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.

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.

Transoral outlet reduction:Outcomes of endoscopic Roux-en-Y gastric bypass revision in 284 patients at a community practice

BACKGROUND Transoral outlet reduction(TORe)is a minimally invasive endoscopic revision of Roux-en-Y gastric bypass(RYGB)for weight recurrence;however,little has been published on its clinical implementation in the community setting.AIM To characterize the safety and efficacy of TORe in the community setting for adults with weight recurrence after RYGB.METHODS This is a retrospective cohort study of argon plasma coagulation and purse-string suturing for gastric outlet reduction in consecutive adults with weight recurrence after RYGB at a single community center from September 2020 to September 2022.Patients were provided longitudinal nutritional support via virtual visits.The primary outcome was total body weight loss(TBWL)at twelve months from TORe.Secondary outcomes included TBWL at three months and six months;excess weight loss(EWL)at three,six,and twelve months;twelve-month TBWL by obesity class;predictors of twelve-month TBWL;rates of post-TORe stenosis;and serious adverse events(SAE).Outcomes were reported with descriptive statistics.RESULTS Two hundred eighty-four adults(91.9%female,age 51.3 years,body mass index 39.3 kg/m^(2))underwent TORe an average of 13.3 years after RYGB.Median pre-and post-TORe outlet diameter was 35 mm and 8 mm,respectively.TBWL was 11.7%±4.6%at three months,14.3%±6.3%at six months,and 17.3%±7.9%at twelve months.EWL was 38.4%±28.2%at three months,46.5%±35.4%at six months,and 53.5%±39.2%at twelve months.The number of follow-up visits attended was the strongest predictor of TBWL at twelve months(R^(2)=0.0139,P=0.0005).Outlet stenosis occurred in 11 patients(3.9%)and was successfully managed with endoscopic dilation.There was one instance of post-procedural nausea requiring overnight observation(SAE rate 0.4%).CONCLUSION When performed by an experienced endoscopist and combined with longitudinal nutritional support,purse-string TORe is safe and effective in the community setting for adults with weight recurrence after RYGB.

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.

Surgical management of gallstone ileus after one anastomosis gastric bypass: A case report

BACKGROUND Gallstone ileus following one anastomosis gastric bypass(OAGB)is an exceptionally rare complication.The presented case report aims to highlight the unique occurrence of this condition and its surgical management.Understanding the clinical presentation,diagnostic challenges and successful surgical inter-vention in such cases is crucial for healthcare professionals involved in bariatric surgery.CASE SUMMARY We present a case report of gallstone ileus following OAGB and discuss its diagnosis and surgical management.A 66-year-old female with a history of OAGB presented to the emergency room with symptoms of small bowel obstru-ction.Computed tomography scan revealed a gallstone impacted in the distal ileum,causing obstruction.The patient underwent a laparoscopically assisted enterolithotomy,during which the gallstone was extracted and the enterotomy was closed.The patient had an uneventful recovery and was dis-charged on postoperative day four.CONCLUSION Gallstone ileus should be considered as a possible complication after OAGB,and prompt surgical intervention is usually required for its management.This case report contributes to the limited existing literature,providing insights into the management of this uncommon complication.

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.

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.

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.

Roux-en-Y gastric bypass promotes expression of PDX-1 and regeneration of β-cells in Goto-Kakizaki rats

AIM:To study the effects of Roux-en-Y gastric bypass(RYGB) on the expression of pancreatic duodenal homeobox-1(PDX-1) and pancreatic β-cell regeneration/neogenesis,and their possible mechanisms in diabetics.METHODS:Three groups of randomly selected nonobese diabetic Goto-Kakizaki(GK) rats were subjected to RYGB,sham-RYGB and sham-operation(sham-op) surgery,respectively.The rats were euthanized at postoperative 1,2,4 and 12 wk.Their pancreases were resected and analyzed using reverse transcription polymerase chain reaction to detect the mRNA of PDX-1.Anti-PDX-1 immunohistochemical(IHC) staining and Western blotting were used to detect the protein of PDX-1.Double IHC staining of anti-Brdu and-insulin was performed to detect regenerated β-cells.The index of double Brdu and insulin positive cells was calculated.RESULTS:In comparison with sham-RYGB and sham-op groups,a significant increase in the expressions of PDX-1 mRNA in RYGB group was observed at all experimental time points(1 wk:0.378 ± 0.013 vs 0.120 ± 0.010,0.100 ± 0.010,F = 727.717,P < 0.001;2 wk:0.318 ± 0.013 vs 0.110 ± 0.010,0.143 ± 0.015,F = 301.509,P < 0.001;4 wk:0.172 ± 0.011 vs 0.107 ± 0.012,0.090 ± 0.010,F = 64.297,P < 0.001;12 wk:0.140 ± 0.007 vs 0.120 ± 0.010,0.097 ± 0.015,F = 16.392,P < 0.001);PDX-1 protein in RYGB group was also increased significantly(1 wk:0.61 ± 0.01 vs 0.21 ± 0.01,0.15 ± 0.01,F = 3031.127,P < 0.001;2 wk:0.55 ± 0.00 vs 0.15 ± 0.01,0.17 ± 0.01,F = 3426.455,P < 0.001;4 wk:0.39 ± 0.01 vs 0.18 ± 0.01,0.22 ± 0.01,F = 882.909,P < 0.001;12 wk:0.41 ± 0.01 vs 0.20 ± 0.01,0.18 ± 0.01,F = 515.833,P < 0.001).PDX-1 mRNA and PDX-1 protein production showed no statistical significance between the two sham groups.Many PDX-1 positive cells could be found in the pancreatic islets of the rats in RYGB group at all time points.In addition,the percentage of Brdu-insulin double staining positive cells was higher in RYGB group than in the other two groups(1 wk:0.22 ± 0.13 vs 0.03 ± 0.06,0.03 ± 0.06,P < 0.05;2 wk:0.28 ± 0.08 vs 0.00 ± 0.00,0.03 ± 0.06,P < 0.05;4 wk:0.24 ± 0.11 vs 0.07 ± 0.06,0.00 ± 0.00,P < 0.001;12 wk:0.20 ± 0.07 vs 0.03 ± 0.06,0.00 ± 0.00,P < 0.05).CONCLUSION:RYGB can increase the expression of pancreatic PDX-1 and induce the regeneration of β-cells in GK rats.The associated regeneration of islet cells may be a possible mechanism that how RYGB could improve type 2 diabetes mellitus.

Gallstone-related complications after Roux-en-Y gastric bypass:a prospective study

BACKGROUND: Gastric bypass is a widespread bariatric procedure that carries a high incidence of gallstone formation postoperatively. Controversy exists regarding the importance and consequences of gallstones in these patients. There are surgeons who consider gallstone-related complications after gastric bypass important enough to require routine removal of the gallbladder during gastric bypass (prophylactic cholecystectomy). However, this can lead to increased costs and risks. This study aimed to identify complications related to cholelithiasis after Roux-en-Y gastric bypass (RYGBP). METHODS: This is a prospective observational study of 40 morbidly obese patients free of gallbladder disease. The patients underwent open RYGBP at a public hospital in Brazil from February to October 2007. They were followed up clinically and ultrasonographically at 6 months and 1, 2, and 3 years after surgery. Of the patients, 38 patients were followed up for 3 years. RESULTS: Eleven patients (28.9%) developed cholelithiasis, four (10.5%) experienced biliary pain, and 2 suffered from acute biliary pancreatitis (5.3%). These patients had their gallbladders removed laparoscopically. No patient presented with acute cholecystitis, choledocholithiasis, or bile duct dilation during the follow-up period. There were no deaths. CONCLUSIONS: Gallstone-related complications after RYGBP were relatively common. Some of these complications, like acute pancreatitis, are known to have potentially severe outcomes. It seems reasonable to perform cholecystectomy during gastric bypass in the presence of cholelithiasis or after this procedure if gallstones develop.

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

AIM 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.METHODS Forty 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., T2 DM, hypertension(HTN), obstructive sleep apnea syndrome(OSAS), hypothyroidism and gastroesophageal reflux disease(GERD).RESULTS Percentage 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 T2 DM 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 T2 DM, 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.CONCLUSION LRYGB has better outcomes in terms of weight loss two years after surgery as compared to LSG. The impact of LRYGB and LSG on T2 DM, HTN, OSAS and hypothyroidism is similar. However, LRYGB has significant resolution of GERD as compared to LSG.

Comparison of different gastric bypass procedures in gastric carcinoma patients with type 2 diabetes mellitus

AIM:To determine the effect of different Roux-en-Y gastric bypass procedures in gastric carcinoma patients with type 2 diabetes mellitus.METHODS:A retrospective analysis of the clinical data of 54 patients with gastric cancer and type 2 diabetes mellitus treated in the Department of General Surgery from January 2006 to June 2013 was conducted.The patients underwent gastrectomy using different Rouxen-Y gastric bypass procedures(traditional,n=26;modified,n=28).Fasting plasma glucose(FPG),two hour postprandial blood glucose(2 h PBG)and hemoglobin A1c(Hb A1c)were analyzed before surgery(0 mo)and 1,3 and 6 mo after surgery.RESULTS:FPG and 2 h PBG levels were significantlydecreased 1 mo after surgery in the traditional Rouxen-Y gastric bypass group(FPG 7.5±1.3 vs 10.7±1.2,P<0.05)(2 h PBG 10.2±1.8 vs 13.8±3.2,P<0.05).FPG and 2 h PBG levels were significantly decreased after surgery in the modified Roux-en-Y gastric bypass group(FPG 6.9±1.2 vs 10.5±1.1,6.5±1.3 vs 10.5±1.1,6.4±1.2 vs 10.5±1.1,P<0.05)(2 h PBG9.9±2.2 vs 14.1±2.9,9.2±2.4 vs 14.1±2.9,8.9±2.6 vs 14.1±2.9,P<0.05).Compared with the levels before surgery,Hb A1c levels were significantly decreased 3 and 6 mo after surgery(7.2±1.1 vs 10.5±1.1,5.5±1.1 vs 10.5±1.1,P<0.05).Significant differences between the two groups regarding FPG,2 h PBG and Hb A1c concentration were observed 3 and 6mo after surgery(FPG 10.1±1.5 vs 6.5±1.3,10.3±1.4 vs 6.4±1.2,P<0.05)(2 h PBG 13.1±2.8 vs 9.2±2.4,13.6±3.1 vs 8.9±2.6,P<0.05)(Hb A1c 10.1±1.4 vs 7.2±1.1,10.5±1.3 vs 5.5±1.1,P<0.05).CONCLUSION:Modified Roux-en-Y gastric bypass can improve glucose metabolism in type 2 diabetic patients with gastric cancer.

Incidence and risk factors for the development of anemia following gastric bypass surgery

AIM:To evaluate the incidence and risk factors for the development of anemia after RouxenY gastric bypass (RYGB).METHODS: A retrospective analysis of patients undergoing RYGB from January 2003 to November 2007 was performed. All patients had a preoperative body mass index > 40 kg/m2. A total of 206 patients were evaluated. All patients were given daily supplements of ferrous sulfate tablets for 2 wk following their operation. Hematological and metabolic indices were routinely evaluated following surgery. Patients were followed for a minimum of 86 wk.RESULTS: There were 41 males and 165 females with an average age of 40.8 years. 21 patients (10.2%) developed postoperative anemia and 185 patients (89.8%) did not. Anemia was due to iron deficiency in all cases. The groups had similar demographics, surgical procedure and comorbidities. Menstruation (P = 0.02) and peptic ulcer disease (P = 0.01) were risk factors for the development of postoperative anemia.CONCLUSION: Iron deficiency anemia is frequent. RYGB surgery compounds occult blood loss. Increased ferrous sulfate supplementation may prevent iron depletion in populations at increased risk.

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.

Outcomes of Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding

AIM:To evaluate weight loss and surgical outcomes of Roux-en-Y gastric bypass(RYGB)and laparoscopic adjustable gastric band(LAGB).METHODS:Data relating to changes in body mass index(BMI)and procedural complications after RYGB(1995-2009;n=609;116M:493F;42.4±0.4 years)or LAGB(2004-2009;n=686;131M:555F;37.2±0.4years)were extracted from prospective databases.RESULTS:Pre-operative BMI was higher in RYGB than LAGB patients(46.8±7.1 kg/m2vs 40.4±4.2 kg/m2,P<001);more patients with BMI<35 kg/m2underwent LAGB than RYGB(17.1%vs 4.1%,P<0.0001).BMI decrease was greater after RYGB.There were direct relationships between weight loss and pre-operative BMI(P<0.001).Although there was no difference in weight loss between genders during the first 3-year post-surgery,male LAGB patients had greater BMI reduction than females(-8.2±4.3 kg/m2vs-3.9±1.9kg/m2,P=0.02).Peri-operative complications occurred more frequently following RYGB than LAGB(8.0%vs0.5%,P<0.001);majority related to wound infection.LAGB had more long-term complications requiring corrective procedures than RYGB(8.9%vs 2.1%,P<0.001).Conversion to RYGB resulted in greater BMI reduction(-9.5±3.8 kg/m2)compared to removal and replacement of the band(-6.0±3.0 kg/m2).Twelve months post-surgery,fasting glucose,total cholesterol and low density lipoprotein levels were significantly lower with the magnitude of reduction greater in RYGB patients.CONCLUSION:RYGB produces substantially greater weight loss than LAGB.Whilst peri-operative complications are greater after RYGB,long-term complication rate is higher following LAGB.

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.

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.

Surgical outcome of laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass for resolution of type 2 diabetes mellitus:A systematic review and meta-analysis

BACKGROUND Bariatric procedures are considered superior to medical therapies in managing type 2 diabetes mellitus(T2DM).Laparoscopic Roux-en-Y gastric bypass(LRYGB)and laparoscopic sleeve gastrectomy(LSG)are the most commonly used procedures for weight loss and comorbidity resolution worldwide.However,it is not yet known whether the degree of T2DM is influenced by the choice of bariatric procedure.AIM To quantitatively compare T2DM resolution over 1-5 years follow-up by LRYGB and LSG in morbidly obese patients.METHODS We searched the selected databases for full-text English language clinical studies that compared the effectiveness of LRYGB and LSG for T2DM resolution.Review manager 5.3 was used for data analysis,and the overall effect summary was represented in a forest plot.RESULTS From 1,650 titles retrieved by an initial search,we selected nine studies for this research.We found insignificant differences for T2DM resolution by LRYGB and LSG,with an odds ratio of 0.93(95%CI:0.64-1.35,Z statistics=0.38,P=0.71).Additionally,subset analyses for T2DM resolution showed insignificant differences after 24 mo(χ^2=1.24,df=4,P=0.87,overall Z effect=0.23),36 mo(χ^2=0.41,df=2,P=0.81,overall Z effect=0.51),and 60 mo(χ^2=4.75,df=3,P=0.19,overall Z effect=1.20)by LRYGB and LSG.This study reports a T2DM remission rate of 82.3%by LRYGB and 80.7%by LSG.CONCLUSION This study reports similar T2DM resolution rates by both LRYGB and LSG during 1-5 years of follow-up.However,long-term follow-up of 10 years is needed to further substantiate these findings.

Management of gallstones and gallbladder disease in patients undergoing gastric bypass

The appropriate management of gallstones and gallbladder disease in patients undergoing gastric bypass remains unknown.Several therapeutic modalities are used and include performing cholecystectomy on all patients at the time of gastric bypass,performing concomitant cholecystectomy only when patients have gallstones and performing cholecystectomy only in the presence of both symptoms and gallstones.Some groups administer ursodeoxycholic acid for gallstone prevention in the postoperative period.All treatment modalities are analyzed and their results and rationality are discussed.

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

AIM:To describe the variation that divalent metaltransporter 1(DMT1)shows in patients after Rouxen-Y gastric bypass(RYGB)surgery.METHODS:Prospective and analytical study of DMT1level at the brush border of proximal jejunum in patients having undergone RYGB surgery.The mucosa of proximal jejunum forming the gastrojejunal anastomosis was biopsied during surgery and after 6 mo later with an endoscopic biopsy.All the patients received precise instructions regarding feeding and nutritional supplementation.Both samples were processed at the same time by immunohistochemistry and western blot.Samples were analysed by a pathologist.For statistical analysis,theχ2 and Wilcoxon tests were used.RESULTS:Sixteen patients were recruited,13 of whom completed the study.Twelve were women.Average age and body mass index(BMI)were 44.1 and 40.4,respectively.Both body weight and BMI decreased significantly during the study period,with an average percent excess weight loss(%EWL)of 60%±13.3%and an average percent excess BMI loss(%EBMIL)of 79.6%±21.6%.Only two patients presented with mild anaemia6 mo after surgery,but their ferritin levels stayed within normal ranges.Staining for DMT1 showed a significant increase in the cytoplasm of enterocytes located at the tips of the villi(χ2=6.03;P=0.049).Nevertheless,the total quantity of DMT1 decreased significantly(Z=2.04;P=0.04).Associated with these results,we observed a significant increase in goblet cells in the villi 6mo postoperatively(Z=-2.47;P=0.013).CONCLUSION:Six months after RYGB surgery,patients exhibit an increase in DMT1 expression in the enterocytes of the tips of the villi at the proximal jejunum.