Postoperative Dumping Syndrome, Health-Related Quality of Life, Anxiety, Depression, and Eating Disturbances: Results of a Longitudinal Obesity Surgery Study.

INTRODUCTION: Given the lack of research on the relationship of post-surgery dumping syndrome and eating disturbances, the purpose of the present longitudinal study was to investigate whether dumping after obesity surgery is associated with pre-/postoperative eating disorder symptoms or addiction-like eating beyond the type of surgery, gender, health-realted quality of life (HRQoL) and anxiety/depressive symptoms. METHODS: The study included 220 patients (76% women) before (t0) and 6 months after (t1) obesity surgery (sleeve gastrectomy [n = 152], Roux-en-Y gastric bypass [n = 53], omega loop gastric bypass [n = 15]). The Sigstad Dumping Score was used to assess post-surgery dumping syndrome. Participants further answered the Eating Disorder Examination Questionnaire (EDE-Q), Yale Food Addiction Scale 2.0 (YFAS 2.0), Short-Form Health Survey (SF-12), and Hospital Anxiety and Depression Scale (HADS) at t0 and t1. RESULTS: The point prevalence of symptoms suggestive of post-surgery dumping syndrome was 33%. Regression analyses indicate an association of dumping with surgical procedure (bypass), female gender, reduced HRQoL, more anxiety/depressive symptoms, and potentially with binge eating but not with eating disorder symptoms in general or with addiction-like eating. CONCLUSION: The current study failed to show a close relationship between the presence of self-reported dumping syndrome and eating disorder symptoms or addiction-like eating following obesity surgery. Further studies with longer follow-up periods should make use of clinical interviews to assess psychosocial variables and of objective measures to diagnose dumping in addition to standardized self-ratings.

Glycemic control and BMI changes after endoscopic implantation of a duodenojejunal bypass liner compared with laparoscopic Roux-en-Y gastric bypass surgery: a propensity score matching analysis.

INTRODUCTION: Both laparoscopic Roux-en-Y gastric bypass (RYGB) and duodenojejunal bypass liner (DJBL) have been shown to induce weight loss and dramatically ameliorate type 2 diabetes mellitus (T2DM). Since DJBL implantation causes nutrients to pass through the duodenum without contact with the digestive juices and the duodenal mucosa, its mechanisms have been suggested to mimic those of RYGB. This study aimed to compare the outcomes of these two bariatric procedures in terms of glycemic control and BMI in patients with obesity and T2DM. RESEARCH DESIGN AND METHODS: A retrospective observational cohort propensity score-weighted comparison of laparoscopic Roux-en-Y gastric bypass (RYGB) vs duodenojejunal bypass liner (DJBL) was conducted in patients with obesity and T2DM undergoing either procedure from 05/2014 to 12/2017. Propensity scores were weighted for body weight, body mass index (BMI), and glycated hemoglobin A1c (HbA1c). The primary outcome was comparative improvement of HbA1c. Secondary comparative effectiveness outcomes were decrease of body weight and BMI. RESULTS: Forty-six patients were included: 21 (10 male, 11 female; mean age 50.6 ± 11.7 years) underwent RYGB, while DJBL was implanted in 25 (10 male, 15 female; 52.5 ± 9.5 years). After twelve months, mean ΔBMI was 11.54 ± 4.47 kg/m2 for RYGB vs. 6.23 ± 2.36 kg/m2 for DJBL (p < 0.05). Mean total weight loss was 27.93 ± 8.57% for RYGB vs. 15.04 ± 5.73% for DJBL (p < 0.05). Glycemic control after one year improved significantly in both groups but did not differ significantly. CONCLUSION: RYGB and DJBL seem to be associated with similar remission rates of hyperglycemia after one year. However, RYGB induces more significant weight loss than DJBL.

[Malnutrition after biliopancreatic diversion--postoperative management and complications]. / Malnutrition nach biliopankreatischer Teilung--postoperative Maßnahmen und Komplikationen.

The biliopancreatic diversion is currently the maximum variant of bariatric surgery. It presents several opportunities of typical surgical complications, beside the risks generally prevailing in bariatric surgery. In addition, there is the procedure-immanent risk of development of nutritional deficiencies in the long-term process, at significant percentages. These deficiencies can, to a great extent, be avoided by consistent supplementation within the scope of a structured follow-up program; they can also be corrected by a substitution therapy. In the future, the risk of malnutrition can possibly be lowered by technically modified procedures with equal bariatric effectiveness. Considering the very good long-term results with regard to stable weight reduction in connection with a high recovery rate of the comorbidities, combined with a consistent postal-surgical management, the problem of malnutrition appears to be of minor importance. However, an appropriate compliance of the patient is also required.

Gorlin syndrome associated with small bowel carcinoma and mesenchymal proliferation of the gastrointestinal tract: case report and review of literature.

UNLABELLED: BACKGROUND AND CASE PRESENTATION: A patient with nevoid basal cell carcinoma syndrome (Gorlin syndrome) presented with two unusual clinical features, i.e. adenocarcinoma of the small bowel and extensive mesenchymal proliferation of the lower gastrointestinal tract. CONCLUSIONS: We discuss the possibility that these two features are pathogenetically linked to the formerly undescribed patient's PTCH germ line mutation.

Status of bariatric surgery in Germany--results of the nationwide survey on bariatric surgery 2005-2007.

BACKGROUND: Most studies on bariatric surgery outcomes are performed as clinical trials or reflect the clinical experience in single centers. The status of bariatric surgery in Germany has been examined with the cooperation of clinics and hospitals at the Institute of Quality Assurance in Surgery at the Ottovon-Guericke University of Magdeburg (Germany) since January 1, 2005. METHODS: In this prospective multicenter observational study, the data obtained for all primary bariatric procedures, including all repeated operations, performed on consecutive patients with morbid obesity at participating hospitals from 2005 to 2007 were prospectively collected using an internet online data registry. Perioperative characteristics such as the spectrum of diagnostic measurements, type of surgical procedures, and short- and long-term outcomes were investigated. RESULTS: During the study period 3,123 surgical procedures were performed. In 2005 and 2006, gastric banding (GB) was the operation performed most frequently, followed by the Roux-en-Y gastric bypass (RYGBP). In 2007, a RYGBP was carried out in 42.1% of all bariatric procedures. Among all patients, 74.4% were female. The mean BMI ranged from 48.5 kg/m2 in 2005 to 48.0 kg/m2 in 2007. Follow-up data after 12 months were available for 63.8% of the patients operated in 2005 and 2006. The mortality was 0.1% (30 days) and 0.16% (overall). CONCLUSION: As indicated by the worldwide trend, there is an ongoing change from GB to sleeve gastrectomy (SG) and malabsorptive procedures. The BMI of German bariatric surgical patients is substantially higher than that of patients from most other countries. There were no differences in overall outcomes during follow-up as compared to published studies.

[Postoperative complications after laparoscopic Roux-en-Y gastric bypass in bariatric surgery]. / Postoperative Komplikationen beim laparoskopischen Roux-Y-Magenbypass in der Adipositaschirurgie.

The laparoscopic Roux-en-Y gastric bypass surgery involves some characteristic surgical complications besides the general risks associated with bariatric surgery. The overall risk could be effectively decreased due to the minimal invasive technique,though. The mortality is 0-0.5% and the risk of morbidity varies between 6 and 30%. However, the specific circumstances of morbidly obese patients make diagnostics difficult. Especially septic complications of any kind represent a high risk of mortality.Therefore, maximal safety und prevention are very important issues to consider. The most common causes of death are pulmonary embolism and insufficiency of anastomosis. Due to the laparoscopic approach complications of wound healing are scarcely observed. The most frequent complications result from pulmonary and cardiac dysfunctions. Surgical complications mainly result from bleedings, problems with the anastomoses and sutures as well as from the small intestine showing any kind of passage malfunction. Overall, the surgical and bariatric results reveal that early postoperative and long-term complications remain within tolerable limits when compared to consequences of a lack of surgery.

Effect of gallbladder mucin on the crystallization of cholesterol in bile.

OBJECTIVES: Mucin is supposed to accelerate the crystallization of cholesterol in model bile while studies in native human gallbladder bile revealed conflicting results. METHODS: Therefore, we determined the relation of mucin concentration and cholesterol crystal observation time in gallbladder bile of 73 patients with cholesterol and mixed and 21 patients with pigment stones. In addition, bile samples of 20 patients with cholesterol gallstones were supplemented with either 0 (control) or 0.5-4.0 mg/ml purified bovine mucin or human mucin isolated from gallbladder bile, to study the effect of variable mucin concentrations on the crystallization of cholesterol. RESULTS: Rapid nucleating biles ( 4 days, n = 35) cholesterol crystal observation times (P < 0.05), but no correlation between mucin concentration and cholesterol crystal observation time was observed. Supplementation experiments with bovine purified mucin (up to 4.0 mg/ml) showed no significant effect on the total amount of newly formed cholesterol crystals within 21 days. However, higher amounts of newly formed cholesterol crystals were seen in bile samples supplemented with human mucin in comparison to negative controls. CONCLUSIONS: Our results demonstrate a dose-dependent effect of human but not of bovine gallbladder mucin on the formation of cholesterol monohydrate crystals in gallbladder bile of patients with cholesterol stones. Therefore, studies of cholesterol crystallization in model bile systems may be valuable but should always be confirmed in native gallbladder bile as the more physiological effector system.

Solubility of cholesterol in the crystal-free gallbladder bile of gallstone patients.

Supersaturation of bile with cholesterol is generally considered the driving force of cholesterol precipitation. However, in most investigations the amount of cholesterol crystals is included in the calculation of the cholesterol saturation index (CSI). We therefore studied the solubility of cholesterol in crystal-free gallbladder bile from gallstone patients. Our results demonstrate significantly ( P <.05) higher CSIs (1.4 +/- 0.5 and 1.4 +/- 0.4 vs 1.1 +/- 0.4, mean +/- SD) in crystal-free gallbladder bile from 66 patients with cholesterol stones and 21 patients with mixed stones compared with those in 30 patients with pigment stones and a significant difference ( P <.001) in the amount of cholesterol in vesicles (19.2% +/- 13.7% and 14.3% +/- 11.6 % vs 4.2% +/- 5.9%) and of the crystal-observation time (COT; 1-21 days, median 2 days and 1-21 days, median 3 days, vs 3-21 days, median 21 days). We detected a positive correlation ( r =.24, P <.01) between the percentage of cholesterol in vesicles and the CSI and a negative correlation between COT and CSI ( r = -.23, P <.02 ) and COT and the percentage of cholesterol in vesicles ( r = -.52, P <.001 ). However, in 14 of 30 gallbladder-bile specimens from patients with pigment stones but in just 5 of 21 specimens from patients with mixed stones patients and 12 of 66 specimens from patients with cholesterol stones, the distribution of cholesterol in different phases (mixed micelles, vesicles, and crystals) was within the limits of solubility determined in previous studies of model bile. Therefore, in addition to the relative composition of biliary lipids, nonlipid components exert considerable influence on the solubility of cholesterol in the gallbladder bile of gallstone patients.

Ursodeoxycholic acid decreases viscosity and sedimentable fractions of gallbladder bile in patients with cholesterol gallstones.

OBJECTIVES: Ursodeoxycholic acid (UDCA) therapy is associated with reduced risk of biliary pain and acute cholecystitis or pancreatitis in patients with cholesterol gallstones. The underlying mechanisms are understood incompletely, which prompted us to study the influence of UDCA treatment on composition, viscosity and sedimentable fractions of gallbladder bile in 25 patients with symptomatic cholesterol gallstones. METHODS: In two randomised groups, either UDCA (750 mg daily) or placebo was given to each patient 10-12 days before cholecystectomy. Gallbladder bile was collected intraoperatively and analysed for protein, mucin, lipid composition, cholesterol crystal observation time, amount of cholesterol in vesicles, viscosity and sedimentable fractions (cholesterol, protein, mucin, bilirubin). RESULTS: UDCA-treated patients showed longer cholesterol crystal observation times and lower concentrations of total cholesterol and percentages of vesicular cholesterol in gallbladder bile. The concentrations of protein and mucin in gallbladder bile tended to be lower in the UDCA-treated group, but phospholipids, bile acids and bilirubin did not differ between the groups. Viscosity and the total sedimentable fractions of gallbladder bile decreased in the UDCA-treated patients. CONCLUSIONS: UDCA treatment reduces total and vesicular cholesterol, the formation of cholesterol crystals, viscosity, and the total amount of sedimentable fractions in gallbladder bile. These observations might explain, at least partially, why UDCA treatment attenuates the occurrence of biliary pain and complications in gallstone patients.

Detrimental immunologic effects of preoperative chemoradiotherapy in advanced rectal cancer.

PURPOSE: Preoperative chemoradiotherapy for advanced rectal cancer has been an important therapeutic tool to improve the long-term results of curative resection. It is not known whether preoperative chemoradiotherapy for advanced rectal cancer influences the perioperative course of immune parameters. METHODS: Thirty patients with rectal cancer underwent surgery with (study group, n = 15) or without (control group, n = 15) preoperative chemoradiotherapy (2 cycles of 5-fluorouracil, 45 Gy). Blood samples were taken before neoadjuvant therapy, preoperatively, and on Days 1, 2, and 5 after surgery. Cell numbers of lymphocyte subpopulations, granulocytes, monocytes, and natural killer cells were determined by flow cytometry; tumor necrosis factor-alpha and interleukin-6 serum levels were measured with enzyme-linked immunosorbent assay. RESULTS: Significant differences between study and control patients (P < 0.05) were detected regarding circulating interleukin-6 and tumor necrosis factor-alpha levels, with depression of the proinflammatory response to surgery in study patients. Similarly, granulocytosis and monocytosis after surgery were significantly lower in patients after neoadjuvant therapy. Furthermore, cell counts of total T lymphocytes, T helper cells, B lymphocytes, and natural killer cells were significantly reduced after preoperative chemoradiotherapy. This depression of cell-mediated immunity in study patients was even more pronounced after surgery. CONCLUSIONS: Preoperative chemoradiotherapy for advanced rectal cancer results in a significant preoperative and postoperative immune dysfunction as indicated by depression of lymphocyte subpopulations, monocytes, granulocytes, and proinflammatory cytokine release. These findings are of importance because increased perioperative morbidity and mortality rates have been observed after preoperative chemoradiotherapy.

Different immune responses to abdominal surgery in men and women.

BACKGROUND: Animal experiments reveal significant gender differences in the immunological response to surgical trauma. This raises the possibility that gender differences may also exist in patients after major abdominal surgery. PATIENTS AND METHODS: This prospective study included 40 patients (20 men, 20 women) with colorectal diseases requiring surgical intervention. To evaluate the immune response to surgery circulating lymphocyte populations and natural killer cells were determined by flow-cytometry, and IL-6 serum levels were measured by enzyme-linked immunosorbent assay. Blood samples were taken before and on days 1, 2, and 5 after surgery. RESULTS: Despite comparable preoperative cell counts we detected significant postoperative gender differences regarding B-lymphocyte, T-lymphocyte, T-helper cell counts, and NK cell counts. While only a short, insignificant depression of these immune competent cells was detected in women, men suffered long-lasting (5 days) depression of these cells. Furthermore, women showed a more pronounced immediate (day 1) proinflammatory response (circulating IL-6) after abdominal surgery. CONCLUSIONS: Significant immunological gender differences following major abdominal surgery were observed in this prospective clinical study. Our findings support the experimental observations of better posttraumatic immune competence in women than in men. These gender differences may be of relevance for short- and long-term results after surgery for colorectal diseases. Future studies will address the use of sex-steroids and/or their antagonists as a therapeutic option for the improvement in perioperative immune dysfunction in patients with major surgery.

Effect of preoperative radiochemotherapy on lymph node retrieval after resection of rectal cancer.

HYPOTHESIS: Preoperative radiochemotherapy for advanced rectal cancer results in fewer lymph nodes detected in the tumor-bearing specimen. DESIGN: Nonrandomized control trial with analysis of a prospective perioperative database. SETTING: Department of Surgery of a large-volume university hospital. PATIENTS: All patients who underwent conventional open surgery to cure rectal cancer between January 1, 1996, and March 31, 2001. INTERVENTIONS: During the study period 184 patients (81%, control group) underwent surgery without receiving preoperative radiochemotherapy. Forty-two patients (19%, study group) who had advanced rectal cancer (modified Dukes stages B [tumors that have penetrated the muscle layer of the bowel wall or have gone through the bowel] or C [tumors that have spread to the lymph nodes in the same region]) received preoperative radiochemotherapy (2 cycles of fluorouracil, 4500 rad) during this period. Most patients underwent anterior rectal resection in both groups (77.7% of those who did not receive preoperative radiochemotherapy and 71.8% of those who did), the remaining patients were treated with abdominoperineal resection. RESULTS: A mean (SEM) of 19 (1) lymph nodes per specimen were detected in the control patients, while significantly fewer lymph nodes were detected in study patients (13 [1]; P<.05). The rate of inadequate lymph node staging (pNx) increased from 7% in the control group to 12% in the study group (P =.06). Pathological lymph node staging disclosed that significantly more study patients who received preoperative radiochemotherapy had modified Dukes stage A (tumors that are found only in the inner wall or rectum) cancer when compared with the control group (17% vs 0%, respectively; P<.05). CONCLUSIONS: Preoperative radiochemotherapy for advanced rectal cancer results in a significant decrease of lymph nodes detected within the tumor-bearing specimen. Preoperative radiochemotherapy induces significant downstaging with fewer positive lymph nodes and more patients presenting with Dukes stage A rectal cancer. Great care must be taken to remove an adequate number of lymph nodes and more sophisticated pathological techniques of lymph node detection are required since the tumors of ever-increasing numbers of patients are inadequately classified.