One anastomosis gastric bypass (OAGB) demonstrated similar results to traditional Roux-en-Y proce... more One anastomosis gastric bypass (OAGB) demonstrated similar results to traditional Roux-en-Y procedures. A possible concern is how to manage a chronic bile reflux when medical therapy results ineffective. Revision of the gastro-jejunal anastomosis, obtaining a Roux-en-Y reconstruction, has already been proposed, but technical details have not been elucidated yet. This video shows how to revise a 200-cm OAGB to treat chronic bile reflux, by converting the procedure to Roux-en-Y, having a short gastric pouch and a long efferent limb. A 51-year-old patient complained of recurrent heartburns 2 months after OAGB. A gastroscopy witnessed the presence of a 6-cm long gastric pouch with pouchitis and bile reflux in esophagus. Specific medications were ineffective. He underwent a revisional laparoscopic procedure. The efferent limb was measured and consisted of 650 cm. The afferent limb was then divided next to the previous gastro-jejunal anastomosis and a jejuno-jejunal anastomosis was perfor...
Bone modulates testis function through osteocalcin (OCN) production. This paper assesses the asso... more Bone modulates testis function through osteocalcin (OCN) production. This paper assesses the association between serum OCN and androgen production recovery in morbidly obese males at 9 months after bariatric surgery. A cohort of n=103 obese males with mean±s.d. body mass index (BMI) 47.7±8.2 kg m(-2), age 42±11 years, consisting of n=76 patients undergoing gastric bypass and n=27 in the waiting list for surgery. At 9 months from surgery, a significant increase was observed in mean±s.d. total OCN (tOCN=10.4±10.3 ng ml(-1), P<0.001) and undercarboxylated OCN (ucOCN=5.4±3.7 ng ml(-1), P<0.001), total testosterone (TT, 5.6±6.5 nM, P<0.001) and calculated free testosterone (cFT, 0.035±0.133 nM, P<0.006), sex hormone binding globulin (SHBG, 21.2±16.7 nM, P<0.001) and decrease in estradiol (E2, -30.1±51.9 pM, P<0.001) levels only in operated patients, with a significant reduction in BMI (24%) and waist (20%). A positive correlation existed between tOCN and ucOCN (age-adju...
Der Chirurg; Zeitschrift für alle Gebiete der operativen Medizen, 1988
The mean age is 50. Symptoms include acute abdominal pain, hypotensive shock, GI bleeding, biliar... more The mean age is 50. Symptoms include acute abdominal pain, hypotensive shock, GI bleeding, biliary colic, jaundice, and/or acute anemia. Less often, pancreatico-duodenal aneurysms may be fortuitously diagnosed by abdominal imaging. Rupture of a PDAA is a grave complication with high mortality and demands urgent intervention. Arterial embolization is the treatment of choice; surgical intervention should be reserved for failures of embolization. We report a case of PDAA successfully treated by arterial embolization but which posed problems in both diagnosis and treatment.
We describe a case of severe acute bleeding from an arterio-duodenal fistula between the duodenum... more We describe a case of severe acute bleeding from an arterio-duodenal fistula between the duodenum and a hepato-hepatic by-pass. Emergency ligation of the common hepatic artery was successfully achieved. After hepatic artery ligation, revascularization of the liver in human subjects occurs through inferior phrenic, pancreatico-duodenal and intercalary de novo arteries.
Laparoscopic gastric bypass is one of the most performed bariatric operations worldwide. The excl... more Laparoscopic gastric bypass is one of the most performed bariatric operations worldwide. The exclusion of stomach and duodenum after this operation makes the access to the biliary tree, in order to perform an endoscopic retrograde cholangiopancreatography (ERCP), very difficult. This procedure could be more often required than in overall population due to the increased incidence of gallstones after bariatric operations. Among the different techniques proposed to overcome this drawback, laparoscopic access to the excluded stomach has been described by many authors with a high rate of success reported. We herein describe our technique to perform laparoscopic transgastric ERCP. A gastrotomy on the excluded stomach is performed to introduce a 15-mm trocar. Two stitches are passed through the abdominal wall and placed at the two sides of the gastrotomy for traction. The intragastric trocar is used to pass a side-viewing endoscope to access the biliary tree. In patients with a past histor...
The presence of disturbed eating patterns can affect the short- and long-term outcomes after bari... more The presence of disturbed eating patterns can affect the short- and long-term outcomes after bariatric surgery. Data about the influence of preoperative eating patterns on outcomes after biliopancreatic diversion (BPD) are lacking. The aim of the present study was to assess the role of preoperative eating behavior in patients&amp;amp;amp;amp;amp;amp;#39; selection for biliopancreatic diversion. Sixty-one consecutive patients who underwent BPD were evaluated for the present study. For each patient, the following preoperative eating patterns were evaluated: sweet eating, snacking, hyperphagia, and gorging. The primary outcome measure was the percentage of excess weight loss (%EWL) at 3, 6, and 12 months in the groups of patients with different eating patterns at the preoperative evaluation. At the preoperative evaluation, snacking was found in 31 patients (50.8 %), sweet eating in 15 patients (24.6 %), hyperphagia in 48 patients (78.7 %), and gorging in 45 patients (73.8 %). For each eating behavior, there was no significant difference in mean preoperative BMI and weight loss at 3, 6, and 12 months between the group of patients with and the group of patients without the eating pattern considered. At the analysis of variance in the four groups of patients presenting the eating patterns considered, there was no difference in mean preoperative BMI (P = 0.66), %EWL at 3 months (P = 0.62), %EWL at 6 months (P = 0.94), and %EWL at 12 months (P = 0.95). Preoperative eating behaviors do not represent reliable outcome predictors for BPD, and they should not be used as a selection criterion for patients who are candidates to this operation.
The Roux-en-Y gastric bypass and the biliopancreatic diversion effectively induce weight loss and... more The Roux-en-Y gastric bypass and the biliopancreatic diversion effectively induce weight loss and long-term control of type 2 diabetes in morbidly obese individuals. It is unknown whether the control of diabetes is a secondary outcome from the treatment of obesity or a direct result of the duodenal-jejunal exclusion that both operations include. The aim of this study was to investigate whether duodenal-jejunal exclusion can control diabetes independently on resolution of obesity-related abnormalities. A gastrojejunal bypass (GJB) with preservation of an intact gastric volume was performed in 10- to 12-week-old Goto-Kakizaki rats, a spontaneous nonobese model of type 2 diabetes. Fasting glycemia, oral glucose tolerance, insulin sensitivity, basal plasma insulin, and glucose-dependent-insulinotropic peptide as well as plasma levels of cholesterol, triglycerides, and free fatty acids were measured. The GJB was challenged against a sham operation, marked food restriction, and medical therapy with rosiglitazone in matched groups of animals. Rats were observed for 36 weeks after surgery. Mean plasma glucose 3 weeks after GJB was 96.3 +/- 10.1 mg/dL (preoperative values were 159 +/- 47 mg/dL; P = 0.01). GJB strikingly improved glucose tolerance, inducing a greater than 40% reduction of the area under blood glucose concentration curve (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). These effects were not seen in the sham-operated animals despite similar operative time, same postoperative food intake rates, and no significant difference in weight gain profile. GJB resulted also in better glycemic control than greater weight loss from food restriction and than rosiglitazone therapy. Results of our study support the hypothesis that the bypass of duodenum and jejunum can directly control type 2 diabetes and not secondarily to weight loss or treatment of obesity. These findings suggest a potential role of the proximal gut in the pathogenesis the disease and put forward the possibility of alternative therapeutic approaches for the management of type 2 diabetes.
European journal of endocrinology / European Federation of Endocrine Societies, 2014
Male obesity is often associated with reduced levels of circulating total (TT) and calculated fre... more Male obesity is often associated with reduced levels of circulating total (TT) and calculated free testosterone (cFT), with normal/reduced gonadotropins. Bariatric surgery often improves sex steroid and sex hormone-binding globulin (SHBG) levels. The aim of this study was to assess the effects of bariatric surgery on waist circumference (WC) and BMI, and on TT levels, in morbidly obese men, stratified, according to the gonadal state, in eugonadal and hypogonadal (TT<8 nmol/l) subjects. A cohort of morbidly obese patients (29 with hypogonadism (HG) and 26 without) undergoing bariatric surgery (37, 10, 6, and 2, with Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, biliopancreatic diversion and gastric sleeve, respectively) was studied at 6 and 12 months from the operation. Anthropometric parameters (weight, BMI, WC) and sex hormones (gonadotropins, TT, cFT, estradiol (E2), SHBG) were assessed. WC was the only parameter significantly correlated with androgens, but...
Intraperitoneal drainage after gastrointestinal surgery is still routinely used in many hospitals... more Intraperitoneal drainage after gastrointestinal surgery is still routinely used in many hospitals. The objective of this study was to determine the evidence-based value of routine drainage after Roux-en-Y gastric bypass (RYGB). An electronic search of the MEDLINE, Cochrane, and Embase databases from 2002 to 2012 was performed to identify articles analyzing the use of drainage after RYGB, its efficacy in determining the presence of an anastomotic leak, and its role in nonoperative treatment of the leakage. Eighteen articles were identified: 6 nonrandomized prospective cohort studies, 1 cohort retrospective study that compared routine drainage versus no drainage, 11 retrospective cohort studies, and no randomized controlled trials (RCTs). The sensitivity of drainage in detecting postoperative leakage varied between 0% and 94.1% in 10 articles (3 prospective and 6 retrospective) reporting data about this matter. The efficacy of drainage for the nonoperative treatment of postoperative leakage could be estimated in 11 articles (5 prospective and 6 retrospective) and varied between 12.5% and 100%. Only 2 studies reported data about nonoperative treatment of leakage without drainage, which was pursued in 0% and 33% of patients, respectively. Evidence-based recommendations on the use of drainage after RYGB cannot be given. Without RCTs, the value of routine drainage cannot be ascertained.
One anastomosis gastric bypass (OAGB) demonstrated similar results to traditional Roux-en-Y proce... more One anastomosis gastric bypass (OAGB) demonstrated similar results to traditional Roux-en-Y procedures. A possible concern is how to manage a chronic bile reflux when medical therapy results ineffective. Revision of the gastro-jejunal anastomosis, obtaining a Roux-en-Y reconstruction, has already been proposed, but technical details have not been elucidated yet. This video shows how to revise a 200-cm OAGB to treat chronic bile reflux, by converting the procedure to Roux-en-Y, having a short gastric pouch and a long efferent limb. A 51-year-old patient complained of recurrent heartburns 2 months after OAGB. A gastroscopy witnessed the presence of a 6-cm long gastric pouch with pouchitis and bile reflux in esophagus. Specific medications were ineffective. He underwent a revisional laparoscopic procedure. The efferent limb was measured and consisted of 650 cm. The afferent limb was then divided next to the previous gastro-jejunal anastomosis and a jejuno-jejunal anastomosis was perfor...
Bone modulates testis function through osteocalcin (OCN) production. This paper assesses the asso... more Bone modulates testis function through osteocalcin (OCN) production. This paper assesses the association between serum OCN and androgen production recovery in morbidly obese males at 9 months after bariatric surgery. A cohort of n=103 obese males with mean±s.d. body mass index (BMI) 47.7±8.2 kg m(-2), age 42±11 years, consisting of n=76 patients undergoing gastric bypass and n=27 in the waiting list for surgery. At 9 months from surgery, a significant increase was observed in mean±s.d. total OCN (tOCN=10.4±10.3 ng ml(-1), P<0.001) and undercarboxylated OCN (ucOCN=5.4±3.7 ng ml(-1), P<0.001), total testosterone (TT, 5.6±6.5 nM, P<0.001) and calculated free testosterone (cFT, 0.035±0.133 nM, P<0.006), sex hormone binding globulin (SHBG, 21.2±16.7 nM, P<0.001) and decrease in estradiol (E2, -30.1±51.9 pM, P<0.001) levels only in operated patients, with a significant reduction in BMI (24%) and waist (20%). A positive correlation existed between tOCN and ucOCN (age-adju...
Der Chirurg; Zeitschrift für alle Gebiete der operativen Medizen, 1988
The mean age is 50. Symptoms include acute abdominal pain, hypotensive shock, GI bleeding, biliar... more The mean age is 50. Symptoms include acute abdominal pain, hypotensive shock, GI bleeding, biliary colic, jaundice, and/or acute anemia. Less often, pancreatico-duodenal aneurysms may be fortuitously diagnosed by abdominal imaging. Rupture of a PDAA is a grave complication with high mortality and demands urgent intervention. Arterial embolization is the treatment of choice; surgical intervention should be reserved for failures of embolization. We report a case of PDAA successfully treated by arterial embolization but which posed problems in both diagnosis and treatment.
We describe a case of severe acute bleeding from an arterio-duodenal fistula between the duodenum... more We describe a case of severe acute bleeding from an arterio-duodenal fistula between the duodenum and a hepato-hepatic by-pass. Emergency ligation of the common hepatic artery was successfully achieved. After hepatic artery ligation, revascularization of the liver in human subjects occurs through inferior phrenic, pancreatico-duodenal and intercalary de novo arteries.
Laparoscopic gastric bypass is one of the most performed bariatric operations worldwide. The excl... more Laparoscopic gastric bypass is one of the most performed bariatric operations worldwide. The exclusion of stomach and duodenum after this operation makes the access to the biliary tree, in order to perform an endoscopic retrograde cholangiopancreatography (ERCP), very difficult. This procedure could be more often required than in overall population due to the increased incidence of gallstones after bariatric operations. Among the different techniques proposed to overcome this drawback, laparoscopic access to the excluded stomach has been described by many authors with a high rate of success reported. We herein describe our technique to perform laparoscopic transgastric ERCP. A gastrotomy on the excluded stomach is performed to introduce a 15-mm trocar. Two stitches are passed through the abdominal wall and placed at the two sides of the gastrotomy for traction. The intragastric trocar is used to pass a side-viewing endoscope to access the biliary tree. In patients with a past histor...
The presence of disturbed eating patterns can affect the short- and long-term outcomes after bari... more The presence of disturbed eating patterns can affect the short- and long-term outcomes after bariatric surgery. Data about the influence of preoperative eating patterns on outcomes after biliopancreatic diversion (BPD) are lacking. The aim of the present study was to assess the role of preoperative eating behavior in patients&amp;amp;amp;amp;amp;amp;#39; selection for biliopancreatic diversion. Sixty-one consecutive patients who underwent BPD were evaluated for the present study. For each patient, the following preoperative eating patterns were evaluated: sweet eating, snacking, hyperphagia, and gorging. The primary outcome measure was the percentage of excess weight loss (%EWL) at 3, 6, and 12 months in the groups of patients with different eating patterns at the preoperative evaluation. At the preoperative evaluation, snacking was found in 31 patients (50.8 %), sweet eating in 15 patients (24.6 %), hyperphagia in 48 patients (78.7 %), and gorging in 45 patients (73.8 %). For each eating behavior, there was no significant difference in mean preoperative BMI and weight loss at 3, 6, and 12 months between the group of patients with and the group of patients without the eating pattern considered. At the analysis of variance in the four groups of patients presenting the eating patterns considered, there was no difference in mean preoperative BMI (P = 0.66), %EWL at 3 months (P = 0.62), %EWL at 6 months (P = 0.94), and %EWL at 12 months (P = 0.95). Preoperative eating behaviors do not represent reliable outcome predictors for BPD, and they should not be used as a selection criterion for patients who are candidates to this operation.
The Roux-en-Y gastric bypass and the biliopancreatic diversion effectively induce weight loss and... more The Roux-en-Y gastric bypass and the biliopancreatic diversion effectively induce weight loss and long-term control of type 2 diabetes in morbidly obese individuals. It is unknown whether the control of diabetes is a secondary outcome from the treatment of obesity or a direct result of the duodenal-jejunal exclusion that both operations include. The aim of this study was to investigate whether duodenal-jejunal exclusion can control diabetes independently on resolution of obesity-related abnormalities. A gastrojejunal bypass (GJB) with preservation of an intact gastric volume was performed in 10- to 12-week-old Goto-Kakizaki rats, a spontaneous nonobese model of type 2 diabetes. Fasting glycemia, oral glucose tolerance, insulin sensitivity, basal plasma insulin, and glucose-dependent-insulinotropic peptide as well as plasma levels of cholesterol, triglycerides, and free fatty acids were measured. The GJB was challenged against a sham operation, marked food restriction, and medical therapy with rosiglitazone in matched groups of animals. Rats were observed for 36 weeks after surgery. Mean plasma glucose 3 weeks after GJB was 96.3 +/- 10.1 mg/dL (preoperative values were 159 +/- 47 mg/dL; P = 0.01). GJB strikingly improved glucose tolerance, inducing a greater than 40% reduction of the area under blood glucose concentration curve (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). These effects were not seen in the sham-operated animals despite similar operative time, same postoperative food intake rates, and no significant difference in weight gain profile. GJB resulted also in better glycemic control than greater weight loss from food restriction and than rosiglitazone therapy. Results of our study support the hypothesis that the bypass of duodenum and jejunum can directly control type 2 diabetes and not secondarily to weight loss or treatment of obesity. These findings suggest a potential role of the proximal gut in the pathogenesis the disease and put forward the possibility of alternative therapeutic approaches for the management of type 2 diabetes.
European journal of endocrinology / European Federation of Endocrine Societies, 2014
Male obesity is often associated with reduced levels of circulating total (TT) and calculated fre... more Male obesity is often associated with reduced levels of circulating total (TT) and calculated free testosterone (cFT), with normal/reduced gonadotropins. Bariatric surgery often improves sex steroid and sex hormone-binding globulin (SHBG) levels. The aim of this study was to assess the effects of bariatric surgery on waist circumference (WC) and BMI, and on TT levels, in morbidly obese men, stratified, according to the gonadal state, in eugonadal and hypogonadal (TT<8 nmol/l) subjects. A cohort of morbidly obese patients (29 with hypogonadism (HG) and 26 without) undergoing bariatric surgery (37, 10, 6, and 2, with Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, biliopancreatic diversion and gastric sleeve, respectively) was studied at 6 and 12 months from the operation. Anthropometric parameters (weight, BMI, WC) and sex hormones (gonadotropins, TT, cFT, estradiol (E2), SHBG) were assessed. WC was the only parameter significantly correlated with androgens, but...
Intraperitoneal drainage after gastrointestinal surgery is still routinely used in many hospitals... more Intraperitoneal drainage after gastrointestinal surgery is still routinely used in many hospitals. The objective of this study was to determine the evidence-based value of routine drainage after Roux-en-Y gastric bypass (RYGB). An electronic search of the MEDLINE, Cochrane, and Embase databases from 2002 to 2012 was performed to identify articles analyzing the use of drainage after RYGB, its efficacy in determining the presence of an anastomotic leak, and its role in nonoperative treatment of the leakage. Eighteen articles were identified: 6 nonrandomized prospective cohort studies, 1 cohort retrospective study that compared routine drainage versus no drainage, 11 retrospective cohort studies, and no randomized controlled trials (RCTs). The sensitivity of drainage in detecting postoperative leakage varied between 0% and 94.1% in 10 articles (3 prospective and 6 retrospective) reporting data about this matter. The efficacy of drainage for the nonoperative treatment of postoperative leakage could be estimated in 11 articles (5 prospective and 6 retrospective) and varied between 12.5% and 100%. Only 2 studies reported data about nonoperative treatment of leakage without drainage, which was pursued in 0% and 33% of patients, respectively. Evidence-based recommendations on the use of drainage after RYGB cannot be given. Without RCTs, the value of routine drainage cannot be ascertained.
Uploads