels before and after surgery, fasting levels of serum insulin and serum glucagon-like peptide-1(GLP-1) and levels 30 min after intragastric injection of glucose, and the amount of A. muciniphila in the stool were determined. Insulin and GLP-1 were measured by enzyme-linked immunosorbent assay, and A. muciniphila were detected by fluorescence-based quantitative polymerase chain reaction. RESULTS: The FBG was improved, and serum GLP-1 and insulin increased significantly(P < 0.05) in the GKRYGB group after surgery compared to levels before surgery and to levels in the GK-Sham group. Before surgery, the amounts of A. muciniphila in the GK-RYGB and GK-Sham groups were significantly lower than in the WS-Sham group(P < 0.05). After surgery, the amount of A. muciniphila in the GK-RYGB group increased markedly compared to that before surgery and to that in the GKSham and WS-Sham groups(P < 0.05). In addition, the A.muciniphila amount was positively related to GLP-1(r = 0.86, P < 0.05). CONCLUSION: Our results demonstrated RYGB surgery may increase GLP-1 secretion, elevate serum insulin after intragastric injection of glucose, and improve insulin resistance in diabetic GK rats, thereby contributing to a significant reduction in blood glucose. The increased amount of A. muciniphila after RYGB surgery may be related to elevated GLP-1 secretion.

Roux-en-Y gastric bypass for Chinese type 2 diabetes mellitus patients with a BMI,28kg/m^2:a multi-institutional study

Roux-en-Y gastric bypass surgery（RYGB） has been demonstrated to be successful for treating type-II diabetes2mellitus（T2DM） patients with a body mass index（BMI）,30 kg/m,but reports of RYGB for T2 DM patients with22 a BMI,28 kg/mare lacking.T2 DM patients with a BMI,28 kg/mwere prospectively recruited to participate in this study in four hospitals.The endpoint was T2 DM remission（defined by fasting blood glucose（FBG） level,110 mg/d L and hemoglobin（Hb）A1c level,6.0% at 12 months postoperatively）.Predictors of remission were investigated by univariate and multivariate analyses.Eighty-six patients were assessed.Eighty-five patients underwent RYGB,with one conversion to open surgery.We compared the values of various variables before and after2 surgery.The mean BMI decreased from 24.68±2.12 to 21.72±2.43 kg/m（P,0.001）.Fifty-eight（67.4%） patients were not treated by drugs or insulin after surgery,and 20 patients（23.3%） had complete remission of T2 DM at12 months after surgery with an acceptable number of complications.The mean Hb A1 c level in the remission group was significantly lower than that in the non-remission group.Patients with a higher weight,lower Hb A1 c level,higher C-peptide level,and higher FBG level were more likely to have T2 DM remission in multivariate2 analyses.In conclusion,RYGB was effective and safe for treating T2 DM patients with a BMI,28 kg/m.Complete remission can be predicted by cases having a higher weight,lower Hb A1 c level,higher C-peptide level,and higher FBG level.

Life threatening bleeding from duodenal ulcer after Roux-en-Y gastric bypass: Case report and review of the literature

Acute upper gastrointestinal bleeding is a rare, but serious complication of gastric bypass surgery. The inaccessibility of the excluded stomach restrains postoperative examination and treatment of the gastric remnant and duodenum, and represents a major challenge, especially in the emergency setting. A 59-year-old patient with previous history of peptic ulcer disease had an upper gastrointestinal bleeding from a duodenal ulcer two years after having a gastric bypass procedure for morbid obesity. After negative upper endoscopy finding, he was urgently evaluated for gastrointestinal bleeding. At emergency laparotomy, the bleeding duodenal ulcer was identified by intraoperative endoscopy through gastrotomy. The patient recovered well after surgical hemostasis, excision of the duodenal ulcer and completion of the remnant gastrectomy. Every general practitioner, gastroenterologist and general surgeon should be aware of growing incidenceof bariatric operations and coherently possible complications after such procedures, which modify patient's anatomy and physiology.

Analysis of long-term outcome of modified gastric bypass for type 2 diabetes mellitus in Chinese patients

BACKGROUND Bariatric and metabolic surgery have been routinely performed following the rapid increase in obesity and metabolic diseases worldwide.Of all evolving procedures,Roux-en-Y gastric bypass(RYGB)is considered the gold standard for surgical treatment of patients with type 2 diabetes mellitus(T2DM)and obesity.RYGB was introduced in China nearly 20 years ago,but the number of RYGB surgeries only accounts for 3.1%of the total number of weight loss and metabolic surgeries in China,it’s effect on Chinese people still needs further study.AIM To investigate the effect and safety of a modified gastric bypass performed in Chinese patients with T2DM.METHODS Patients with obesity and T2DM who underwent modified gastric bypass,with>5-year follow-up data,were analyzed.RESULTS All 37 patients underwent uneventful laparoscopic surgery,no patient was switched to laparotomy during the surgery,and no severe complications were reported.Average weight and body mass index of the patients reduced from 84.6±17.3(60.0–140.0)kg and 30.9±5.0(24.7–46.2)kg/m2 to 67.1±12.2(24.7–46.2)kg and 24.6±3.9(17.7–36.5)kg/m2,respectively,and fasting plasma glucose and glycated hemoglobin decreased from 7.4±3.4 mmol/L and 8.2%±1.7%preoperatively to 6.5±1.3 mmol/L and 6.5%±0.9%5-years postoperatively,respectively.Only 29.7%(11/37)of the patients used hypoglycemic drugs 5-years postoperatively,and the complete remission rate of T2DM was 29.7%(11/37).Triglyceride level reduced significantly but high-density lipoprotein increased significantly(both P<0.05)compared with those during the preoperative period.Liver and renal function improved significantly postoperatively,and binary logistic regression analysis revealed that the patients’preoperative history of T2DM and fasting C-peptide were significant prognostic factors influencing complete T2DM remission after RYGB(P=0.006 and 0.012,respectively).CONCLUSION The modified gastric bypass is a safe and feasible procedure for Chinese patients with obesity and T2DM,exhibiting satisfactory amelioration of weight problems,hyperglycemia,and combination disease.

Gastroenteroanastomosis Techniques for Laparoscopic Gastric Bypass: Linear vs Circular Stapler

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is an effective and well-accepted procedure for the treatment of morbid obesity but has complications such as stenosis of the gastroenteroanastomosis (GE), GE leak, surgical site infection, and stapling malfunction. This study evaluated the efficiency of weight loss and the incidence of short- and mid-term postoperative complications in patients undergoing LRYGB in which anastomosis was performed using a linear stapler (LSA) or a circular stapler (CSA). Methods: Prospective observational study conducted between April 2016 and March 2019. The data were extracted from a hospital database that includes patients undergoing LRYGB in two different GE techniques, assessing postoperative complications and excess body weight loss. Results: Data from 457 patients were analyzed, of which 216 were in the LSA group and 241 were in the CSA group. There were four cases (1.7%) of GE stenosis in the CSA group and only one (0.5%) in the LSA group. Stapler malfunction occurred in both groups: CSA (0.4%) and LSA (0.5%), and a GE leak developed only in the CSA group (0.4%). Surgical site infection was found in five patients in the CSA group (2.1%) and two in the LSA group (0.9%). No statistical difference was found between the two groups in any of the variables analyzed (p > 0.05). Conclusions: Both stapling techniques resulted in a similar loss of excess body weight during the follow-up period. Although the LSA group had fewer total complications, these were not statistically significant, which substantiates the fact that both techniques are safe and feasible, provided they are performed by a surgeon with a long learning curve in laparoscopic bariatric surgery.

Application of side-to-side anastomosis of the lesser curvature of stomach and jejunum in gastric bypass

AIM To evaluate the feasibility of side-to-side anastomosis of the lesser curvature of stomach and jejunum in laparoscopic Roux-en-Y gastric bypass(LRYGB).METHODS Seventy-seven patients received side-to-side anastomosis of the lesser curvature of stomach and jejunum by utilization of linear stapler in LRYGB from April 2012 to July 2015 were retrospectively analyzed.RESULTS All patients were successfully completed laparoscopic gastric bypass with the side-to-side anastomosis of the lesser curvature of stomach and jejunum. No patient was switched to laparotomy during operation. No early complications including gastrointestinal anastomotic bleeding, fistula, obstruction, deep vein thrombosis, incision infections, intra-abdominal hernia complications were found. One patient complicated with stricture of gastrojejunal anastomosis(1.3%) and six patients complicated with incomplete intestinal obstruction(7.8%). BMI and Hb A1 c determined at 3, 6, 12, 24 mo during follow up period were significantly reduced compared with preoperative baselines respectively. The percentage of patients who maintain HbA 1c(%) < 6.5% without taking antidiabetic drugs reached to 61.0%, 63.6%, 75.0%, and 63.6% respectively. The outcome parameters of concomitant diseases were significantly improved too.CONCLUSION Present surgery is a safety and feasibility procedure. It is effective to lighten the body weight of patients and improve type 2 diabetes and related complications.

Laparoscopic gastrojejunostomy for gastric outlet obstruction in patients with unresectable hepatopancreatobiliary cancers: A personal series and systematic review of the literature

The major symptoms of advanced hepatopancreaticbiliary cancer are biliary obstruction, pain and gastric outlet obstruction(GOO). For obstructive jaundice, surgical treatment should de consider in recurrent stent complications. The role of surgery for pain relief is marginal nowadays. On the last, there is no consensus for treatment of malignant GOO. Endoscopic duodenal stents are associated with shorter length of stay and faster relief to oral intake with more recurrent symptoms. Surgical gastrojejunostomy shows better long-term results and lower re-intervention rates, but there are limited data about laparoscopic approach. We performed a systematic review of the literature, according PRISMA guidelines, to search for articles on laparoscopic gastrojejunostomy for malignant GOO treatment. We also report our personal series, from 2009 to 2017. A review of the literature suggests that there is no standardized surgical technique either standardized outcomes to report. Most of the studies are case series, so level of evidence is low. Decisionmaking must consider medical condition, nutritional status, quality of life and life expectancy. Evaluation ofthe patient and multidisciplinary expertise are required to select appropriate approach. Given the limited studies and the difficulty to perform prospective controlled trials, no study can answer all the complexities of malignant GOO and more outcome data is needed.

Laparoscopic revolution in bariatric surgery

The history of bariatric surgery is investigational. Dedicated surgeons have continuously sought for an ideal procedure to relieve morbidly obese patients from their burden of comorbid conditions, reduced life expectancy and low quality of life. The ideal procedure must have low complication risk, both in short- and long term, as well as minimal impact on daily life. The revolution of laparoscopic techniques in bariatric surgery is described in this summary. Advances in minimal invasive techniques have contributed to reduced operative time, length of stay, and complications. The development in bariatric surgery has been exceptional, resulting in a dramatic increase of the number of procedures performed world wide during the last decades. Although, a complex bariatric procedure can be performed with operative mortality no greater than cholecystectomy, specific procedure-related complications and other drawbacks must be taken into account. The evolution of laparoscopy will be the legacy of the 21st century and at present, day-care surgery and further reduction of the operative trauma is in focus. The impressive effects on comorbid conditions have prompted the adoption of minimal invasive bariatric procedures into the field of metabolic surgery.

Changes in iron transporter divalent metal transporter 1 in proximal jejunum after gastric bypass

AIM: To describe the variation that divalent metal transporter 1 (DMT1) shows in patients after Roux-en-Y gastric bypass (RYGB) surgery.

Gastric Bypass with Long Pouch and Transit Bipartition for Endoscopic Access to the Remaining Stomach

Introduction: obesity has a complex and multifactorial etiology, difficult treatment and increasing incidence rates in recent decades. The treatment involves clinical and pharmacological approaches and, in case of lack of results, surgical interventions. Roux-en-Y gastric bypass (RYGB) is one of these surgical interventions in which the stomach is divided, creating a small pouch, and the remaining portion of the stomach become excluded and left without endoscopic access. Objective: to evaluate the results of modified RYGB with long pouch and endoscopic access to the remaining stomach. Materials and Methods: prospective clinical trial with sample selected among patients seen at the Alberto Rassi General State Hospital of Goi&#226nia (HGG) and indicated for bariatric and metabolic surgery confirmed by the medical and multidisciplinary team. The study was conducted from January 2020 to August 2021. Clinical history and laboratory test results of the selected patients were collected through consultations with the medical and multidisciplinary team. Results: twelve participants were included in the study. Of these, 11 (91.7%) were women and the mean age was 46.3 years. The weight before surgery was 112.17 kg (92.00 - 150.00) and the Body Mass Index (BMI) was 44.89 (35.06 - 74.39). After 18 months of surgery, the mean weight was 80.77 kg (±11.92) and the mean BMI was 29.46 (±11.00), showing a significant reduction in both (p = 0.003 and p = 0.002, respectively). All patients underwent endoscopic evaluation of the pouch, remaining stomach and duodenum at 12 months postoperatively. The mean percentage of lost excess weight loss was 68.21%. Conclusion: We conclude that the proposed changes in RYGB (GBLP + GIB – Roux-en-Y gastric bypass with long pouch and gastrointestinal bipartition) did not compromise weight loss or control of type 2 diabetes and other comorbidities and proved to be a safe and effective alternative without gastroduodenal exclusion, enabling a better postoperative follow-up.

Alcohol associated liver disease and bariatric surgery:Current perspectives and future directions

Bariatric surgery is a routinely performed procedure and is associated with a reduction in all-cause mortality in patients with obesity.However,bariatric sur-gery has also been linked to increased alcohol use with up to 30%of these patients developing alcohol use disorder(AUD).The mechanism of AUD after bariatric surgery is multifactorial and includes anatomic,metabolic,and neurohumoral changes associated with post-surgical anatomy.These patients are at increased risk of alcohol associated liver disease and,in some cases,require liver trans-plantation.In this article,we provide a scoping review of epidemiology,patho-physiology,and clinical outcomes of alcohol-related health conditions after bariatric surgery.

腹腔镜Roux-en-Y胃旁路术治疗2型糖尿病

目的探讨腹腔镜Roux-en-Y胃旁路手术(LRYGB)治疗2型糖尿病的方法、可行性及效果。方法 12例2型糖尿病患者根据BMI分为糖尿病合并肥胖症组及单纯糖尿病组,施行LRYGB,观察患者术前、术后体质量、空腹血糖、餐后2 h血糖、C肽及糖化血红蛋白情况。结果 12例皆成功完成手术,无中转开放。糖尿病合并肥胖症组术后3月糖尿病治愈率85.7%,单纯糖尿病组术后3月糖尿病治愈率80.0%,未治愈的2例患者术后降糖药物或胰岛素使用量较术前减少,血糖较术前降低。所有患者无明显手术并发症发生。结论 LRYGB治疗2型糖尿病手术操作可行,近期效果明显,长期效果仍待观察。

既往腹部手术史对腹腔镜Roux-en-Y胃旁路术的影响

目的:总结腹部手术史患者行腹腔镜Roux-en-Y胃旁路术(laparoscopic Roux-en-Y gastric bypass,LRYGB)的可行性及安全性。方法:回顾分析2011年1月至2013年10月89例LRYGB患者的资料。根据有无腹部手术史将患者分为腹部手术史组(n=19)与无腹部手术史组(n=70)。评估两组患者性别、年龄、美国麻醉医师协会(American Society of Anesthesiologists,ASA)病情分级、腹腔粘连发生率及粘连松解率、手术时间、术中失血量、中转开腹率、术中及术后并发症发生率、住院时间等指标。结果:无腹部手术史组与腹部手术史组患者术中发现腹腔粘连率分别为7.1%与73.7%,其中需松解率分别为0与71.4%,无因松解粘连引发的并发症。腹部手术史组女性患者所占比例、ASA分级及年龄较无腹部手术史组高(P<0.05),腹部手术史与增加的手术时间、住院时间有关(P<0.05)。两组患者术中失血量、中转开腹率、术中与术后并发症发生率差异无统计学意义(P>0.05)。结论:腹部手术史并非LRYGB的手术禁忌证。然而有腹部手术史的患者往往年龄、ASA分级高,增加了手术风险,且术中粘连松解率较高,手术时间、住院时间较长。

121例腹腔镜Roux-en-Y胃空肠吻合术后随访结果

目的探讨腹腔镜Roux-en-Y胃空肠吻合术（laparoscopic Roux-en-Y gastric bypass，LRYGBP）治疗病态肥胖的术后营养和代谢方面的变化。方法121例LRYGBP，男40例，女81例。分别测定术前1个月及术后6个月的体重指数（body mass index，BMI）。对比分析6个月、12个月，24个月血清铁（Fe）、钙（Ca）、锌（Zn）、硒（Se）及维生素A（VitA）、维生素D（VitD）、维生素B12（VitB12）和甲状旁腺素（parathyroid hormone，PTH）的水平变化。结果术前1个月BMI（47．00±7．15）kg／m^2，术后6个月BMI（33．79±6．06）kg／m^2，BMI下降（13．21±5．47）kg／m^2（t=26．103，P=0．000）。术后血清Fe、Ca、Zn、Se及ViLA、VitD、VitB12均在正常范围，其中术后6个月血清Zn、Se和VitA水平虽然在正常范围内，但分别有19．5％（17／87）、22．7％（20／88）和33．7％（28／83）的患者低于正常水平，但术后2年仅有6．7％（2／30）、11．5％（3／26）和17．2％（5／29）的患者低于正常水平。血清PTH术后6个月11～161pg／ml，（66±34）pg／ml、1年24～154pg／ml，（72±34）pg／ml、2年21～194pg／ml，（75±40）pg／ml（正常值9～44pg／ml）。结论LRYGBP治疗病态肥胖是有效、安全的。术后2年血清Fe、Ca及VitD、VitB12均正常；血清锌、硒及维生素A经术后6个月给予补充剂大多接近正常；血清PTH水平明显高于正常。建议患者术后长期服用复合维生素、矿物质补充剂，定期到医院随访。

Improved glucose metabolism following bariatric surgery is associated with increased circulating bile acid concentrations and remodeling of the gut microbiome

Clinical studies have indicated that circulating bile acid(BA) concentrations increase following bariatric surgery, especially following malabsorptive procedures such as Roux-en-Y gastric bypasses(RYGB). Moreover, total circulating BA concentrations in patients following RYGB are positively correlated with serum glucagonlike peptide-1 concentrations and inversely correlated with postprandial glucose concentrations. Overall, these data suggest that the increased circulating BA concentrations following bariatric surgery- independently of calorie restriction and body-weight loss- could contribute, at least in part, to improvements in insulin sensitivity, incretin hormone secretion, and postprandial glycemia, leading to the remission of type-2 diabetes(T2DM). In humans, the primary and secondary BA pool size is dependent on the rate of biosynthesis and the enterohepatic circulation of BAs, as well as on the gut microbiota, which play a crucial role in BA biotransformation. Moreover, BAs and gut microbiota are closely integrated and affect each other. Thus, the alterations in bile flow that result from anatomical changes caused by bariatric surgery and changes in gutmicrobiome may influence circulating BA concentrations and could subsequently contribute to T2 DM remission following RYGB. Research data coming largely from animal and cell culture models suggest that BAs can contribute, via nuclear farnezoid X receptor(FXR) and membrane G-protein-receptor(TGR-5), to beneficial effects on glucose metabolism. It is therefore likely that FXR, TGR-5, and BAs play a similar role in glucose metabolism following bariatric surgery in humans. The objective of this review is to discuss in detail the results of published studies that show how bariatric surgery affects glucose metabolism and subsequently T2 DM remission.