Bariatric Surgery

Obstructive sleep apnoea (OSA) and obstructive sleep apnoea syndrome (OSAS) are subsets of sleep-disordered breathing. Awareness about OSA and its consequences amongst the general public as well as the majority of primary care physcians across India is poor. This necessiated the development of the INdian initiative on Obstructive Sleep Apnoea (INOSA) guidelines under the auspices of Department of Health Research, Ministry of Health & Family Welfare, Government of India. OSA is the occurrence of an average five or more episodes of obstructive respiratory events per hour of sleep with either sleep related symptoms or comorbidities or ≥ 15 such episodes without any sleep related symptoms or comorbidities. OSAS is defined as OSA associated with daytime symptoms, most often excessive sleepiness. Patients undergoing routine health check-up with snoring, daytime sleepiness, obesity, hypertension, motor vehicular accidents and high risk cases should undergo a comprehensive sleep evaluation....

Background: Laparoscopic sleeve gastrectomy (LSG) started as the restrictive part of the more complex laparoscopic duodenal switch (LDS) operation. There is no long-term experience with the isolated LSG. The main concern about the isolated LSG is the possibility of dilatation of the gastric pouch, long-term loss of restrictive function and weight regain. Laparoscopic re-sleeve gastrectomy (LRSG) has been used sparingly, but it also may become a possibility if more patients have the isolated LSG. Methods: 2 patients with BMI 58 and 65 respectively, underwent LSG as the first stage of the LDS. Later, when the patients regained some weight and their gastric pouch was found to be too large, the LRSG/DS was done. Results: The patient with BMI 58 had an initial drop to BMI 34 and regained weight to BMI 46, but after the LRSG/DS her BMI is 36 at 4 months. The BMI patient with BMI 65 had a drop to BMI 42, and after the LRSG/DS his BMI is 33 at 3 months later. Conclusion: LRSG may become necessary after gastric tube dilatation or insufficient original gastric volume reduction. LRSG is feasible, available and easy to perform when the resulting gastric pouch is too large or dilates after the original LSG.

Background The enzyme 11-β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) catalyzes intracellular glucocorticoid reactivation by conversion of cortisone to cortisol in different tissues and have been implicated in several metabolic disorders associated with obesity. The aim of this study was to evaluate the 11β-HSD1 expression in liver, visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT) in morbidly obese patients undergoing bariatric surgery and its correlations with clinical, anthropometric, and biochemical variables. Methods A prospective study was conducted over a 27-month period. Hepatic, VAT, and SAT samples were obtained at the time of surgery. 11β-HSD1 and 18S gene expression was measured using real-time quantitative reverse transcriptase-polymerase chain reaction. Results Forty nine patients met the inclusion criteria [mean age: 42.2 ± 10 years, body mass index (BMI): 42 ± 6 kg/m2, 71% women and 63% with metabolic syndrome (MS)]. 11β-HSD1 mRNA levels were higher in liver than fat tissue (p < 0.001), being higher in SAT than in VAT (p < 0.001) without gender-specific differences. Hepatic expression of 11β-HSD1 correlated positively with SAT and VAT, alanine aminotransferase (ALT), and serum glucose and was inversely associated with BMI. 11β-HSD1 mRNA in VAT correlated positively with insulinemia, ALT, and LDL cholesterol. There were no associations between 11β-HSD1 mRNA in SAT and the variables analyzed. Conclusions 11β-HSD1 expression is higher in liver in comparison to adipose tissue in obese patients. The observed correlations between hepatic and VAT 11β-HSD1 expression with dyslipidemia and insulin resistance suggest that this enzyme might have a pathogenic role in obesity and related metabolic disorders.

Advanced Surgical & Bariatrics
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PURPOSE A case representative of issues dental practitioners may face when providing care to patients with a history of bariatric surgery is reviewed. Meta-analysis shows that, following bariatric surgery, 43 to 79% of diabetes, hyperlipidemia and hypertension in patients resolved to normal levels or no longer required therapy. However, bariatric surgery side effects have implications for oral health, including nutrient deficiencies impacting healing of oral tissues and gastroesophageal reflux, resulting in tooth erosion. Patients who have undergone bariatric surgery are seen with increasing frequency in dental offices and dental professionals need to be familiar with the challenges these patients present.

Background: Bariatric surgery has the potential for serious complications. A case is presented of unilateral lower extremity compartment syndrome after a laparoscopic Roux-en-Y gastric bypass performed in the modified lithotomy position. Case report: A 38-year-old female (weight 134.5 kg, BMI 49.6) underwent a laparoscopic Roux-en-Y gastric bypass (operating time 375 min). Postoperatively, she complained of bilateral lower extremity pain that gradually subsided over the course of the day. However, on the 1st postoperative day she developed numbness on the dorsum of the foot and compartment syndrome was diagnosed (anterior compartment pressure 71 mmHg). She underwent emergency fasciotomy,which resulted in a reduction of the pain and numbness on the dorsum of the foot. The next day she ambulated without difficulty and was discharged home on the 5th postoperative day. 12 days after her operation, delayed primary closure of the fasciotomy wound was done with the assistance of a novel device (Proxiderm) that applies constant tension to the wound edges. Subsequent recovery was uneventful, and at 4- month follow-up the patient had a weight loss of 28 kg without any right leg motor or sensory deficits. Conclusion: Bariatric surgeons should be aware of compartment syndrome as a rare but serious complication. Prevention, early recognition, and prompt fasciotomy are crucial for a favorable outcome.

Background. Polycystic ovary syndrome (PCOS) is the commonest cause of female infertility. Visceral obesity and insulin resistance are key pathophysiological mechanisms behind PCOS. Women suffering from this syndrome and infertility often seek bariatric surgery hoping that they would be able to conceive postoperatively. Objective. At present, there is no consensus on the role of bariatric surgery in the management of PCOS-associated infertility within the medical community, making it difficult to give specific advice to these women, so a review of the literature was necessary. Results. A detailed review of the literature was performed. Only 6 manuscripts were relevant and contained quantitative data. They demonstrated that bariatric surgery results in postoperative conception rates varying from 33% to 100%. Surgery is also associated with amelioration of menstrual irregularities, hormonal abnormalities, and hirsutism that are associated with PCOS. These studies were retrospective an...

Background: Abnormalities in calcium and vitamin D metabolism are observed early after gastric bypass, whereas clinical or biochemical evidence of metabolic bone disease might not be detected until many years after the procedure. The aim of the present study was to evaluate the impact of bariatric surgery on bone metabolism determined on the basis of postoperative laboratory changes in calcium, phosphorus, magnesium, alkaline phosphatase and parathormone (PTH) levels. Methods: 110 patients submitted to Roux-en-Y gastric bypass (RYGBP) were followed after surgery, and the following parameters were determined: intact PTH molecule (PTHi; chemiluminescence), alkaline phosphatase (colorimetric method), ionic calcium (selective electrode), phosphorus and magnesium (colorimetric method). Results: Elevated serum PTHi levels were observed in 29% of the patients and hypocalcemia in 0.9% from the 3rd postoperative month and afterwards (3 to 80 months after surgery). Conclusion: There is a need for careful evaluation of bone metabolism and for routine calcium replacement after RYGBP.

Objective: The objective of this study is to assess whether vertical sleeve gastrectomy (VSG) increases the incidence of gastroesophageal reflux disease (GERD), esophagitis and Barrett esophagus (BE) relative to patients under- going Roux-en-Y gastric bypass (RYGB) in patients with and without preoperative GERD.
Summary of Background Data: Concerns for potentiation of GERD, sup- ported by multiple high-quality retrospective studies, have hindered greater adoption of the VSG.

Methods: From the OptumLabs Data Warehouse, VSG and RYGB patients with 􏰁2 years enrollment were identified and matched by follow-up time. GERD [reflux esophagitis, prescription for acid reducing medication (Rx) and/or diagnosis of BE], upper endoscopy (UE), and re-admissions were evaluated beyond 90 days.

Results: A total of 8362 patients undergoing VSG were matched 1:1 to patients undergoing RYGB, on the basis of post-operative follow-up interval. Age, sex, and follow-up time were similar between the 2 groups (P > 0.05). Among all patients, postoperative GERD was more frequently observed in VSG patients relative to RYGB patients (60.2% vs 55.6%, respectively; P < 0.001), whereas BE was more prevalent in RYGB patients (0.7% vs 1.1%; P 1⁄4 0.007). Postoperatively, de novo esophageal reflux symptomatology was more common in VSG patients (39.3% vs 35.3%; P < 0.001), although there was no difference in development of the histologic diagnoses reflux esophagitis and BE. Further- more, postoperative re-admission was higher in the RYGB cohort (38.9% vs 28.9%; P < 0.001).

Conclusions: Compared to RYGB, VSG may not have inferior long-term GERD outcomes, while also leading to fewer re-hospitalizations. These data challenge the prevailing opinion that patients with GERD should undergo RYGB instead of VSG.

This presentation was prepared by RUTAYISIRE François Xavier and ISHIMWE Diane, Medical students in Year 4(Doctorate 2) at University of RWANDA school of medicine and Pharmacy, Department of Medicine and Surgery. we did the work under supervision of Dr Ntakiyiruta Georges,Mmed,FCSECSA

About 2.6 million stillbirths annually are estimated to occur worldwide, mainly in developing countries, although much of the data is incomplete. The aim of the present study was to analyze cases of stillbirth examined in an Institute of Forensic Medicine of the Federal District (IML-DF), Brazil. A total of 38 cases were analyzed, mostly male, with a mean gestational age of 32.9 ± 6.38 weeks. Maternal causes predominated, with hypertensive disorders during pregnancy and trauma as the leading causes; placental causes followed, the most frequent being premature detachment of the placenta. Fetal causes occurred in three cases (one of the case is cardiac malformation and two are kidney disease). In nine cases, the cause of stillbirth could not be determined. The authors call attention to the importance of stillbirth rate, which is considered one of the best indicators of quality of life in a population; to the lack of reliable data for assessing such rate; and to the main factors associated with fetal death and the measures that could be taken to prevent such death. The occurrence of a stillbirth affects the mother, the family, the professionals responsible, the community, and the society. It is a heavy burden for the affected families, and psychological symptoms often persist long after the death of the babies. The authors believe that stigmas and taboos exacerbate the trauma for the families and that fatalism undermines the prevention of stillbirths, which in most cases is possible with the improvement of health services.

BACKGROUND: Short-segment Barrett&#x27;s esophagus (SSBE) or long-segment Barrett&#x27;s esophagus (LSBE) is the consequence of chronic gastroesophageal reflux disease (GERD), which is frequently associated with obesity. Obesity is a significant risk factor for the development of GERD symptoms, erosive esophagitis, Barrett&#x27;s esophagus, and esophageal adenocarcinoma. Morbidly obese patients who submitted to gastric bypass have an incidence of GERD as high as 50% to 100% and Barrett&#x27;s esophagus reaches up to 9% of patients. METHODS: In this prospective study, we evaluate the postoperative results after three different procedures-calibrated fundoplication + posterior gastropexy (CFPG), fundoplication + vagotomy + distal gastrectomy + Roux-en-Y gastrojejunostomy (FVDGRYGJ), and laparoscopic resectional Roux-en-Y gastric bypass (LRRYGBP)-among obese patients. RESULTS: In patients with SSBE who submitted to CFPG, the persistence of reflux symptoms and endoscopic erosive esophagi...