Gastrobronchial fistula after sleeve gastrectomy and gastric bypass: endoscopic management and prevention.

Gastrobronchial fistula (GBF) is a serious complication following bariatric surgery, whose treatment by thoracotomy and/or laparotomy involves a high morbidity rate. We present the outcomes of endoscopic management for GBF as a helpful technique for its healing process. This is a multicenter retrospective study of 15 patients who underwent gastric bypass (n = 10) and sleeve gastrectomy (n = 5) and presented GBF postoperatively (mean of 6.7 months). Ten patients developed lung abscess and were treated by antibiotic therapy (n = 10) and thoracotomy (n = 3). Abdominal reoperation was performed in nine patients for abscess drainage (n = 9) and/or ring removal (n = 4) and/or nutritional access (n = 6). The source of the GBF was at the angle of His (n = 14). Furthermore, 14 patients presented a narrowing of the gastric pouch treated by 20 or 30 mm aggressive balloon dilation (n = 11), stricturotomy or septoplasty (n = 10) and/or stent (n = 7). Fibrin glue was used in one patient. We performed, on average, 4.5 endoscopic sessions per patient. Endotherapy led to a 93.3% (14 out of 15) success rate in GBF closure with an average healing time of 4.4 months (range, 1-10 months), being shorter in the stent group (2.5 × 9.5 months). There was no recurrence during the average 27.3-month follow-up. A patient persisted with GBF, despite the fibrin glue application, and decided to discontinue it. GBF is a highly morbid complication, which usually arises late in the postoperative period. Endotherapy through different strategies is a highly effective therapeutic option and should be implemented early in order to shorten leakage healing time.

Laparoscopic Roux-en-Y gastric bypass versus laparoscopic adjustable gastric banding: five years of follow-up.

BACKGROUND: Bariatric surgery is an effective treatment for morbid obesity. Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) are commonly performed procedures. The aim of the present study was to evaluate and compare the long-term outcomes after LRYGB and LAGB. METHODS: We studied the data from a prospective database of all patients undergoing LRYGB or LAGB with 5 years of follow-up. RESULTS: From July 2001 to September 2003, 91 and 62 patients underwent LRYGB and LAGB, respectively. Of these patients, 73.6% of the LRYGB and 91.9% of the LAGB patients had 5 years of follow-up. Of the 91 and 62 patients, 89% and 82% were women, respectively. The mean age and body mass index was 34.5 ± 11.0 years and 39.6 ± 4.9 kg/m(2) for the LRYGB group and 38.4 ± 13.1 years and 35.8 ± 4.0 kg/m(2) for the LAGB group, respectively. The mean operative time was 150 ± 58 minutes for LYRGB and 73 ± 23 minutes for LAGB (P <.05). The conversion and reoperation rate was 8% and 4.3%, respectively, for the LRYGB group versus 0% for the LAGB group. Early postoperative complications were observed in 12 and 1 patient (P = .014) after LRYGB and LAGB, respectively. Late complications developed in 33 and 17 patients after LYRGB and LAGB, respectively (P = NS). The percentage of excess weight loss at 5 years postoperatively was 92.9% ± 25.6% and 59.1% ± 46.8% (P <.001) for LRYGB and LAGB, respectively. Surgical failure (percentage of excess weight loss <50%) at 5 years was 6% for LRYGB and 45.6% for LAGB. A late reoperation was needed in 24.1% of the LAGB patients. CONCLUSION: A greater percentage of excess weight loss at 1 and 5 years was observed after LRYGB than LAGB. The LAGB group had a >40% rate of surgical failure and a 24.1% reoperation rate at 5 years of follow-up.

Initial human experience with restrictive duodenal-jejunal bypass liner for treatment of morbid obesity.

BACKGROUND: The duodenal-jejunal bypass liner is an endoscopically placed and removable intestinal liner that creates a duodenal-jejunal bypass, leading to diabetes improvement and weight loss. The aim of the present study was to evaluate the clinical effects and safety of the duodenal-jejunal bypass liner combined with a restrictor orifice (flow restrictor). METHODS: The device was endoscopically implanted in 10 patients (body mass index 40.8 +/- 4.0 kg/m(2)) and removed after 12 weeks. Dilation of the restrictor orifice was performed as clinically indicated with a 6-, 8-, or 10-mm diameter through-the-scope balloon. The measured outcomes included the percentage of excess weight loss, total weight loss, adverse events, and gastric emptying (GE) at baseline, weeks 4 and 12 of implantation, and 3-5 months after device removal. GE was measured by scintigraphy at 1, 2, and 4 hours after implantation. RESULTS: The percentage of excess weight loss and total weight loss at explantation was 40% +/- 3% (range 21-64%) and 16.7 +/- 1.4 kg (range 12.0-26.0), respectively. The 4-hour GE was 98% +/- 1% at baseline, 72% +/- 6% at 4 weeks (P = 0.001 versus baseline), and 84% +/- 5% at 12 weeks (P <.05 versus baseline). After explantation, the rate of GE returned to normal in 7 of 8 subjects, but remained slightly delayed in 1 subject (84% at 4 hours). Episodes of nausea, vomiting, and abdominal pain required endoscopic dilation of the restrictor orifice with a 6-mm through-the-scope balloon in 7 patients and a 10-mm balloon in 1, with no clinically significant adverse events. CONCLUSION: Endoscopic implantation of a combination flow restrictor and duodenal-jejunal bypass liner induced substantial weight loss. The implanted patients exhibited delayed GE that was reversed after device removal.

Hypoadiponectinemia and its association with liver fibrosis in morbidly obese patients.

BACKGROUND: Reduced serum levels of adiponectin have been associated with insulin resistance and non-alcoholic fatty liver disease (NAFLD). However, the relationship between serum adiponectin levels and hepatic histology in NAFLD is controversial. The aim of this study was to explore associations between plasma adiponectin concentrations and liver histology in morbidly obese patients. METHODS: We conducted a case-control study including obese patients undergoing bariatric surgery and normal controls. Anthropometric, standard biochemical variables as well as plasma adiponectin and leptin levels were determined. Liver biopsy was performed in all patients at the time of surgery. RESULTS: Seventy morbidly obese patients (mean BMI, 40.6 ± 5.6 kg/m(2)) met the inclusion criteria and were compared with 69 controls (mean BMI, 22.8 ± 1.6 kg/m(2), p = 0.0001). Thirty patients (43%) had NAFLD and 20 (28%) of them fulfilled the histological criteria for steatohepatitis. Obesity was associated with increased leptin and decreased adiponectin levels. NAFLD patients exhibited decreased levels of serum adiponectin compared with matched controls [median (Q1-Q3), 3.9 (3.2-4.3) vs. 8.6 (6.5-9.2) µg/mL, p < 0.0001]. In univariate analysis, age, gender, type 2 diabetes mellitus, BMI, HOMA-IR, aspartate aminotransferase (AST), alanine aminotransferase, serum glucose, and adiponectin levels were independently associated with hepatic fibrosis. In multivariate analysis, AST [OR = 1.082 (1.000-1.170)], age [OR = 1.119 (1.023-1.225)], and serum adiponectin levels [OR = 0.529 (0.299-0.936)] were significantly associated with the presence of liver fibrosis. CONCLUSIONS: NAFLD patients have lower plasma adiponectin concentrations than control subjects. Low adiponectin levels are associated with more severe liver histology. Serum adiponectin may be useful to estimate the severity of liver damage in obese patients with NAFLD.