- Case for sleeve gastrectomy. [REVIEW, JOURNAL ARTICLE]
- Surg Obes Relat Dis 2016 Jul; 12(6):1243-1246.
During the last 10 years, laparoscopic sleeve gastrectomy (LSG) has progressively increased in popularity as a primary procedure because of its simplicity, safety, and effectiveness to achieve sustained weight loss over time. The efficacy of LSG in the metabolic control of type 2 diabetes (T2D) is the result of various mechanisms not thoroughly elucidated. Thus, excellent short-term outcomes have been published in glycemic control after SG at comparable rates to Roux-en-Y gastric bypass (RYGB). Unfortunately, head-to-head comparative studies between SG and RYGB are limited and long-term follow-up data is not abundant. The aim of this manuscript is to describe current evidence on the clinical impact of SG on T2D as well as to provide a critical appraisal of the available published data.
- Mechanisms of surgical control of type 2 diabetes: GLP-1 is the key factor-Maybe. [REVIEW, JOURNAL ARTICLE]
- Surg Obes Relat Dis 2016 Jul; 12(6):1230-1235.
Bariatric surgery is the most effective treatment for obesity and diabetes. The 2 most commonly performed weight-loss procedures, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy, improve glycemic control in patients with type 2 diabetes independent of weight loss. One of the early hypotheses raised to explain the immediate antidiabetic effect of RYGB was that rapid delivery of nutrients from the stomach pouch into the distal small intestine enhances enteroinsular signaling to promote insulin signaling. Given the tenfold increase in postmeal glucagon-like peptide-1 (GLP-1) response compared to unchanged integrated levels of postprandial glucose-dependent insulinotropic peptide after RYGB, enhanced meal-induced insulin secretion after this procedure was thought to be the result of elevated glucose and GLP-1 levels. In this contribution to the larger point-counterpoint debate about the role of GLP-1 after bariatric surgery, most of the focus will be on RYGB.
- Effects of various gastrointestinal procedures on β-cell function in obesity and type 2 diabetes. [REVIEW, JOURNAL ARTICLE]
- Surg Obes Relat Dis 2016 Jul; 12(6):1213-1219.
Bariatric surgery is a gastrointestinal procedure that has emerged as the most effective treatment for weight loss. Roux-en-Y gastric bypass and sleeve gastrectomy are the main procedures currently performed. However, the benefits of bariatric surgery extend beyond weight loss. In fact, improvements in β-cell function occur before clinically meaningful weight loss and contribute to type 2 diabetes mellitus (T2D) remission. Herein, we discuss evidence supporting the efficacy of bariatric surgery for weight loss and improved insulin secretion in patients with and without T2D. The exact mechanism by which bariatric surgery elicits a favorable change in β-cell function remains unclear, but a leading hypothesis is that rerouted nutrient flow to the gut alters enteroendocrine hormone production (e.g., glucagon-like polypeptide 1, polypeptide tyrosine-tyrosine, ghrelin), gut microbiome metabolites (e.g., lipopolysaccharides, short-chain fatty acids), and circulating bile acid changes that favor appetite suppression, metabolic rate, and insulin action. We also highlight the role of adipose-derived factors (e.g., pancreatic fat content, adiponectin) that may have an effect on β-cell function, as well as discuss the clinical determinants of diabetes remission (e.g., age and T2D duration). Taken together, the acute improvements seen with bariatric surgery are weight-independent and likely related to incretin-mediated effects on postprandial glucose metabolism and insulin sensitivity. Over longer periods of time, increases in bile acids, reductions in pancreatic lipid content, and elevated adiponectin levels may also contribute to reduced disease risk. As a result, the gut appears to be a novel target for favorably preventing and treating obesity-related metabolic disorders.
- Changes of insulin sensitivity and secretion after bariatric/metabolic surgery. [REVIEW, JOURNAL ARTICLE]
- Surg Obes Relat Dis 2016 Jul; 12(6):1199-1205.
Type 2 diabetes (T2D) is classically characterized by failure of pancreatic β-cell function and insulin secretion to compensate for a prevailing level of insulin resistance, typically associated with visceral obesity. Although this is usually a chronic, progressive disease in which delay of end-organ complications is the primary therapeutic goal for medical and behavioral approaches, several types of bariatric surgery, especially those that include intestinal bypass components, exert powerful antidiabetes effects to yield remission of T2D in most cases. It has become increasingly clear that in addition to the known benefits of acute caloric restriction and chronic weight loss to ameliorate T2D, bariatric/metabolic operations also engage a variety of weight-independent mechanisms to improve glucose homeostasis, enhancing insulin sensitivity and secretion to varying degrees depending on the specific operation. In this paper, we review the effects of Roux-en-Y gastric bypass, biliopancreatic diversion, and vertical sleeve gastrectomy on the primary determinants of glucose homeostasis: insulin sensitivity, insulin secretion, and, to the lesser extent that it is known, insulin-independent glucose disposal. A full understanding of these effects should help optimize surgical and device-based designs to provide maximal antidiabetes impact, and it holds the promise to identify targets for possible novel diabetes pharmacotherapeutics. These insights also contribute to the conceptual rationale for use of bariatric operations as "metabolic surgery," employed primarily to treat T2D, including among patients not obese enough to qualify for surgery based on traditional criteria related to high body mass index.
- Saphenous Vein Graft Aneurysm Repaired with Radial Artery Graft Pre-Sewn Vascular Prosthesis Patch. [JOURNAL ARTICLE]
- Heart Lung Circ 2016 Aug 11.
Saphenous vein graft aneurysms are rare but are potentially fatal and their optimal management is not clearly established. Herein, we report a case of a saphenous vein graft aneurysm that was successfully treated with surgical intervention, including aneurysmal resection and re-grafting. The aneurysm, detected 36 years after coronary artery bypass grafting, was located at the proximal part of the saphenous vein graft to the posterolateral branch; the flow of the left anterior descending coronary artery was limited due to compression of the left internal thoracic artery by the adjacent aneurysm. The proximal anastomotic site was reconstructed under deep hypothermic circulatory arrest using a radial artery graft pre-sewn vascular prosthesis patch.
- Risky Business or Acceptable Risk? Open Arch Repair After Coronary Artery Bypass Surgery. [EDITORIAL]
- Semin Thorac Cardiovasc Surg 2016 Spring; 28(1):36-37.
- Open Aortic Arch Reconstruction After Coronary Artery Bypass Surgery: Worth the Effort? [JOURNAL ARTICLE]
- Semin Thorac Cardiovasc Surg 2016 Spring; 28(1):26-35.
Open aortic arch surgery after coronary artery bypass grafting (CABG) is considered a high-risk operation. We reviewed our surgical approach and outcomes to establish the risk profile for this patient population. In methods, from 2000-2014, 650 patients underwent aortic arch surgery with circulatory arrest. Of these, 45 (7%) had previous CABG. Complete medical record was available for review including all preoperative coronary angiograms and detailed management of myocardial protection. In results, the mean interval from previous CABG to aortic arch surgery was 6.8 ± 7.1 years. At reoperation, 33 (73%) patients had hemiarch replacement and 12 (27%) had a total arch replacement. The following were the indications for surgery: fusiform aneurysm in 20 (44%), pseudoaneurysm in 6 (13%), endocarditis in 4 (9%), valvular disease in 5 (11%), and acute aortic dissection in 10 (22%). There were 6 perioperative deaths (13%) and 1 stroke (2.2%). Selective antegrade cerebral perfusion was used in 13 patients (28.9%) and retrograde perfusion in 6 (13.3%). Survival was 74%, 65%, and 52% at 1, 3, and 5-year follow-up, respectively. Only predictors of early mortality were age (odds ratio = 1.20, CI: 1.01-1.44; P = 0.04) and nonuse of retrograde cardioplegia for myocardial protection (odds ratio = 6.80, CI: 1.06-43.48; P = 0.04). Intermediate survival of these patients was significantly lower than those of a sex-matched and age-matched population (P < 0.001). In conclusion, aortic arch surgery after previous CABG can be performed with acceptable early and midterm results and low risk of stroke. Perfusion strategies and myocardial protection contribute to successful outcomes.
- Does the Routine Availability of CT-Derived FFR Influence Management of Patients With Stable Chest Pain Compared to CT Angiography Alone?: The FFRCT RIPCORD Study. [JOURNAL ARTICLE]
- JACC Cardiovasc Imaging 2016 Aug 20.
This study sought to determine the effect of adding computed tomography-derived fractional flow reserve (FFRCT) data to computed tomography angiographic (CTA) data alone for assessment of lesion severity and patient management in 200 patients with chest pain.Invasive and noninvasive tests used in the assessment of patients with angina all have disadvantages. The ideal screening test for patients presenting for the first time with chest pain would describe both coronary anatomy and the presence of ischemia and would be readily accessible, low cost, and noninvasive.Two hundred patients with stable chest pain underwent CTA for clinical reasons, and FFRCT was calculated. Three experienced interventional cardiologists assessed the CTA result for each patient and by consensus developed a management plan (optimal medical therapy, percutaneous coronary intervention, coronary artery bypass graft surgery, or more information required). FFRCT data for each vessel were then revealed, and the interventional cardiologists made a second plan by consensus, using the same 4 options. The primary endpoint for the study was the difference between the 2 strategies.Overall, after disclosure of FFRCT data there was a change in the allocated management category on the basis of CTA alone in 72 cases (36%). This difference is explained by a discordance between the CTA- and FFRCT-derived assessments of lesion severity. For example, FFRCT was >0.80 in 13 of 44 vessels (29.5%) graded as having a stenosis >90%. In contrast, FFRCT was ≤0.80 in 17 of 366 vessels (4.6%) graded as having stenosis ≤50%.This study demonstrates proof of concept that the availability of FFRCT results has a substantial effect on the labeling of significant coronary artery disease and therefore on the management of patients compared to CTA alone. Further studies are needed to determine whether FFRCT has potential as a noninvasive diagnostic and management screening tool for patients with stable chest pain.
- The Impact of Upper Abdominal Pain During Pregnancy Following a Gastric Bypass. [JOURNAL ARTICLE]
- Obes Surg 2016 Aug 27.
The aim of the present study was to describe the risk of internal herniation (IH) and the obstetric outcome in pregnant women with Roux-en-Y gastric bypass (RYGB) and episodes of upper abdominal pain.The cohort included 133 women with RYGB: 94 with 113 pregnancies, from the local area referred for routine antenatal care (local cohort) and 39 with 40 pregnancies referred from other hospitals for specialist consultation due to RYGB. RYGB was mainly performed without closure of the mesenteric defects. Data collected from medical records were episodes of upper abdominal pain, pregestational and gestational abdominal surgery and pregnancy outcome. The risk of upper abdominal pain was estimated in the local cohort. Surgical intervention, IH and obstetric outcome according to pain were evaluated for 139 pregnancies with delivery of a singleton after 24 weeks of gestation (birth cohort).Upper abdominal pain complicated 42/113 (37.2 %) pregnancies in the local cohort and 11 women (9.7 %) had IH. In the birth cohort, upper abdominal pain complicated 64/139 (46.0 %) pregnancies; surgery was performed in 30/64 (46.9 %), and IH diagnosed in 21/64 (32.8 %). The median gestational age at onset of pain was 25 + 3 weeks. Women reporting abdominal pain had a higher risk of preterm birth (n = 14/64 vs. 1/75, p < 0.005), lower median gestational length (269 vs. 278 days, p < 0.005) and lower median birth weight (3018 vs. 3281 g, p = 0.002) compared to women without abdominal pain.Upper abdominal pain during pregnancy is frequent among women with Roux-en-Y gastric bypass, is often due to IH and is associated with adverse pregnancy outcome.
- The SYNTAX battle in the war between stent and bypass: A landmark surgical win. [EDITORIAL]
- J Thorac Cardiovasc Surg 2016 Jul 28.