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07:42 12/09/13 | Owen Haskins | Editor in chief, Bariatric News

This week we report on papers from the Journal of the Minerva Chirurgica, the Journal of the Society of Laparoendoscopic Surgeons, the Annals of Surgery, Surgery Today and the Journal of Visceral Surgery.

Gastric emptying after sleeve gastrectomy: statistical evidence of a controlled prospective study with gastric scintigraphy

Writing in the Journal of the Minerva Chirurgica, researchers from the Department of Medicine and Surgery University of Salerno, Salerno, Italy, assess gastric emptying after laparoscopic sleeve gastrectomy using gastric scintigraphy.

All patients performed gastric emptying scintigraphy through a standard semisolid meal (250 kcal), marked with 0.5 mCiTc 99. Group A performed the exam before (A1) and after the operation (A2). A control group (Group B) included 20 patients undergoing scintigraphic assessment for other reasons. They concluded that gastric motility plays a role in the pathogenesis of obesity. LSG reduces gastric emptying time, but further studies are necessary to reach statistical significance. (Abstract)

A systematic review of staple-line reinforcement in laparoscopic sleeve gastrectomy.

Reporting in the Journal of the Society of Laparoendoscopic Surgeons, investigators from the Central Michigan University College of Medicine, performed a systematic review to evaluate the effect of staple-line reinforcement on the gastric leak rate, morbidity and mortality rate, after LSG.

Rates of leak, bleeding, surgical-site infection, re-intervention, readmission, and mortality were analysed and they calculated differences between the reinforcement group (group A) and non-reinforcement group (group B). They identified 30 articles that met the inclusion criteria. The leak rate was 3.9% (95% confidence interval, 2.9%-5.5%) in group A and 3.2% (95% confidence interval, 2.8%-4.1%) in group B. The mortality rate was 0.8% (95% confidence interval, 0.4%-1.5%) in group A and 0.7% (95% confidence interval, 0.4%-1.1%) in group B.

They conclude that the study shows a lack of statistical difference in leak rate, overall morbidity, or mortality rate in laparoscopic sleeve gastrectomy with or without staple-line reinforcement. (Abstract)

08:30 30/07/13 | Anonymous (not verified) |

The importance of 3rd party oversight

Bariatric-metabolic (BM) surgery delivers extraordinary outcomes, excellent sustained weight loss, saves lives, improves quality of life and improves weight-related comorbidity. Improvements in efficacy, and in particular safety, have been evident over the last decade. Innovation has always been a major part of surgery and, consequently, new techniques and procedures emerge without the rigorous evaluation that is generally required for the approval of drugs and devices. The excitement of innovation is lauded by surgeons, their institutions, and industry, and consumers may feel that “new” is synonymous with improved.

At BM surgical meetings we are enticed by future opportunities - the simplicity of gastric plication; the opportunity to develop a diabetes-specific procedure without the need for weight loss; novel modifications to established procedures to reduce complications; and novel combinations of procedures to reduce risk and improve efficacy.  These surgical “improvements” are often promoted enthusiastically from the podium and there can be urgency for a range of stakeholders to promote local or regional expertise, encourage champions to innovation and encourage an early uptake of innovative change. This rapid sequence of change is associated with considerable risk and, by the very nature of BM surgery; it will take many years, not days or months, to evaluate the outcomes.

The concept of “innovation” in surgery is itself difficult to define and can vary from minor personal improvisation or variations in clinical practice, to more fundamental changes in technique or procedure, which should involve rigorous processes of documentation and oversight. Indeed, the terms “improvisation”, “innovation” and “surgical research” are often used interchangeably, even though they can in reality refer to very different things. A clear definition is important for all stakeholders, especially the patient. Surgeons argue that oversight is not needed as it is tedious and time consuming, and will reduce innovation and slow the progress in the evolution of surgery. I will argue that a low threshold for rigorous documentation and oversight is essential, and indeed is required by the World Medical Society Declaration of Helsinki, as modified in 2008, Seoul, South Korea.

03:46 18/07/13 | Owen Haskins | Editor in chief, Bariatric News

This week we report on papers from the journal of Clinical Orthopaedics and Related Research, Diabetes, Theoretical Biology and Medical Modelling, Surgical Endoscopy and the Journal of Surgical Research.

Bariatric Orthopaedics: Total Knee Arthroplasty in Super-obese Patients (BMI > 50 kg/m2). Survivorship and Complications.

Writing in the journal Clinical Orthopaedics and Related Research, researchers from the Rubin Institute for Advanced Orthopedics, Baltimore, compared a group of super-obese patients undergoing total knee arthroplasty with a matched group of patients with BMI <30 in terms of (1) implant survivorship, (2) complications, (3) functional parameters, and (4) intraoperative variables (including operative time and estimated blood loss).

One-hundred and one knees in 95 patients (74 women) who had a minimum BMI 50 were compared with a group of patients who had a BMI <30 who were matched by age, gender, preoperative clinical scores, and mean follow-up.

There were no differences in aseptic implant survivorship however, medical and surgical complication rates (14% versus 5%, OR: 3.1, 95% CI=1.07-8.9; p=0.037) were significantly higher in the super-obese patients, compared with the nonobese matching group, respectively.

The researchers did not identify what might have been “modest differences in implant survivorship”, however, complications were more frequent and functional outcomes were significantly lower in super-obese patients. (Abstract)

Long-term effects of bariatric surgery on meal disposal and ß-cell function in diabetic and nondiabetic patients

Investigators the University of Pisa, Italy, writing the journal Diabetes, examined the impact on glucose fluxes in response to a physiological stimulus, ie. mixed meal (MMT). They administered an MTT to 12 obese type 2 diabetic patients and 15 obese non-diabetic subjects before and one year after surgery.

The results revealed that surgery lowered fasting and postprandial glucose levels in diabetic patients, whereas peripheral insulin sensitivity increased in proportion to weight loss (∼30%), ß-cell glucose sensitivity doubled but did not normalise (viz. 21 nonsurgical obese and lean controls).

04:46 15/07/13 | Anonymous (not verified) |

Over the last two decades, minimally invasive surgery has been incorporated into standard general surgical practice. Robotic surgery, since the year 2000 through the advent of the Da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) has also enabled many complex procedures including bariatric surgery to be performed with minimally invasive techniques.1

Bariatric surgery is currently the only current evidence-based and durable treatment for morbid obesity.2 Consequently, bariatric surgery has grown, not only in terms of number of procedures but also in terms of new surgical operations and endoscopic procedures. Robotic bariatric surgery has also increased in popularity with the first reported application attributed to Dr. Guy Bernard Cadière, by the placement of a gastric band robotically in 1999.3 Moreover robotic surgery has also been used in performing sleeve gastrectomy and Roux en Y gastric bypass (RYGB).4

In the United States the Food and Drug Administration (FDA) approved the da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale, California) for use in general laparoscopic surgery in the year 2000. The robot has been used in the United States for RYGB and also in revisional bariatric surgery. The main advantages afforded by robotic bariatric surgery compared with the traditional laparoscopic approach relate to the superior imaging, freedom of movements and surgeon comfort. In addition abdominal wall thickness does not affect the surgeon because the arms of the robot overcome the torque experienced during standard laparoscopic surgery in patients with significant central obesity.

Da Vinci Surgical System