Plasma cells and lymphoid aggregates in sleeve gastrectomy specimens: Normal or gastritis?

Lymphoid follicles/aggregates in gastric biopsies have been traditionally linked to Helicobacter pylori gastritis, and less commonly to other inflammatory and neoplastic conditions. The frequency of such aggregates in normal stomachs has yet to be adequately evaluated. This is especially relevant when it comes to diagnosing non-specific chronic gastritis in biopsy specimens with chronic inflammation but no evidence of H pylori infection. Sleeve gastrectomies represent an opportunity to study adequately preserved gastric mucosa in patients who are otherwise asymptomatic and lack a history of gastric disease.To study sleeve gastrectomy specimens to quantify the amount of lymphoid follicles/aggregates and lymphocytic infiltration in normal stomachs.Sixty-eight bariatric sleeve gastrectomies and 13 control specimens from Whipple resections were examined for multiple histologic features including type, quantity, and distribution of chronic inflammation and lymphoid follicles/aggregates. Presence of H pylori was documented by both Hematoxylin and eosin-stained (H&E) and immunohistochemistry (IHC). Clinical information including age, sex, medication intake, prior endoscopy, and/or H pylori infection was recorded. The patient population was divided in 2 groups, H pylori negative versus H pylori positive, and statistical analysis was performed by a biostatistician.Two hundred sixty three fundic sections from 68 bariatric patients were examined. Fifty three patients were found to be H pylori-negative, compared with 15 who were positive for H pylori. Among the H pylori-negative group, the average number of lymphoid aggregates was 3.33, compared with an average of 6.26 in the H pylori positive group (the difference was statistically significant with a P-value of .008). The average number of plasma cells per high power field was 2.15 in the H pylori negative group, compared and average of 5.07 in the H pylori positive group (the difference was also statistically significant with a P-value <.001). Clinically, 10 of the 53 H pylori-negative patients had esophagogastroduodenoscopy (EGD) that showed endoscopic mild non-erosive gastric erythema. The remaining had no documentation of symptoms or medication intake, including Non-steroidal anti-inflammatory drugs (NSAIDs) and Proton Pump Inhibitors (PPI).Our results suggest that the presence of lymphoid aggregates and plasma cells infiltration can be a normal finding in otherwise normal gastric mucosa, though more pronounced in H pylori infected patients.

Long-Term Outcomes of Roux-en-Y Gastric Bypass Conversion of Failed Laparoscopic Gastric Band.

BACKGROUND: Laparoscopic adjustable gastric band (LAGB) carries a high rate of failure and reoperation. Laparoscopic conversion of failed LAGB to Roux-en-Y gastric bypass (RYGB) has been shown to be safe and feasible, but long-term follow-up data is still limited. OBJECTIVES: The aim of this study is to evaluate the safety and effectiveness of RYGB after failed LAGB in our patient population. SETTING: The setting was the University Hospital, Beirut, Lebanon. METHODS: Using a prospectively collected database, we retrospectively reviewed data of patients who underwent LAGB revision to RYGB at our institution between 2006 and 2014. RESULTS: A total of 58 patients underwent RYGB after failed LAGB in our institution between 2006 and 2014. Of those, 20 patients (34.5%) had concomitant band removal while the rest underwent a two-stage RYGB after a mean of 30 months after band removal. A follow-up was achieved in 84.5, 82, 83, 95, and 76% of patients at 1, 2, 3, 4, and 5 years after RYGB. Percentage of excess weight loss (%EWL) was 62.8, 68.1, 64.2, 63.8, and 61.3% at 1, 2, 3, 4, and 5 years, respectively, while percentage of total weight loss (%TWL) was 28.4, 30.7, 29.4, 28.9, and 28.6% at the corresponding time periods. The most common short-term complications were abscesses/leaks (5.2%) while the most common long-term complications were symptomatic gallstones necessitating laparoscopic cholecystectomy (5.2%), incisional hernias (5.2%), and small-bowel obstruction (3.4%). No surgery-related mortality was recorded. CONCLUSIONS: RYGB is a safe procedure with favorable weight loss outcomes at 5 years and can be considered a good rescue procedure after failed LAGB.

Long-term outcomes of laparoscopic sleeve gastrectomy: a Lebanese center experience.

BACKGROUND: Long-term data of laparoscopic sleeve gastrectomy (LSG) are still scarce in the Middle East. OBJECTIVES: The aim of this study was to assess the efficacy and safety at 5 years and beyond. SETTING: Tertiary referral hospital between April 2007 and March 2015. METHODS: A retrospective review of 76 patients who underwent LSG at the senior author's institution between April 2007 and March 2010. RESULTS: Mean preoperative body mass index (BMI) was 42.8±7.1 kg/m2. Follow-up rates were 90.4%, 86.3%, and 77.8% at 5, 6, and 7 years, respectively. Percentage of excess weight loss (%EWL) was 69.8%±28.7% at 5 years, 70.6%±32.7% at 6 years, and 76.6%±21.2% at 7 years, respectively. Mean total weight loss was 26.5%±8.7%, 24.9%±8.8%, and 26.6%±6.0% at 5, 6, and 7 years, respectively. %EWL at 5-years was significantly higher for patients with a preoperative BMI<45 kg/m2 (83.1% versus 46.3%, P<.0001). LSG improved or resolved diabetes, hypertension, and asthma in 87.5%, 68%, and 81.7% of patients, respectively. New onset gastroesophageal acid reflux disease developed in 21.2% of patients. Long-term complications included hiatal hernias necessitating repair (1.4%), incisional hernias (2.7%), and symptomatic gallstones (9.6%), as well as depression necessitating admission (4.1%). CONCLUSION: In the present patient population, LSG resulted in satisfactory %EWL and co-morbidity resolution after 5 years. The results were excellent for patients with a BMI<45 kg/m2. De novo acid reflux symptoms developed in 1 of 5 patients. Cholelithiasis necessitating cholecystectomy was the most common long-term complication.

Prevalence of vitamin D deficiency in adults presenting for bariatric surgery in Lebanon.

BACKGROUND: Vitamin D deficiency is common among obese patients presenting for bariatric surgery in Europe and North America. The prevalence of vitamin D deficiency in this patient population in Lebanon and the Middle East has not been studied. OBJECTIVES: The aim of this study was to determine the rate of vitamin D deficiency in a cohort of patients presenting for bariatric surgery in Lebanon. SETTING: American University of Beirut Medical Center, Beirut, Lebanon. METHODS: Data was extracted from a prospective database of patients presenting for bariatric surgery at the American University of Beirut Medical Center from July 2011 until June 2014. The prevalence of vitamin D deficiency was determined using established cut-offs followed by analysis of the relationship between low vitamin D and certain patient characteristics. RESULTS: More than two thirds of all patients (68.9%) were vitamin D deficient (≤19.9 ng/mL), whereas 22.6% had insufficient levels (20-29.9 ng/mL) and only 8.6 % had sufficient levels (≥30 ng/mL). Vitamin D levels were inversely associated with BMI>50 kg/m(2). Low vitamin D levels were also correlated with younger age, male gender, lack of physical exercise, and nonsunny season. No association was shown between 25-hydroxyvitamin D deficiency and type 2 diabetes mellitus, cardiovascular disease, osteoarticular disease, hypertension, or depression. CONCLUSION: Vitamin D deficiency is prevalent among patients with Class II or Class III obesity presenting for bariatric surgery in Lebanon. These findings emphasize the need for careful attention when evaluating patients before bariatric surgery and the importance of providing patients with adequate supplementation.

Definitive surgical management of staple line leak after sleeve gastrectomy.

BACKGROUND: Sleeve gastrectomy (SG) has become a widely adopted bariatric surgical procedure. The most serious complication is staple line leak (SLL), which is potentially life threatening and, in some patients, becomes chronic and difficult to manage. Definitive surgical management of SLL is effective but seldom published in the literature. OBJECTIVES: This study aims to review the outcome of definitive surgical management of SLL after SG, looking at short-term and long-term results. SETTING: Single surgeon experience based at a tertiary university hospital in Beirut, Lebanon. METHODS: Retrospective review of records of patients with SLL who underwent definitive surgical treatment by the senior author (B.Y.S.) from January 2008 until December 2013. RESULTS: Ten patients (50% female) underwent definitive surgical repair during the study period. The mean age, weight, and body mass index at the time of SG were 35 years, 121 kg, and 41.5 kg/m(2), respectively. Most leaks (90%) were at the esophagogastric junction. All underwent multiple operative, endoscopic, or radiologic procedures before definitive surgical repair. Methods of definitive repair included open Roux-en-Y (RY) esophagojejunostomy (70%), open RY gastric bypass (10%), laparoscopic RY esophagojejunostomy (10%), and one laparoscopic RY fistulojejunostomy (10%). Six patients (60%) underwent definitive surgical treatment because of chronic SLL, on average, 26 weeks after leak detection (range 13-39 wk). The other 4 underwent repair earlier, on average 4 weeks after leak detection (1-7 wk). There were no mortalities, and all patients healed without residual leak. Perioperative morbidity developed in 1 of 6 (17%) patients who underwent delayed repair and in 75% of patients who underwent repair early. Patients who underwent early repair were heavier (body mass index 40.5 kg/m(2) versus 30 kg/m(2)) and nutritionally more deplete (albumin 26.7 g/L versus 39.2 g/L). All patients are well at a mean follow-up of 21.6 months (7.5-55.9 mo) with an average percentage excess weight loss of 74% (57%-120%). CONCLUSIONS: Definitive surgical management of SLL was uniformly effective with acceptable morbidity. It is indicated in patients with chronic persistent fistula beyond 12 weeks, provided patients are kept in good nutritional state. Some select patients may benefit from this approach in the early phases, but the surgical risks are higher.