Exocrine pancreatic insufficiency after bariatric surgery: a bariatric surgery center of excellence experience.

INTRODUCTION: Gastrointestinal symptoms such as diarrhea, bloating, abdominal pain, and nausea are common after bariatric surgery (BS) and can lead to significant morbidity. While many diagnoses can explain these symptoms, post-bariatric exocrine pancreatic insufficiency (EPI) is becoming increasingly recognized as contributor to gastrointestinal symptoms. The frequency and outcomes of EPI after BS are not well understood. We investigated the prevalence and outcomes of EPI over 18 years at a tertiary bariatric referral center. METHODS: A retrospective review of patients who underwent primary or revisional BS from 2002 to 2020 was performed. Patients were included if they were suspected of having EPI or underwent fecal elastase testing (FE-1). EPI diagnosis was defined as positive FE-1 testing or improvement with empiric pancreatic enzyme replacement therapy (PERT). RESULTS: EPI was suspected in 261 patients, and 190 were tested via FE-1 (89.5%) or empirically treated (10.5%). EPI was diagnosed in 79 (41.6%) patients and was associated with older age and lower BMI. Therapeutic PERT was given to 65 patients diagnosed with EPI, and 56 (86.2%) patients reported improved symptoms. Patients who underwent RYGB and BPD-DS were more likely to have EPI than those after SG (47.9% and 70.0% vs 17.4%, p < 0.01). EPI diagnosis was associated with a history chronic pancreatitis. While diarrhea and abdominal pain were the most common symptoms prompting FE-1 testing, no symptoms were significantly associated with EPI. EPI was also associated with abnormal fecal fat results and treatment with bile acid sequestrants, but not small intestinal bacterial overgrowth. CONCLUSION: This study highlights that exocrine pancreatic insufficiency can account to for previously unexplained GI complaints after bariatric surgery. Therefore, bariatric surgery programs should consider this diagnosis in symptomatic patients, especially following RYGB and BPD-DS. Further work to define patient factors that should prompt evaluation, optimal treatment, and prevention is necessary.

Exploring the Relationship Between Bariatric Surgery and Inflammatory Bowel Disease: A Systematic Review.

Background: Obesity affects over 40% of Americans. Bariatric surgery is an increasingly popular and well-studied method to achieve weight loss, improve metabolic homeostasis, and resolve obesity-related comorbid conditions. While the impact of bariatric surgery on weight loss and metabolic health has been extensively studied, there is an increasing body of literature characterizing the impact of bariatric surgery on gastrointestinal health and inflammation. Inflammatory bowel disease (IBD) leads to inflammation in both the small and large intestine, and leads to significant patient morbidity. Similar to obesity, the incidence of IBD is also rising. Patients with IBD and obesity may seek bariatric surgery. The impact of bariatric surgery on IBD is not well understood, but critical to understand for optimal patient care. Herein, we review the currently available literature on the impact of bariatric surgery on IBD including common trends, discrepancies in findings, and remaining knowledge gaps in need of further study. Methods: A systematic review of the PubMed/MEDLINE database using PRISMA guidelines was performed. Results: We identified 12 manuscripts discussing de novo IBD after bariatric surgery and 16 studying bariatric surgery in patients with pre-existing IBD. Overall, bariatric surgery appears to be safe in patients with pre-existing IBD but may increase the risk of developing de novo IBD. Conclusions: Further research into optimal surgical approaches, patient selection, and mechanisms on how bariatric surgery impacts IBD is needed.

Retroperitoneal extramedullary hematopoietic pseudotumor in ataxia-telangiectasia.

Ataxia-telangiectasia confers a significant increase in the development of several cancer types, most commonly leukemia and lymphoma. However, as the natural history for these patients is evolving and their lifespan is increasing, there is the potential for the development of additional uncommon tumors in an already rare patient population. We report the first case, to our knowledge, of an incidental retroperitoneal tumor in a 26-year-old woman undergoing evaluation for hepatic dysfunction. The mass was suspicious for retroperitoneal sarcoma, but proved to be an extramedullary hematopoietic pseudotumor after extensive pathologic evaluation. The changing landscape of neoplasms associated with ataxia-telangiectasia is discussed with emphasis on previously underreported benign and malignant tumors.

Randomized study of effectiveness of computerized ultrasound simulators for an introductory course for residents in Brazil.

PURPOSE: This study aimed to assess the impact of ultrasound simulation (SonoSim) on educational outcomes of an introductory point-of-care ultrasound course compared to hands-on training with live models alone. METHODS: Fifty-three internal medicine residents without ultrasound experience were randomly assigned to control or experimental groups. They participated in an introductory point-of-care ultrasound course covering eight topics in eight sessions from June 23, 2014 until July 18, 2014. Both participated in lecture and hands-on training, but experimental group received an hour of computerized simulator training instead of a second hour of hands-on training. We assessed clinical knowledge and image acquisition with written multiple-choice and practical exams, respectively. Of the 53 enrolled, 40 participants (75.5%) completed the course and all testing. RESULTS: For the 30-item written exam, mean score of the experimental group was 23.1±3.4 (n=21) vs. 21.8±4.8 (n=19), (P>0 .05). For the practical exam, mean score for both groups was 8.7 out of 16 (P>0 .05). CONCLUSION: The substitution of eight hours of ultrasound simulation training for live model scanning in a 24 hour training course did not enhance performance on written and image acquisition tests in an introductory ultrasound course for residents. This result suggests that ultrasound simulation technology used as a substitute for live model training on an hour-for-hour basis, did not improve learning outcomes. Further investigation into simulation as a total replacement for live model training will provide a clearer picture of the efficacy of ultrasound simulators in medical education.