Colonoscopy in the nonagenarian population.

BACKGROUND: With increasing life expectancy, there is an increasing proportion of nonagenarians undergoing both elective and emergency surgical procedures. The decision as to whom will benefit from surgical procedures is however difficult to ascertain and still remains a challenge to clinicians. This study is aimed to evaluate the clinical outcomes of colonoscopy in the nonagenarian population, and to determine if the outcomes are acceptable for us to continue to offer such interventions. METHODS: Retrospective study of patients of Dr. G.R (Gastroenterologist) and Dr. W.B (Colorectal Surgeon) between 1 January 2018 and 31 November 2022. All patients who were ≥90 years old and had a colonoscopy was included in the study. Exclusion criteria were patients who were less than 90 years old, had a flexible sigmoidoscopy or colonoscopy as part of their surgical procedure. PRIMARY OUTCOME MEASURES: post-colonoscopy complications and length of stay. SECONDARY OUTCOME MEASURES: reasons for colonoscopy, significant colonoscopy findings, 30-day morbidity and mortality. RESULTS: Sixty patients were included in the study. Median age was 91 (90-100) years old. 33.3% of the patients were males. Seventy percent of the patients were ASA 3. Median length of hospital stay was 1 day. 11.7% of patients were found to have colorectal malignancy. There were no complications after the colonoscopy. There were no 30-day re-admission, morbidity or mortality. CONCLUSION: Colonoscopy can be performed safely in carefully selected nonagenarian patients with acceptable low complication rates.

Matched Endoscopic Sleeve Gastroplasty and Laparoscopic Sleeve Gastrectomy Cases: Formative Cohort Study.

BACKGROUND: Bariatric weight-loss surgery rates are increasing internationally. Endoscopic sleeve gastroplasty (ESG) is a novel, minimally invasive endoscopic procedure thought to mimic some of the effects of a more common surgery, laparoscopic sleeve gastrectomy (LSG). Patient factors affecting procedural choice are unexplored. OBJECTIVE: This formative study aimed to determine the preoperative and early postoperative characteristics of adults matched for age, sex, and BMI who chose ESG versus LSG. METHODS: This prospective cohort study recruited ESG and matched LSG adults in Australia. Preoperative outcomes were medical history, glycemic biomarkers, blood lipids, liver function enzymes, albumin, blood pressure, hepatic steatosis index, the Gastrointestinal Symptom Rating Scale, the Impact of Weight on Quality of Life-Lite questionnaire, and body composition via dual-energy x-ray absorptiometry. Adverse events were recorded preoperatively and up to 2 weeks postoperatively. SPSS was used to test if there were differences between cohorts by comparing means or mean ranks, and binary regression was used to understand how characteristics might predict procedure choice. RESULTS: A total of 50 (including 25 ESG and 25 LSG) patients were recruited, who were primarily White (45/50, 90%) and female (41/50, 82%) with a mean age of 41.7 (SD 9.4) years. Participants had a mean of 4.0 (SD 2.2) active comorbid conditions, with the most common being nonalcoholic fatty liver disease (38/50, 76%), back pain (32/50, 64%), anxiety or depression (24/50, 48%), and joint pain (23/50, 46%). The LSG cohort had higher hemoglobin A1c (5.3%, SD 0.2%) than the ESG cohort (5%, SD 0.2%; P=.008). There was a 2.4 kg/m2 difference in median BMI (P=.03) between the groups, but fat and fat-free mass had no meaningful differences. Comparing the LSG and ESG groups showed that the LSG group had lower total quality of life (49.5%, SD 10.6% vs 56.6%, SD 12.7%; P=.045), lower weight-related self-esteem (10.7%, IQR 3.6%-25% vs 25%, IQR 17.9%-39.3%; P=.02), and worse abdominal pain (38.9%, IQR 33.3%-50% vs 53.9%, SD 14.2%, P=.01). For every percent improvement in weight-related self-esteem, the odds for selecting ESG increased by 4.4% (95% CI 1.004-1.085; P=.03). For every percent worsening in hunger pain, the odds for selecting ESG decreased by 3.3% (95% CI 0.944-0.990; P=.004). CONCLUSIONS: There was very little evidence that Australian adults who chose an endoscopic versus surgical sleeve had different rates of comorbidities, body fat percentage, or weight-related quality of life. There was evidence against the test hypothesis, that is, there was evidence suggesting that lower self-esteem predicted choosing a more invasive sleeve (ie, LSG rather than ESG). TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry ACTRN12618000337279; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374595.

Efficacy and safety of endoscopic sleeve gastroplasty and laparoscopic sleeve gastrectomy with 12+ months of adjuvant multidisciplinary support.

BACKGROUND: The laparoscopic sleeve gastrectomy (LSG) and the incisionless endoscopic sleeve gastroplasty (ESG) weight loss procedures require further investigation of their efficacy, safety and patient-centered outcomes in the Australian setting. METHODS: The aim was to examine the 6- and 12-month weight loss efficacy, safety, and weight-related quality of life (QoL) of adults with obesity who received the ESG or LSG bariatric procedure with 12+ months of adjuvant multidisciplinary pre- and postprocedural support. Data were from a two-arm prospective cohort study that followed patients from baseline to 12-months postprocedure from a medical center in Queensland. Percent excess weight loss (%EWL) was the primary outcome. Secondary outcomes were body composition (fat mass, fat-free mass, android:gynoid ratio, bone mineral content) via dual energy X-ray absorptiometry, weight-related QoL, lipid, glycemic, and hepatic biochemistry, and adverse events. RESULTS: 16 ESG (19% attrition; 81.2% female; aged:41.4 (SD: 10.4) years; BMI: 35.5 (SD: 5.2) kg/m2) and 45 LSG (9% attrition; 84.4% female; aged:40.4 (SD: 9.0) years; BMI: 40.7 (SD: 5.6) kg/m2) participants were recruited. At 12-months postprocedure, ESG %EWL was 57% (SD: 32%; p < 0.01) and LSG %EWL was 79% (SD: 24%; p < 0.001). ESG and LSG cohorts improved QoL (19.8% in ESG [p > 0.05]; 48.1% in LSG [p < 0.05]), liver function (AST: - 4.4 U/L in ESG [p < 0.05]; - 2.7 U/L in LSG [p < 0.05]), HbA1c (- 0.5% in ESG [p < 0.05]; - 0.1% in LSG [p < 0.05]) and triglycerides (- 0.6 mmol/L in ESG [p > 0.05]; - 0.4 mmol/L in LSG [P < 0.05]) at 12-months. Both cohorts reduced fat mass (p < 0.05). The ESG maintained but LSG decreased fat-free mass at 6-months (p < 0.05); and both cohorts lost fat-free mass at 12-months (p < 0.05). There were no adverse events directly related to the procedure. The ESG reported 25% mild-moderate adverse events possibly related to the procedure, and the LSG reported 27% mild-severe adverse events possibly related to the procedure. CONCLUSIONS: In this setting, the ESG and LSG were safe and effective weight loss treatments for obese adults alongside multidisciplinary support. Patients who elected the ESG maintained fat-free mass at 6-months but both cohorts lost fat-free mass at 12-months postprocedure. Patients who elected the LSG had large and significant improvements to weight-related quality of life. Further well-powered studies are required to confirm these findings. TRIAL REGISTRATION: This study was registered prospectively at the Australia New Zealand Clinical Trials Registry on 06/03/2018, Registration Number ACTRN12618000337279 .

Induction of Meal-related Symptoms as a Novel Mechanism of Action of the Duodenal-Jejunal Bypass Sleeve.

BACKGROUND: Treatment with a duodenal-jejunal bypass sleeve (DJBS) induces clinically significant weight loss, but little is known about the mechanisms of action of this device. AIM: The aim of this study was to characterize the mechanisms of action of the DJBS and determine the durability of weight loss and metabolic improvements. MATERIALS AND METHODS: We studied a cohort of 19 subjects with severe obesity and type 2 diabetes (baseline body mass index: 43.7±5.3 kg/m). Anthropometry, body composition, blood pressure, biochemical measures, and dietary intake were monitored for 48 weeks after DJBS implantation, and then for 1 year after device removal. Gastric emptying and triglyceride absorption were measured at baseline, 8 weeks after implant, and within 3 weeks of device explant. Visceral sensory function was assessed at baseline, 4 weeks after implant, and within 3 weeks after explant. RESULTS: Significant weight loss (P<0.01) occurred following DJBS placement, with a mean weight reduction of 17.0±6.5% at 48 weeks. The symptom burden following a standardized nutrient challenge was increased after DJBS implantation (P<0.05), returning to baseline after DJBS removal. Neither gastric emptying nor triglyceride absorption changed with the device in situ. A significant reduction in energy intake was observed [baseline: 7703±2978 kJ (1841±712 kcal), 24 weeks: 4824±2259 kJ (1153±540 kcal), and 48 weeks: 4474±1468 kJ (1069±351 kcal)]. After 1 year, anthropometry remained significantly improved, but there was no durable impact on metabolic outcomes. CONCLUSIONS: DJBS treatment resulted in substantial weight loss. Weight loss is related to reduced caloric intake, which seems linked to an augmented upper gastrointestinal symptom response, but not altered fat absorption.

Overlap of Irritable Bowel Syndrome and Functional Dyspepsia in the Clinical Setting: Prevalence and Risk Factors.

BACKGROUND: According to Rome IV criteria, functional dyspepsia (FD) and irritable bowel syndrome (IBS) are distinct functional gastrointestinal disorders (FGID); however, overlap of these conditions is common in population-based studies, but clinical data are lacking. AIMS: To determine the overlap of FD and IBS in the clinical setting and define risk factors for the overlap of FD/IBS. METHODS: A total of 1127 consecutive gastroenterology outpatients of a tertiary center were recruited and symptoms assessed with a standardized validated questionnaire. Patients without evidence for structural or biochemical abnormalities as a cause of symptoms were then categorized based upon the symptom pattern as having FD, IBS or FD/IBS overlap. Additionally, this categorization was compared with the clinical diagnosis documented in the integrated electronic medical records system. RESULTS: A total of 120 patients had a clinical diagnosis of a FGID. Based upon standardized assessment with a questionnaire, 64% of patients had FD/IBS overlap as compared to 23% based upon the routine clinical documentation. In patients with severe IBS or FD symptoms (defined as symptoms affecting quality of life), the likelihood of FD/IBS overlap was substantially increased (OR = 3.1; 95%CI 1.9-5.0) and (OR = 9.0; 95%CI 3.5-22.7), respectively. Thus, symptom severity for IBS- or FD symptoms were significantly higher for patients with FD/IBS overlap as compared to patients with FD or IBS alone (p all < 0.01). Age, gender and IBS-subtype were not associated with overlap. CONCLUSION: In the clinical setting, overlap of FD and IBS is the norm rather than the exception. FD/IBS overlap is associated with a more severe manifestation of a FGID.