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.

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.

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.

Excessive Weight Loss Following Laparoscopic Gastric Mini Bypass or Roux-En-Y Gastric Bypass Surgery

Background: More than 90 percent of obesity surgery is done using a laparoscope. This method is superior to open surgery and lead to fewer complications, shorter hospital stay and faster recovery. This study compared course of weight loss following laparoscopic Gastric Mini Bypass or Roux-En-Y Gastric Bypass surgery, after one year of follow up. Materials and Methods: This randomized clinical trial was conducted among obese patients admitted to Rasoul Akram Hospital Obesity Clinic, Half underwent laparoscopic Roux-En-Y Gastric Bypass and the rest were undergoing laparoscopic Mini Gastric Bypass. The amount of weight loss during the first year after surgery will be discussed. Results: In this study, 75 obese patients were studied. Most of the participants were female (82.7%). Participants aged between 18 and 59 years old (average = 36.8 ± 9.8 y/o). Before the surgery, there was no significant difference in weight between the two groups. Excessive weight loss after one month, six months nine months and one year between the two groups was significant and was more in Mini Gastric Bypass (p < 0.05). Conclusion: Respecting the benefits of Mini Gastric Bypass compared to the Roux-En-Y Gastric Bypass technique, it is suggested for patients with morbid obesity.

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.

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.

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.

Computed tomography as primary postoperative follow-up after laparoscopic Roux-en-Y gastric bypass

AIM To evaluate upper abdominal computed tomography(CT) scan as primary follow-up after laparoscopic Rouxen-Y gastric bypass(LRYGB). METHODS This prospective study was approved by the Ethical Committee of the State of Zurich, and informed consent was obtained from all patients. Sixty-one patients who underwent LRYGB received upper abdominal CT on postoperative day 1, with the following scan parameters: 0.6 mm collimation, 1.2 mm pitch, Care KV with reference 120 m As and 120 kV, and 0.5 s rotation time. Diluted water-soluble radiographic contrastmedium(50 mL) was administered to achieve gastric pouch distension without movement of the patient. 3 D images were evaluated to assess postoperative complications and the radiation dose received was analysed. RESULTS From the 70 patients initially enrolled in the study, 9 were excluded from analysis upon the intraoperative decision to perform a sleeve gastrectomy and not a LRYGB. In all of the 61 patients who were included in the analysis, CT was feasible and there were no instances of aspiration or vomiting. In 7 patients, two upper abdominal scans were necessary as the pouch was not distended by contrast medium in the first acquisition. Radiologically, no leak and no relevant stenosis were found on the first postoperative day. These early postoperative CT findings were consistent with the findings at clinical follow-up 6 wk postoperatively, with no leaks, stenosis or obstructions being diagnosed. The average total dose length product in CT was 536.6 m Gycm resulting in an average effective dose of 7.8 m Sv. The most common surgical complication, superficial surgical site infections(n = 4), always occurred at the upper left trocar site, where the circular stapler had been introduced. CONCLUSION Early LRYGB postoperative multislice spiral CT scan is feasible, with low morbidity, and provides more accurate anatomical information than standard upper gastrointestinal contrast study.

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.

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.

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.

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.

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.

Roux-en-Y gastric bypass or sleeve gastrectomy for obstructive sleep apnea:A systematic review and meta-analysis

Objective:Bariatric surgery has been shown to be an effective method of treatment for obstructive sleep apnea(OSA)with long-term benefits,however,the mechanisms of action and the optimum operative procedure remains unclear.The aim of this systemic review was to compare the efficacy of laparoscopic sleeve gastrectomy(LSG)and Roux-en-Y gastric bypass(RYGB)in resolving OSA.Methods:A comprehensive search of MEDLINE,Pubmed,Embase,and OVID was performed.Studies that reported OSA resolution in obese patients with BMI>30 kg/m2 were included in the study.RCTs,comparative prospective and matched cohort studies comparing RYGB with LSG were considered for this study.Results:Five studies(309 participants)were included:4 cohort studies and 1 RCT;all with low risk of bias.At 12 months follow-up,there was a trend towards improved resolution of OSA with LSG(OR 0.47,95%CI[0.20 to 1.06];p=0.07)when compared to RYGB.In contrast,there was a trend to poorer weight loss in the LSG group(SMD 3.83,95%CI[-1.82 to 9.48];p=0.18).Similarly,at 36 months follow-up,there was a trend towards better resolution of OSA with LSG(OR 0.52,95%CI[0.16 to 1.71];p=0.28)and a significantly poorer weight loss in LSG when compared to RYGB(SMD 8.25,95%CI[2.91 to 13.58];p=0.002).Conclusion:Despite poorer weight loss following LSG,there is a trend towards increased resolution of sleep apnea post-LSG.These findings suggest the possibility of weight loss independent factors causing OSA resolution,which should be further investigated.Registration:PROSPERO:CRD42018090367.

Laparoscopic retrosternal gastric pull-up for fistulized mediastinal mass

We describe the case of a patient successfully reconstructed with laparoscopic retrosternal gastric pull-up after esophagectomy for unresectable posterior mediastinal inflammatory myofibroblastic tumor, eroding into the esophagus and compressing the airways. A partial esophagectomy with esophagostomy was performed for treatment of esophageal pleural fistula and empyema, while the airways were managed with the placement of an endobronchial stent. Gastrointestinal reconstruction was performed using a laparoscopic approach to create a retrosternal tunnel for gastric conduit pull-up and cervical anastomosis. The patient was discharged uneventfully after 6 d, and has done very well at home with normal diet.

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.

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.

Long-term effectiveness,outcomes and complications of bariatric surgery

Dietary imbalance and overeating can lead to an increasingly widespread disease-obesity.Aesthetic considerations aside,obesity is defined as an excess of adipose tissue that can lead to serious health problems and can predispose to a number of pathological changes and clinical diseases,including diabetes;hypertension;atherosclerosis;coronary artery disease and stroke;obstructive sleep apnea;depression;weight-related arthropathies and endometrial and breast cancer.A body weight 20%above ideal for age,gender and height is a severe health risk.Bariatric surgery is a set of surgical methods to treat morbid obesity when other treatments such as diet,increased physical activity,behavioral changes and drugs have failed.The two most common procedures currently used are sleeve gastrectomy and gastric bypass.This procedure has gained popularity recently and is generally considered safe and effective.Although current data show that perioperative mortality is low and better control of comorbidities and short-term complications is achieved,more randomized trials are needed to evaluate the long-term outcomes of bariatric procedures.This review aims to synthesize and summarize the growing evidence on the long-term effectiveness,outcomes and complications of bariatric surgery.