Israel Medical Association Journal

Background: Local anesthetics are used in various sites and mechanisms to maximize perioperative analgesia and reduce opioid use and side effects. Pain management in the bariatric setting is challenging and the efficacy of local anesthetics intraoperatively is under current evaluation.

Objectives: To determine the safety and efficacy of a new intra-abdominal anesthetic technique performed during laparoscopic bariatric operations: visceral block.

Methods: During this prospective randomized double-blinded pilot study, 16 patients undergoing bariatric surgery were treated with the injection of ropivacaine to the anterior esophagogastric junction fat, and 15 were injected with saline as control.

Results: The procedure was shown to be safe, and no adverse events nor side effects were encountered. A non-statistically significant trend toward the use of a non-opioid analgesia was documented during the first postoperative hours.

Conclusions: Visceral block is a safe and feasible intraoperative procedure. A trend toward its efficacy warrants future larger scale studies.

Background: Long-term outcome data for bariatric surgery in patients with severe obesity (SO) (body mass index [BMI] ³ 50 kg/m²) are scarce.

Objectives: To compare perioperative morbidity and long-term outcomes between patients with SO and non-SO (NSO).

Methods: Patients with SO who underwent primary bariatric surgery with a follow-up ³ 5 years were age- and gender-matched with NSO patients in a retrospective, case-control study. Data included demographics, BMI, co-morbidities, early outcomes, current and nadir weight, co-morbidity status, and general satisfaction.

Results: Of 178 patients, 49.4% were male, mean age 44.5 ± 14 years. Mean preoperative BMI was 54.7 ± 3.6 and 41.8 ± 3.8 kg/m² in SO and NSO, respectively (P = 0.02). Groups were similar in preoperative characteristics. Depression/anxiety was more prevalent in NSO (12.4% vs. 3.4%, P = 0.03). Obstructive sleep apnea was higher in SO (21.3% vs. 10.1%, P = 0.04). Sleeve gastrectomy was performed most often (80.9%), with a tendency toward bypass in SO (P = 0.05). Early complication rates were: 13.5% in SO and 12.4% in NSO (P = 0.82). Mean follow-up was 80.4 ± 13.3 months. BMI reduction was higher in SO (31.8 ± 5.9 vs. 26.8 ± 4.2 kg/m², P < 0.001) and time to nadir weight was longer (22.1 ± 21.3 vs. 13.0 ± 12.0 months, P = 0.001). Co-morbidity improvement and satisfaction were similar.

Conclusions: Patients with SO benefited from bariatric surgery with reduced BMI and fewer co-morbidities. No added risk of operative complications was found compared to patients with NSO.

Background: The effect of weight reduction following bariatric surgery is already well known.

Objectives: To investigate the effects of abdominoplasty on metabolic markers indicative of weight loss.

Methods: The authors prospectively enrolled consecutive obese patients after laparoscopic sleeve gastrectomy. They were candidates for post-bariatric surgery abdominoplasty. The authors measured metabolic markers one day prior to surgery, 24 hours after, and 3 months following surgery. They recorded medical and demographic parameters.

Results: Sixteen patients were recruited for participation in the study. Mean age was 47 years and 88% of the patients were female. Bariatric surgery achieved a mean decline in body mass index of 13.8 kg/m². All patients underwent abdominoplasty. Leptin and insulin levels were slightly increased at 3 months postoperative. No significant changes were observed in glucose, hemoglobin, or triglycerides throughout the study.

Conclusions: In a cohort of obese patients undergoing laparoscopic sleeve gastrectomy followed by abdominoplasty, no significant changes were noted in a patient’s metabolic profiles. The results suggest that abdominoplasty has no effect on the metabolic markers tested in contrast to other reports; however, the cosmetic, behavioral, and psychological advantages of abdominoplasty are well established.

Background: Bariatric surgery has become the most common and effective therapeutic option for obesity. However, it is associated with morbidity and complications. Identification of predictors for surgical complications is an unmet need.

Objectives: To determine a simple non-invasive parameter that predicts early postoperative complications following bariatric surgery.

Methods: In this retrospective study of all patients who underwent elective bariatric surgery at Nazareth Hospital EMMS during a 4-year period (2015–2018). We collected clinical and laboratory parameters and determined predictors of complications.

Results: A total of 345 patients underwent bariatric surgery during the study period. Of the patients, 51 experienced early post-bariatric surgery complications as compared to 294 patients who had no complications. Univariate analysis revealed that neutrophil-to-lymphocyte ratio (NLR) (odds ratio [OR] 1.912, P < 0.0001) and platelet to lymphocyte ratio (OR 1.015, P < 0.0001) were associated with post-bariatric surgery complications. In a multivariate logistic regression analysis, only NLR remained a significant predictor (OR 1.751, 95% confidence interval 1.264–2.425, P = 0.0008) with a receiver operating characteristic curve for NLR of 0.8404.

Conclusions: We found that the NLR predicts post bariatric surgery early complications. Further prospective studies are needed to validate our findings.

Background: Weight loss surgery is the most effective treatment for obesity, and it reduces cardiovascular and cancer risk through poorly understood mechanisms. MicroRNAs (miRNAs) are short RNA molecules that regulate the stability and translation of many mRNAs. We hypothesized that levels of specific circulating miRNAs are altered following surgery and may contribute to lower cancer risk.

Objectives: To investigate the change of miRNA following surgery.

Methods: All patients underwent gastric “sleeve operation”. RNA was isolated from sera of 21 patients (14 men, 7 women) before and 3 months after surgery. Sera were combined into two pools, which served for cDNA library construction followed by miSeq sequencing. The levels of candidate miRNAs were validated in the individual samples by QRT-PCR.

Results: Serum miR-122 was significantly up-regulated 3 months post-bariatric surgery in sera of patients, whose endothelial function had greatly improved. In addition, serum miR-122 levels correlated positively with endothelial function as measured by FMD. The changes in miR-122 levels from pre-surgery to 3 months post-surgery also tended to correlate with the respective changes in FMD.

Conclusions: The serum miR-122/miR-451 ratio may serve as a marker for endothelial function in obese patients. miR-122 is the dominant miRNA in the liver and a known tumor suppressor. Our findings suggest a role for circulating miR-122 in the maintenance of vascular endothelial cells (VECs) and in the prevention of cancer. Further studies are required to elucidate the mechanism of its secretion into circulation and its absorption by VECs, as well as its relevant cellular targets.

Background: Leakage from the staple line is the most serious complication encountered after sleeve gastrectomy, occurring in 2.4% of surgeries. The use of inappropriately sized staplers, because of variability in stomach wall thickness, is a major cause of leakage.

Objectives: To measure stomach wall thickness across different stomach zones to identify variables correlating with thickness.

Methods: The study comprised 100 patients (52 females). Stomach wall thickness was measured immediately after surgery using a digital caliper at the antrum, body, and fundus. Results were correlated with body mass index (BMI), age, gender, and pre-surgical diagnosis of diabetes, hypertension, hyperlipidemia and fatty liver.

Results: Stomach thickness was found to be 5.1 ± 0.6 mm at the antrum, 4.1 ± 0.6 mm at the body, and 2. 6 ± 0.5 mm at the fundus. No correlation was found between stomach wall thickness and BMI, gender, or co-morbidities. 

Conclusions: Stomach wall thickness increases gradually from the fundus toward the antrum. Application of the correct staple height during sleeve gastrectomy is important and may, theoretically, prevent leaks. Staplers should be chosen according to the thickness of the tissue.

 

Background: Gallbladder (GB) cancer is rare. Most cases are incidentally found in specimens after a cholecystectomy. Cholelithiasis is almost always present when this diagnosis is made. Obesity is a known risk factor for gallstone formation and thus may be related to GB cancer. 

Objectives: To highlight the importance of evaluation of the gallbladder before surgery, resection of the gallbladder whenever required, and screening the resected tissue for malignancy.

Methods: We retrospectively queried a prospectively maintained database of all bariatric procedures during the last 8 years for cases of concomitant laparoscopic sleeve gastrectomy (LSG) and laparoscopic cholecystectomy (LC). Pathologic reports of the gallbladders were reviewed. Demographic data and perioperative parameters were documented. 

Results: Of 2708 patients reviewed, 1721 (63.55%) were females and 987 (36.45%) males. Excluded were 145 (5.35%) who had a previous cholecystectomy. Of the remaining 2563, 180 (7.02%) had symptomatic gallbladder disease and underwent LSG with LC. Of these, two females (BMI 53 kg/m² and BMI 47 kg/m², both age 60) were found by histological examination to have adenocarcinoma in their GB specimens (1.11%). Both were reoperated, which included partial hepatectomy of the GB bed, resection of the cystic stump, lymph node dissection, and resection of the port sites. One patient is doing well, with no evidence of disease at a postoperative follow-up of 4 years. The second patient had recurrent disease with peritoneal spread and ascites 20 months post-surgery and died 18 months later. 

Conclusions: GB cancer is a rare finding in cholecystectomy specimens. The incidence of this entity might be higher in obese older females owing to the higher incidence of cholelithiasis in these patients. 

 

Background: Obesity causes specific sexual problems, including diminished sexual desire, poor performance and avoidance of sexual encounters.

Objectives: To systematically evaluate the effect of bariatric surgery on patients' sexual function as compared to their preoperative status.

Methods: Bariatric surgery candidates were given a validated sexual function questionnaire the day before surgery and again 1 year after surgery. Females were polled with the Female Sexual Function Index (FSFI) and males with the Brief Sexual Function Inventory (BSFI). Statistical analysis was performed to elucidate differences in response to the questionnaires.

Results: The study population included 34 females and 14 males. Mean age and body mass index (BMI) were 40.2 ± 10.2 years and 43.4 ± 5.3 kg/m2, respectively. Postoperative BMI was 31.4 ± 4.9 kg/m2 (P < 0.001). Laparoscopic sleeve gastrectomy was performed in 36 patients and laparoscopic Roux-y gastric bypass in 12. In females, the FSFI index rose significantly from 24 to 30 (P = 0.006), indicating increased sexual performance and satisfaction. In males the BSFI increased from 40.2 to 43.9 but did not reach statistical significance (P = 0.08). However, general satisfaction, desire and erection were each significantly improved within the BSFI.

Conclusions: In addition to the well-documented medical and quality-of-life benefits of bariatric surgery, there is also clear improvement in patients' sexual function, both physical and psychosexual.

 

Objectives: To prove the safety and efficacy of LSG surgery in an adolescent population

Methods: Data were prospectively collected regarding adolescent patients undergoing LSG. All patients underwent pre- and postoperative medical and professional evaluation by a multidisciplinary team.

Results: Between the years 2006 and 2011, 32 adolescents underwent LSG in our center (20 females and 12 males). Mean age was 16.75 years (range 14–18 years), mean weight was 121.88 kg (83–178 kg), and mean body mass index 43.23 (35–54). Thirty-four comorbid conditions were identified. In all the patients LSG was the primary bariatric procedure. Mean operative time was 60 minutes (range 45–80 min). There were two complications (6.25%): an early staple line leak and a late acute cholecystitis. There was no mortality. Mean percent excess weight loss at 1, 3, 6, 9,12, 24, 36, 48, and 60 months post-surgery was 27.9%, 41.1%, 62.6%, 79.2%, 81.7% , 71%, 75%, 102.9% and 101.6%, respectively. Comorbidities were completely resolved or ameliorated within 1 year following surgery in 82.4% and 17.6%, respectively.

Conclusions: LSG is feasible and safe in morbidly obese adolescents, achieving efficient weight loss and impressive resolution of comorbidities. Further studies are required to evaluate the long-term results of this procedure, as well as its place among other bariatric options. 

Background: Roux-en-Y gastric bypass is currently considered the gold standard surgical option for the treatment of morbid obesity. Open RYGB[1] is associated with a high risk of complications. Laparoscopic RYGB has been shown to reduce perioperative morbidity and improve recovery.

Objectives: To review our experience with laparoscopic RYGB during a 19 month period.

Methods: The data were collected prospectively. The study group comprised all patients who underwent laparoscopic RYGB for treatment of morbid obesity as their primary operation between February 2006 and July 2007. The reported outcome included surgical results, weight loss, and improved status of co-morbidities, with follow-up of up to 19 months.

Results: The mean age of the 50 patients was 36.7 years. Mean body mass index was 44.7 kg/m² (range 35–76 kg/m²); mean duration of surgery was 171 minutes. There was no conversion to open surgery. The mean length of stay was 4 days (range 2–7 days). Five patients (10%) developed a complication, but none of them required early reoperation and there were no deaths. Mean follow-up was 7 months (range 40 days–19 months). The excess body weight loss was 55% and 61% at 6 and 12 months respectively. Diabetes resolved completely or significantly improved in all five patients with this condition, as did hypertension in eight patients out of nine.

Conclusions: Laparoscopic RYGB is feasible and safe. The results in terms of weight loss and correction of co-morbidities are comparable to other previously published studies. However, only surgeons with experience in advanced laparoscopic as well as bariatric surgery should attempt this procedure.