Novel subtype of obesity influencing the outcomes of sleeve gastrectomy:Familial aggregation of obesity

BACKGROUND Differences in the preoperative characteristics and weight loss outcomes after sleeve gastrectomy(SG)between patients with familial aggregation of obesity(FAO)and patients with sporadic obesity(SO)have not been elucidated.AIM To explore the impact of SG on weight loss and the alleviation of obesity-related comorbidities in individuals with FAO.METHODS A total of 193 patients with obesity who underwent SG were selected.Patients with FAO/SO were matched 1:1 by propensity score matching and were categorized into 4 groups based on the number of first-degree relatives with obesity(1 SO vs 1FAO,2SO vs 2FAO).The baseline characteristics,weight loss outcomes,prevalence of obesity-related comorbidities and incidence of major surgeryrelated complications were compared between groups.RESULTS We defined FAO as the presence of two or more first-degree relatives with obesity.Patients with FAO did not initially show significant differences in baseline data,short-term postoperative weight loss,or obesity-related comorbidities when compared to patients with SO preoperatively.However,distinctions between the two groups became evident at the two-year mark,with statistically significant differences in both percentage of total weight loss(P=0.006)and percentage of excess weight loss(P<0.001).The FAO group exhibited weaker remission of type 2 diabetes mellitus(T2DM)(P=0.031),hyperlipidemia(P=0.012),and non-alcoholic fatty liver disease(NAFLD)(P=0.003)as well as a lower incidence of acid reflux(P=0.038).CONCLUSION FAO patients is associated with decreased mid-to-long-term weight loss outcomes;the alleviation of T2DM,hyperlipidemia and NAFLD;and decreased incidence of acid reflux postoperatively.

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.

Research on Sleeve Grouting Density Detection Based on the Impact Echo Method

Grouting defects are an inherent challenge in construction practices,exerting a considerable impact on the operational structural integrity of connections.This investigation employed the impact-echo technique for the detection of grouting anomalies within connections,enhancing its precision through the integration of wavelet packet energy principles for damage identification purposes.A series of grouting completeness assessments were meticulously conducted,taking into account variables such as the divergent material properties of the sleeves and the configuration of adjacent reinforcement.The findings revealed that:(i)the energy distribution for the highstrength concrete cohort predominantly occupied the frequency bands 42,44,45,and 47,whereas for other groups,it was concentrated within the 37 to 40 frequency band;(ii)the delineation of empty sleeves was effectively discernible by examining the wavelet packet energy ratios across the spectrum of frequencies,albeit distinguishing between sleeves with 50%and full grouting density proved challenging;and(iii)the wavelet packet energy analysis yielded variable detection outcomes contingent on the material attributes of the sleeves,demonstrating heightened sensitivity when applied to ultrahigh-performance concrete matrices and GFRP-reinforced steel bars.

Left lower lobe sleeve resection for the clear cell variant of pulmonary mucoepidermoid carcinoma:A case report

BACKGROUND Pulmonary mucoepidermoid carcinoma(PMEC)is a rare malignancy that arises from minor salivary glands within the tracheobronchial tree.The clear cell variant of PMEC is exceptionally uncommon and presents notable diagnostic challenges,primarily attributable to its morphological similarity to other tumors containing clear cells.CASE SUMMARY A 22-year-old male,formerly in good health,came in with a two-month duration of persistent cough and production of sputum.Subsequent imaging and bronchoscopy examinations revealed a 2 cm tumor in the distal left main bronchus,which resulted in complete atelectasis of the left lung.Further assessment via positron emission tomography/computed tomography scans and endoscopic biopsy confirmed the primary malignant nature of the tumor,charac-terized by clear cell morphology in most of the tumor cells.The patient underwent a left lower lobe sleeve resection accompanied by systematic mediastinal lymph node dissection.Molecular pathology analysis subsequently revealed a CRTC3-MAML2 gene fusion,leading to a definitive pathological diagnosis of the clear cell variant of PMEC,staged as T2N0M0.After surgery,the patient experienced a smooth recovery and exhibited no signs of recurrence during the one-and-a-half-year follow-up period.CONCLUSION This article describes an unusual case of a clear cell variant of PMEC characterized by the presence of a CRTC3-MAML2 gene fusion in a 22-year-old male.The patient underwent successful left lower lobe sleeve resection.This case underscores the distinctive challenges associated with diagnosing and treating this uncommon malignancy,underscoring the importance of precise diagnosis and personalized treatment strategies.

Endoscopic sleeve gastroplasty in class Ⅲ obesity:Efficacy, safety, and durability outcomes in 404 consecutive patients

BACKGROUND Endoscopic sleeve gastroplasty(ESG) is an effective therapy for class Ⅰ-Ⅱ obesity, but there are knowledge gaps in the published literature about its implementation in patients with class Ⅲ obesity [body mass index(BMI) ≥ 40 kg/m2].AIM To evaluate the safety, clinical efficacy, and durability of ESG in adults with class Ⅲ obesity.METHODS This was a retrospective cohort study that used prospectively collected data on adults with BMI ≥ 40 kg/m2who underwent ESG and longitudinal lifestyle counseling at two centers with expertise in endobariatric therapies from May 2018-March 2022. The primary outcome was total body weight loss(TBWL) at 12 mo. Secondary outcomes included changes in TBWL, excess weight loss(EWL) and BMI at various time points up to 36 mo, clinical responder rates at 12 and 24 mo, and comorbidity improvement. Safety outcomes were reported through the study duration. One-way ANOVA test was performed with multiple Tukey pairwise comparisons for TBWL, EWL, and BMI over the study duration.RESULTS 404 consecutive patients(78.5% female, mean age 42.9 years, mean BMI 44.8 ± 4.7 kg/m2) were enrolled. ESGs were performed using an average of 7 sutures, over 42 ± 9 min, and with 100% technical success. TBWL was 20.9 ± 6.2% at 12 mo, 20.5 ± 6.9% at 24 mo, and 20.3 ± 9.5% at 36 mo. EWL was 49.6 ± 15.1% at 12 mo, 49.4 ± 16.7% at 24 mo, and 47.1 ± 23.5% at 36 mo. There was no difference in TBWL at 12, 15, 24, and 36 mo from ESG. TBWL exceeding 10%, 15%, and 20% was achieved by 96.7%, 87.4%, and 55.6% of the cohort at 12 mo, respectively. Of the cohort with the relevant comorbidity at time of ESG, 66.1% had improvement in hypertension, 61.7% had improvement in type Ⅱ diabetes, and 45.1% had improvement in hyperlipidemia over study duration. There was one instance of dehydration requiring hospitalization(0.2% serious adverse event rate).CONCLUSION When combined with longitudinal nutritional support, ESG induces effective and durable weight loss in adults with class Ⅲ obesity, with improvement in comorbidities and an acceptable safety profile.

Nerve growth factor-basic fibroblast growth factor poly-lactide co-glycolid sustained-release microspheres and the small gap sleeve bridging technique to repair peripheral nerve injury

We previously prepared nerve growth factor poly-lactide co-glycolid sustained-release microspheres to treat rat sciatic nerve injury using the small gap sleeve technique.Multiple growth factors play a synergistic role in promoting the repair of peripheral nerve injury;as a result,in this study,we added basic fibroblast growth factors to the microspheres to further promote nerve regeneration.First,in an in vitro biomimetic microenvironment,we developed and used a drug screening biomimetic microfluidic chip to screen the optimal combination of nerve growth factor/basic fibroblast growth factor to promote the regeneration of Schwann cells.We found that 22.56 ng/mL nerve growth factor combined with 4.29 ng/mL basic fibroblast growth factor exhibited optimal effects on the proliferation of primary rat Schwann cells.The successfully prepared nerve growth factor-basic fibroblast growth factor-poly-lactide-co-glycolid sustained-release microspheres were used to treat rat sciatic nerve transection injury using the small gap sleeve bridge technique.Compared with epithelium sutures and small gap sleeve bridging alone,the small gap sleeve bridging technique combined with drug-free sustained-release microspheres has a stronger effect on rat sciatic nerve transfection injury repair at the structural and functional level.

Numerical study on erosion behavior of sliding sleeve ball seat for hydraulic fracturing based on experimental data

The sleeve sealing ball seat is one of the important components in the multistage fracturing process of horizontal wells.The erosion and wear of the surface will decrease the sealing performance of the fracturing ball and the ball seat.This leads to pressure leakage during the fracturing process and fracturing failure.In this paper,combined with the actual ball seat materials and working conditions during the fracturing process,the erosion tests of ductile iron and tungsten carbide materials under different erosion speeds,angles,and mortar concentrations are carried out.Then the erosion test results were analyzed by mathematical fitting,and a set of erosion models suitable for sliding sleeve setting ball seat materials were innovatively established.For the first time,this paper combines the erosion model obtained from the experiment and the computational fluid dynamics(CFD)with Fluent software to simulate the erosion of the ball seat.Based on the simulation results,the morphology of the sliding sleeve seat ball after erosion is predicted.Through analysis of the test and simulation results,it is showed that the erosion rate of tungsten carbide material is lower and the wear resistance is better under the condition of small angle erosion.This research can offer a strong basis for fracturing site selection,surface treatment methods,and prediction of failure time of ball seats.

Laparoscopic Sleeve Gastrectomy following Pylorus-Preserving Pancreaticoduodenectomy

Background: A 35-year-old married female (68 kg, 150 cm, BMI: 30.2) with pancreatic divisum complicated chronic pancreatitis and underwent pylorus-preserving pancreaticoduodenectomy in 2010. After that, her condition was well. However, body weight gained progressively to 76 kg (BMI: 33.7) and hypertension developed. During these two years, tried exercise and medication control for hypertension, but in vain. She received a laparoscopic sleeve gastrectomy in October 2013. The post-operative course was uneventful. Methods: We applied three ports for laparoscopic operation, including two 12 mm and one 5 mm trocars. The liver was not needed to be elevated due to adhesion. The operative time was 75 minutes. Results: The patient’s body weight was 10 kg reduced in the first two months and reduced to 59 kg 6 months later. Conclusions: We report a case that received laparoscopic sleeve gastrectomy following pylorus-preserving pancreaticoduodenectomy due to pancreatic divisum. This case encourages us to extend the indication of laparoscopic sleeve gastrectomy.

Effect of laparoscopic sleeve gastrectomy on related variables of obesity complicated with polycystic ovary syndrome

BACKGROUND Polycystic ovary syndrome(PCOS)is closely related to obesity,and weight loss can significantly improve the metabolic,endocrine and reproductive functions of obese individuals with PCOS.However,the efficacy of laparoscopic sleeve gastrectomy(LSG)for obesity with PCOS are unclear.AIM The purpose of the study was to investigate the effect of LSG on related variables in obese patients with PCOS.METHODS A retrospective analysis was performed on 32 obese patients with PCOS who received LSG treatment at the Third Hospital of Shanxi Medical University from 2013 to 2020.The changes in anthropometric indices,insulin,testosterone,estradiol,follicle stimulating hormone(FSH),luteinizing hormone(LH),menstrual cycle and LH/FSH ratio before and 1 mo,3 mo,6 mo and 12 mo after the operation were statistically analyzed.RESULTS At 1 mo,3 mo,6 mo and 12 mo after surgery,the anthropometric indices,such as body weight and body mass index,of all patients were lower than those before the operation.The percentage excess weight loss(EWL%)at 1 mo,3 mo,6 mo and 1 year of follow-up were 25,40,46 and 65,respectively.The PCOS-related indices,such as insulin,testosterone,estradiol,follicle stimulating hormone(FSH),luteinizing hormone(LH)and menstrual cycle,were improved to varying degrees.During the 1-year follow-up,the average serum testosterone decreased from preoperative 0.72 ng/mL to 0.43 ng/mL(P<0.05),average fasting insulin level(9.0 mIU/mL,preoperative 34.2 mil,LH level,4.4 mIU/mL,preoperative 6.1 mIU/mL).The level of FSH(3.8 U/L,4.8 U/p0.05)and the ratio of LH/FSH(0.7,1.3/p0.05)were more relieved than those before surgery.During the postoperative follow-up,it was found that the menstrual cycle of 27 patients(nasty 27)returned to normal,and 6 patients(18%)who intended to become pregnant became pregnant within 1 year after surgery.CONCLUSION The weight loss effect of LSG is obvious and affirmative,and the endocrine index of obese patients with PCOS is also improved to some extent,although the mechanism is not clear.Laparoscopic sleeve gastrectomy is expected to become a backup choice for patients with polycystic ovaries in the future.

Sleeve Gastrectomy Associated with Antral Lesion Resection and Roux-en-Y Antrojejunal Reconstruction

Obesity has been growing worldwide, reaching epidemic proportions. Bariatric surgery is the most effective and durable treatment for severe obesity and related diseases. Roux-en-Y Gastric Bypass (RYGB) and Sleeve Gastrectomy (SG) are the most frequently performed bariatric operations, with long-term good results, in terms of weight loss and comorbidities control. Gastroesophageal Reflux Disease (GERD) is commonly associated with obesity. In general, it precludes the indication of sleeve gastrectomy, since this technique has a refluxogenic potential, as shown in many studies. In such cases, RYGB is considered the best surgery, reaching good weight loss and gastroesophageal reflux disease control. The drawback of this technique is that it leaves the remnant stomach, the duodenum, and the proximal part of the jejunum inaccessible. Besides, RYGB makes transoral endoscopic access to the biliary tree impossible. For all these reasons, this bariatric technique is not indicated in cases of gastric polyposis, gastric dysplasia, or strong family history of cancer, among others. We report a case of a morbidly obese patient with intense GERD, for whom a RYGB was precluded due to her strong family history of cancer, even knowing that it would be the best choice for reflux disease control. Instead, SG was chosen, even knowing it could worsen the gastroesophageal reflux disease. The patient signed an informed consent, after being fully enlightened about the risks. During the surgery, a small subserosal whitish lesion was detected, near the pylorus, on the anterior wall of the antrum. Thinking in a Gastrointestinal Stromal Tumor (GIST), it was resected, with a 2 cm safety margin, leaving a 4 to 5 cm hole on the gastric wall. The decision to maintain the proposed sleeve gastrectomy was made, to avoid leaving a remnant stomach, in a patient with such a strong family history of cancer. In the area of the resected lesion, an intraoperative decision was made not to just close the big gastric hole, being afraid of causing some anatomic or functional disturbance in gastric emptying. Instead, we decided to use the gastric opening to construct a Roux-en-Y antrotrojejunal anastomosis, with a 50 cm alimentary limb and a 200 cm biliopancreatic limb. Accordingly, it was performed a sleeve gastrectomy, associated with an antrojejunostomy in a Roux-en-Y fashion. The patient had an uneventful postoperative course. In the second year, she achieved normal weight and good nutritional status, without gastroesophageal reflux symptoms complaints. Seriography study shows that most of the contrast material passes through the antrojejunal anastomosis, instead of the pylorus, while the duodenum is endoscopically patent. This case report shows an unexpected surgical finding that led to a tactic of adding a Roux-en-Y gastric bypass in the antrum, associated with a sleeve gastrectomy, a strategy that may be adopted in cases of morbidly obese patients with important GERD, for whom gastrointestinal exclusions are contraindicated. To confirm this hypothesis, controlled studies are needed.

Fibroblast growth factor 15,induced by elevated bile acids,mediates the improvement of hepatic glucose metabolism after sleeve gastrectomy

BACKGROUND Fibroblast growth factor(FGF)15/19,which is expressed in and secreted from the distal ileum,can regulate hepatic glucose metabolism in an endocrine manner.The levels of both bile acids(BAs)and FGF15/19 are elevated after bariatric surgery.However,it is unclear whether the increase in FGF15/19 is induced by BAs.Moreover,it remains to be understood whether FGF15/19 elevations contribute to improvements in hepatic glucose metabolism after bariatric surgery.AIM To investigate the mechanism of improvement of hepatic glucose metabolism by elevated BAs after sleeve gastrectomy(SG).METHODS By calculating and comparing the changes of body weight after SG with SHAM group,we examined the weight-loss effect of SG.The oral glucose tolerance test(OGTT)test and area under the curve of OGTT curves were used to assess the anti-diabetic effects of SG.By detecting the glycogen content,expression and activity of glycogen synthase as well as the glucose-6-phosphatase(G6Pase)and phosphoenolpyruvate carboxykinase(Pepck),we evaluated the hepatic glycogen content and gluconeogenesis activity.We examined the levels of total BA(TBA)together with the farnesoid X receptor(FXR)-agonistic BA subspecies in systemic serum and portal vein at week 12 post-surgery.Then the histological expression of ileal FXR and FGF15 and hepatic FGF receptor 4(FGFR4)with its corresponding signal pathways involved in glucose metabolism were detected.RESULTS After surgery,food intake and body weight gain of SG group was decreased compare with the SHAM group.The hepatic glycogen content and glycogen synthase activity was significantly stimulated after SG,while the expression of the key enzyme for hepatic gluconeogenesis:G6Pase and Pepck,were depressed.TBA levels in serum and portal vein were both elevated after SG,the FXR-agonistic BA subspecies:Chenodeoxycholic acid(CDCA),lithocholic acid(LCA)in serum and CDCA,DCA,LCA in portal vein were all higher in SG group than that in SHAM group.Consequently,the ileal expression of FXR and FGF15 were also advanced in SG group.Moreover,the hepatic expression of FGFR4 was stimulated in SG-operated rats.As a result,the activity of its corresponding pathway for glycogen synthesis:FGFR4-Ras-extracellular signal regulated kinase pathway was stimulated,while the corresponding pathway for hepatic gluconeogenesis:FGFR4-cAMP regulatory element-binding protein-peroxisome proliferator-activated receptorγcoactivator-1αpathway was suppressed.CONCLUSION Elevated BAs after SG induced FGF15 expression in distal ileum by activating their receptor FXR.Furthermore,the promoted FGF15 partly mediated the improving effects on hepatic glucose metabolism of SG.

State of art on the mechanisms of laparoscopic sleeve gastrectomy in treating type 2 diabetes mellitus

Obesity and type-2 diabetes mellitus(T2DM)are metabolic disorders.Obesity increases the risk of T2DM,and as obesity is becoming increasingly common,more individuals suffer from T2DM,which poses a considerable burden on health systems.Traditionally,pharmaceutical therapy together with lifestyle changes is used to treat obesity and T2DM to decrease the incidence of comorbidities and allcause mortality and to increase life expectancy.Bariatric surgery is increasingly replacing other forms of treatment of morbid obesity,especially in patients with refractory obesity,owing to its many benefits including good long-term outcomes and almost no weight regain.The bariatric surgery options have markedly changed recently,and laparoscopic sleeve gastrectomy(LSG)is gradually gaining popularity.LSG has become an effective and safe treatment for type-2 diabetes and morbid obesity,with a high cost-benefit ratio.Here,we review the mechanism associated with LSG treatment of T2DM,and we discuss clinical studies and animal experiments with regard to gastrointestinal hormones,gut microbiota,bile acids,and adipokines to clarify current treatment modalities for patients with obesity and T2DM.

Methodology for Obtaining Optimal Sleeve Friction and Friction Ratio Estimates from CPT Data

Cone penetration testing (CPT) is a cost effective and popular tool for geotechnical site characterization. CPT consists of pushing at a constant rate an electronic penetrometer into penetrable soils and recording cone bearing (qc), sleeve friction (fc) and dynamic pore pressure (u) with depth. The measured qc, fs and u values are utilized to estimate soil type and associated soil properties. A popular method to estimate soil type from CPT measurements is the Soil Behavior Type (SBT) chart. The SBT plots cone resistance vs friction ratio, Rf [where: Rf = (fs/qc)100%]. There are distortions in the CPT measurements which can result in erroneous SBT plots. Cone bearing measurements at a specific depth are blurred or averaged due to qc values being strongly influenced by soils within 10 to 30 cone diameters from the cone tip. The qcHMM algorithm was developed to address the qc blurring/averaging limitation. This paper describes the distortions which occur when obtaining sleeve friction measurements which can in association with qc blurring result in significant errors in the calculated Rf values. This paper outlines a novel and highly effective algorithm for obtaining accurate sleeve friction and friction ratio estimates. The fc optimal filter estimation technique is referred to as the OSFE-IFM algorithm. The mathematical details of the OSFE-IFM algorithm are outlined in this paper along with the results from a challenging test bed simulation. The test bed simulation demonstrates that the OSFE-IFM algorithm derives accurate estimates of sleeve friction from measured values. Optimal estimates of cone bearing and sleeve friction result in accurate Rf values and subsequent accurate estimates of soil behavior type.

Infusa Sleeve导管血管内局部给药的实验研究

目的：评价ＩｎｆｕｓａＳｌｅｅｖｅ（ＩＳ）导管局部给药的可行性。方法：１３只家兔随机分成Ａ组（ｎ＝８）和Ｂ组（ｎ＝５），给药压力分别为６０７．９ｋＰａ（６个标准大气压）（Ａ组）和２０２．６ｋＰａ（２个标准大气压）（Ｂ组），用标准血管成形导管损伤腹主动脉下端后，经ＩＳ导管向腹主动脉下端球囊损伤处局部注入１ｍｌ放射性同位素锝标记的甲氧基异丁基异腈（９９ｍＴｃ－ＭＩＢＩ）注射液。术后３０分钟、６小时、２４小时分别处死动物后，取两组动物靶点血管（腹主动脉下端）、心、肝、骨骼肌、小肠、血液、非靶点血管（肺动脉）组织，用γ计数仪计数后称组织重量。结果：Ａ组和Ｂ组给药后３０分钟靶点血管局部的放射强度分别占给药总量的４９．２５０％和２２．０００％、分别是血液的４５倍和８倍、是非靶点血管的７０倍和１２倍。靶点血管局部放射强度Ａ组大于Ｂ组（Ｐ＜０．０５）。６小时和２４小时后靶点血管局部放射强度占给药总量的０．３４３％（Ａ组）和０．２５５％（Ａ组）。结论：ＩＳ导管可经血管局部靶向给药。ＩＳ导管局部导入的药物浓度呈压力依赖性。

Laparoscopic sleeve gastrectomy and gastroesophageal reflux

Bariatric surgery is the only effective procedure that provides long-term sustained weight loss. Sleeve gastrectomy(SG) has emerged over the last few years to be an ideal bariatric procedure because it has several advantages compared to more complex bariatric procedures,including avoiding an intestinal bypass. However,several published follow-up studies report an increased rate of gastroesophageal reflux(GERD) after a SG. GERD is described as either de novo or as being caused by aggravation of preexisting symptoms. However,the literature on this topic is ambivalent despite the potentially increased rate of GERDs that may occur after this common bariatric procedure. This article reviews the mechanisms responsible for GERD in obese subjects as well as the results after a SG with respect to GERD. Future directions for clinical research are discussed along with the current surgical options for morbidly obese patients with GERD and undergoing bariatric surgery.

The success of sleeve gastrectomy in the management of metabolic syndrome and obesity

The rapid reversal of diabetes,hypertension,hyperlipidaemia and obesity by surgical means has challenged accepted doctrines regarding the management of metabolic syndrome.Sleeve gastrectomy,which developed initially as a preparatory procedure for biliopancreatic diversion with duodenal switch,has seen an exponential rise in popularity as an effective lone laparoscopic bariatric procedure.Superior excess weight loss,a low complication rate,and excellent food tolerance,combined with a short hospital stay,have made this the procedure of choice for patients and surgeons across the globe.High volume centres nurture the ongoing development of experienced and specialized teams,pathways and regimens.Optimum surgical outcomes allow minimization of metabolic syndrome,reducing cardiovascular and cerebrovascular risk.

Laparoscopic sleeve gastrectomy:More than a restrictive bariatric surgery procedure?

Sleeve gastrectomy(SG) is a restrictive bariatric surgery technique that was first used as part of restrictive horizontal gastrectomy in the original Scopinaro type biliopancreatic diversion. Its good results as a single technique have led to a rise in its use, and it is currently the second most performed technique worldwide. SG achieves clearly better results than other restrictive techniques and is comparable in some aspects to the Roux-en-Y gastric bypass, the current gold standard in bariatric surgery. These benefits have been associated with different pathophysiologic mechanisms unrelated to weight loss such as increased gastric emptying and intestinal transit, and activation of hormonal mechanisms such as increased GLP-1 hormone and decreased ghrelin. The aim of this review was to highlight the salient aspects of SG regarding its historical evolution, pathophysiologic mechanisms, main results, clinical applications and perioperative complications.

Gastric remnant twist in the immediate post-operative period following laparoscopic sleeve gastrectomy

Twist of stomach remnant post sleeve gastrectomy is a rare entity and difficult to diagnose pre-operatively. We are reporting a case of gastric volvulus post laparoscopic sleeve gastrectomy, which was managed conservatively. A 38-year-old lady with a body mass index of 54 underwent laparoscopic sleeve gastrectomy. Sleeve gastrectomy was performed over a 32 French bougie using Endo-GIA tri-stapler. On post-operative day 1, patient had nausea and non-bilious vomiting. An upper gastrointestinal gastrografin study on postoperative days 1 and 2 revealed collection of contrast in the fundic area of stomach with poor flow distally, and she vomited gastrograffin immediately post procedure. With the suspicion of a stricture in the mid stomach as the cause, the patient was taken back for a exploratory laparoscopy and intra-operative endoscopy. We found a twist in the gastric tube which was too tight for the endoscope to pass through. This was managed conservatively with a long stent to keep the gastric tube straight and patent. The stent was discontinued in 7 d and the patient did well. In laparoscopic sleeve gastrectomy the stomach is converted into a tube and is devoid of its supports. If the staples fired are not aligned appropriately, it can predispose this stomach tube to undergo torsion along its long axis. Such a twist can be avoided by properly aligning the staples and by placing tacking sutures to the omentum and new stomach tube. This twist is a functional obstruction rather than a stricture; thus, it can be managed by endoscopy and stent placement.

Effects of sleeve gastrectomy with jejuno-jejunal or jejuno-ileal loop on glycolipid metabolism in diabetic rats

AIM To explore the effect of sleeve gastrectomy(SG) with jejuno-jejunal or jejuno-ileal loop on glycolipid metabolism in diabetic rats.METHODS Diabetic rats, which were induced by high-fat diet(HFD), nicotinamide and low-dose streptozotocin, underwent sham operations, SG, SG with jejuno-ileal loop(SG-JI) and SG with jejuno-jejunal loop(SG-JJ) followed by postoperative HFD. Then, at the time points of baseline and 2, 12 and 24 wk postoperatively, we determined and compared several variables, including the area under the curve for the results of oral glucose tolerance test(AUCOGTT), serum levels of triglyceride, cholesterol and ghrelin in fasting state, homeostasis model assessment of insulin resistance(HOMA-IR), body weight, calorie intake, glucagon-like peptide(GLP)-1 and insulin secretions after glucose gavage at dose of 1 g/kg.RESULTS At 2 wk postoperatively, rats that underwent SG, SGJJ and SG-JI, compared with sham-operated(SHAM)rats, demonstrated lower body weight, calorie intake and ghrelin(P < 0.05 vs SHAM), enhanced secretion of insulin and GLP-1 after glucose gavage(P < 0.05 vs SHAM), improved AUCOGTT, HOMA-IR, fasting serum triglyceride and cholesterol(AUCOGTT: 1616.9 ± 83.2, 837.4 ± 83.7, 874.9 ± 97.2 and 812.6 ± 81.9, P < 0.05 vs SHAM; HOMA-IR: 4.31 ± 0.54, 2.94 ± 0.22, 3.17 ± 0.37 and 3.41 ± 0.22, P < 0.05 vs SHAM; Triglyceride: 2.35 ± 0.17, 1.87 ± 0.23, 1.98 ± 0.30 and 2.04 ± 0.21 mmol/L, P < 0.05 vs SHAM; Cholesterol: 1.84 ± 0.21, 1.53 ± 0.20, 1.52 ± 0.20 and 1.46 ± 0.23 mmol/L). At 12 wk postoperatively, rats receiving SG-JJ and SG-JI had lower body weight, reduced levels of triglyceride and cholesterol and elevated level of GLP-1 compared to those receiving SG(P < 0.05 vs SG). At 24 wk after surgery, compared with SG, the advantage of SG-JJ and SG-JI for glucolipid metabolism was still evident(P < 0.05 vs SG). SG-JI had a better performance in lipid metabolism and GLP-1 secretion of rats than did SG-JJ.CONCLUSION SG combined with intestinal loop induces better glycolipid metabolism than simple SG, with the lipid metabolism being more improved with SG-JI compared to SG-JJ.

Bariatric surgery and diabetes remission: Sleeve gastrectomy or mini-gastric bypass?

AIM:To investigate the weight loss and glycemic control status[blood glucose,hemoglobin A1c(HbA1c)and hypoglycaemic treatment].METHODS:The primary risk factor for type 2 diabetes is obesity,and 90%of all patients with type 2 diabetes are overweight or obese.Although a remarkable effect of bariatric surgery is the profound and durable resolution of type 2 diabetes clinical manifestations,little is known about the difference among various weight loss surgical procedures on diabetes remission.Data from patients referred during a 3-year period(from January2009 to December 2011)to the University of Naples"FedericoⅡ"diagnosed with obesity and diabetes were retrieved from a prospective database.The patients were split into two groups according to the surgical intervention performed[sleeve gastrectomy(SG)and mini-gastric bypass(MGB)].Weight loss and glycemic control status(blood glucose,HbA1c and hypoglycaemic treatment)were evaluated.RESULTS:A total of 53 subjects who underwent sleeve gastrectomy or mini-gastric bypass for obesity and diabetes were screened for the inclusion in this study.Of these,4 subjects were excluded because of surgical complications,7 subjects were omitted because young surgeons conducted the operations and 11 subjects were removed because of the lack of follow-up.Thirtyone obese patients were recruited for this study.A total of 15 subjects underwent SG(48.4%),and 16underwent MGB(51.6%).After adjusting for various clinical and demographic characteristics in a multivariate logistic regression analysis,high hemoglobin A1c was determined to be a negative predictor of diabetes remission at 12 mo(OR=0.366,95%CI:0.152-0.884).Using the same regression model,MGB showed a clear trend toward higher diabetes remission rates relative to SG(OR=3.780,95%CI:0.961-14.872).CONCLUSION:Although our results are encouraging regarding the effectiveness of mini-gastric bypass on diabetes remission,further studies are needed to provide definitive conclusions in selecting the ideal procedure for diabetes remission.