|Year : 2016 | Volume
| Issue : 1 | Page : 40-43
|Date of Web Publication||25-Oct-2016|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Others. Saudi J Laparosc 2016;1:40-3
| Impact of sleeve gastrectomy on glycemic control and resolution of type II DM in morbidly obese Saudi patients: 30 months follow-up|| |
Samah Melibary, Khalid Alshahrani Sayed Asim, Hanan Moaber, Raad Fayez, Ashraf Maghrabi, Ali Almontashery
Department of Surgery, King Abdullah Medical City, Makkah, Saudi Arabia
Background: Obesity is major health care challenge in Saudi Arabia. Type II DM is the most common obesity-related comorbidity in Saudi Arabia with more than 80% of diabetic patients being obese. Recent data showed beneficial effects of sleeve Gastrectomy on the control of DM. Our objective was to evaluate the effectiveness of sleeve Gastrectomy in glycemic control and remission of type II DM for morbidity obese patients with type II diabetes mellitus (DM) in Saudi Arabia.
Methods: After IRB approval, prospective analysis of all morbidity obese Saudi patients going for LSG at KAMC as weight loss operation "according to NIH 1991 guidelines", from Feb 201 was conducted. 56 Morbidly obese patients having type II DM were included in our study. Pre and post-operative demographic data, weight, BMI, duration of DM, FBS, HbA1c level, lipid profile, number, doses and frequencies of DM medications is analyzed. Patients were followed at 3, 6,12,24,30 months postoperative.
Results: Resolution of DM was observed in 22%, 54%, 90%, 83% and 79% at 3, 6, 12, 24 and 30 months of follow-up. Glycosylated hemoglobin decreased from 8.5 preoperatively to 6.2, 5.7, 5.1, 5.8, 5.9, at 3, 6, 12, 24, 30 months after surgery. Patients with a shorter duration of DM (<5 years) and better weight loss after surgery achieved early and greater resolution rates.
Conclusion: LSG provides durable glycemic control, resolution and improvement of Type II DM in morbidly obese Saudi individuals over 30 months follow-up. Further follow-up and more patients would help to give firm conclusion.
| Efficacy of intragastric balloon for the management of obesity: Experience from Kuwait|| |
Al-Sabah S, Al-Ghareeb F, Ali DA, Al-Adwani A
Introduction: Traditional methods of treating obesity have shown only limited efficacy. Intragastric ballo on (BIB) is considered a new potential alternative method in the management of obesity. There is limited information in the literature about the outcome of BIB in the region of the A rabian Gulf. This study examined the efficacy and satisfaction of BIB in obese patients in Al-Amiri Hospital in Kuwait.
Methods: A retrospective review of BIB in patients from October 2009 through December 2012 at Al-Amiri Hospital, Kuwait, included 179 patients. Weight loss, complications, satisfaction level, and weight gain after removal of the balloon were assessed. The weight loss was analyzed further according to different demographic groups.
Results: A total of 179 patients were included in the study. Their data were collected, and the pre- insertion and post-removal body mass index (BMI) was calculated. Before insertion of the BIB, there was a mean weight of 99.7 kg (SD 26.7); after removal, they showed a mean weight of 88.9 kg (SD 25). There was a mean weight loss of 10.9 kg (SD 8). The patients experienced a median excess weight loss of 38.5%. There was no significant variation in the weight loss according to age, gender, and nationality. There was a satisfaction level of 44% among the patients. Weight gain after removal was experienced by 34.7 % of patients.
Conclusions: BIB seems to be an effective method of significant weight reduction with little complications, making it a good alternative in the management of obesity in females with lower BMI.
| None invasive new technology for weight loss (Obalon)|| |
Khalid Mirza Garzaie
Saad Specialist Hospital, AlKhobar, Saudi Arabia
It is a swallow able capsule contains the balloon and allows for easy administration without the need for sedation (under fluoroscopy monitoring) connected to a thin catheter attached to the balloon facilitates inflation and rapid tube removal leaving the inflated balloon behind (in the stomach) ready toward. Each balloon volume 250 ml filled with nitrogen. The program duration is 12-13 weeks using 2-3 balloon, one to two weeks' intervals and to be removed after 12-13 weeks. Expected weight loss 7-10 kg.
Methods: From April to December 2014, 187 patient joined the program. Retrospective data collection using the electronic medical record system. 31 patient are still not completed the program. 27 patient are not completed the program. 129 were included in the study. The program structure: First balloon is followed by second balloon after two weeks and removal after 12 to 13 weeks. Male/Female: 40/85. Age range: 13 to 64. BMI: 26 to above 40. Removal of all balloon done by endoscopy for all patient. Excluding criteria includes: History of upper GI disease and abnormalities. DM, pregnancy.
Results: 27 patient were excluded due to: Intolerance=15 patients. Only one balloon=3 patient. Loss of contact=8 patients. Pregnancy=1 patient. 129 patients were classified into 4 groups: Group 1 : BMI 26-30 = 18 patients. Group 2: 31-35 = 54 patients. Group 3: 36-40 = 35 patients. Group 4: above 40 = 22 patients. 2 cases of balloon were spontaneously deflated and caused intestinal obstruction, one was treated conservative and the second was treated by laparoscopic weight loss.
Results: Less than 7 kg: (60%) Group 1 = 14/18 cases Group 2 = 33/54 cases, Group 3 = 21/35 cases Group 4 = 10/22 cases, W.L (7-12 kg): (33.3%) Group 1 = 4/18 cases. Group 2 = 20/54 cases. Group 3 = 10/35 cases. Group 4 = 9/22 cases. W.L (more than 12 kg): (6.2%) Group 1 = 0, Group 2 = 1, Group 3 = 4, Group 4 = 3, Failure: 60% Success: 40% Intolerance: 8%, Intestinal obstruction: 1.5%.
Conclusion: The Obalon as none invasive technique is effective safe in weight loss more in downgrading of morbid obese patient. (1) Better outcome can be achieved by more patient education and close monitoring. (2) Intestinal obstruction could be a major complication.
| Clinical experience with a port-free internal liver: Retractor in laparoscopic bariatric surgery|| |
Aseer Central Hospital, Abha, Saudi Arabia
Background: As laparoscopic techniques and instrumentation advance, bariatric surgery has begun to be performed through smaller incisions and fewer ports. Since the visualization of the dorso- lateral portion of the left liver lobe is critical for most bariatric procedures, surgeons have developed various techniques for providing adequate liver retraction without compromising patient safety. Herein, we present our experience with a port-free internal liver retractor used for bariatric cases.
Methods: Endolift™ does not require an additional port or anchoring to an external device. After insertion through an existing 5-mm port by means of the applier, one of the two attached clips (one on either end) was anchored to the left crus of the diaphragm while the other was fixed to the peritoneum above the right liver lobe through or beneath the falciform ligament. At the end of the surgery, the device was easily removed by using the applier.
Results: We used this technique for 31 Roux-en-Y gastric bypasses and 2 single-incision sleeve gastrectomies. There were 24 females and 9 males with a mean age of 46 and mean body mass index 45.0 kg/m 2 . The mean operative time was 136.5 min. The time required for the placement of the device was 1-3 min. The approach to the upper part of the stomach was satisfactory in all patients. No device-related complications were observed.
Conclusions: The internal liver retractor is easy to handle and provides adequate retraction and exposure for bariatric cases. It also has potential benefits for single-incision and reduced port laparoscopic procedures.
| Epidemiology of obesity and type 2 diabetes mellitus in Saudi Arabia|| |
University Diabetes Center, King Saud University, Riyadh, Saudi Arabia
The Ministry of Health in the Kingdom of Saudi Arabia have realized the huge pressure diabetes is putting on the health system, so it was the decision of the health policy maker to come up with the clear understanding of the direction by which diabetes is going. Clear understanding of this medical problem will be drawn from real time wide spread clinical, social and financial impact of this disease at the population level. Randomized household epidemiological survey for 80,000 Saudi inhabitants was started six months ago. The survey includes all family members with the different age spectrum. The Saudi Abnormal Glucose Metabolism and Diabetes Impact Study (SAUDI-DM) have shown the overall prevalence of abnormal glucose metabolism was 34.5%, which included 22.6% patients with IFG, 11.9% patients with diabetes, and 6.2% patients who unaware of their disease. Diabetes prevalence was 40.2% for subjects aged ≥45 years and 25.4% for those aged ≥30 years that decreased to 11.9% when the full age spectrum was considered. The major two risk factors for type 2 diabetes in Saudi population are strong family history that was 50.1% among diabetic population versus 17.4% for non-diabetic subjects, if both first and second degree relatives are taking in consideration. This was also clearly related to the high consanguinity rate found among studied subject. The second most important risk factor was obesity which was present in 34.1% of the subjects above 65 years but was worse among people aged 46-65 accounting for 48.7%. This percent will be less in age group between 19-45 years accounting for 28.8%.
| Genetic susceptibility to type 2 diabetes and obesity: Concepts, methodologies and outcomes|| |
Amr TM Saeb
Diabetes Center, Riyadh, Saudi Arabia
A wide range of researches focusing on genetic approaches, especially Genome Wide Association Studies (GWAS), have been used to elucidate the underlying genetic variants influencing both type 2 diabetes (T2D), obesity and interrelated phenotypes. Up to date, more than 180 loci are found to be associated with these phenotypes. However, genetic studies revealed very few genetic risk loci in common between type 2 diabetes and obesity. These includes, transcription factor 7 like 2 (TCF7L2) that confers risk for T2D and fat mass and Obesity associated protein (FTO) that confers risk for obesity/BMI. This, by some means limited success have led to shift genetic approaches toward custom/targeted array genotyping and whole exome and genome sequencing to investigate the discrete and joint effect of low frequency and rare variants associated with type 2 diabetes and obesity. In this lecture, I will discuss genetic approaches used that studied type 2 diabetes and obesity and its outcomes and current and futuristic methodologies that can shed more light on the genetic architecture of type 2 diabetes and obesity.
| Interventional Radiology (KKUH) experience in the management of laparoscopic sleeve gastrectomy complications|| |
Syed Obaidullah Ahsan
Interventional Radiology, King Saud University Medical City, Riyadh, Saudi Arabia
Obesity is one of the major causes of morbidity. Many surgical procedures are popular for the management of obesity. One of the procedure is Laparoscopic Sleeve Gastrectomy. Among other postoperative complications of Sleeve Gastrectomy, leak is common. We used Imaging as a guidance for treatment of these complications. There were 33 patients, 17 females and 16 males, age range 20-60 years. All patients underwent Laparoscopic Sleeve Gastrectomy. All of our patients presented with leak after the procedure. Out of 33 patients, 20 patients had collection at angle of HIS / peri gastro-easophageal region, 9 collections were in left sub phrenic / peri-splenic region and few of them in sub-hepatic and pelvic regions. All patients were treated with drainage catheters insertion mainly under CT guidance. We were successful in all cases of collection drainage by catheter placement. We also perform PICC line, N.J tube insertion and pleural drainage for these patients.
| Conversion of failed laparoscopic adjustable gastric band to laparoscopic conversion to Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy: Excess weight loss % does not match primary procedures|| |
Ahmad Bashir 1,2,3
1 American and Jordanian Boards of Surgery, 2 Minimally Invasive and Bariatric Surgery-UCSF, Fresno, 3 Minimally Invasive and Bariatric Surgeon, Jordan Hospital, Amman, Jordan
Background: Conversion of failed gastric banding to Roux-En-Y Gastric Bypass (LRYGB) and Sleeve Gastrectomy (LSG) is considered safe and effective in achieving weight loss, which has been reported in the bariatric literature in many series. It is also comparable to primary procedures in the excess weight loss percentage (EWL %) in those series as well.
Methods: We retrospectively reviewed our prospectively collected data. From October 2010 till currently, all patients who underwent revisions of failed LAGB due to weight recidivism to other procedures were reviewed for procedure selected, 30-day morbidity, mortality, excess weight loss and excess weight loss percentage.
Results: We identified 49 patients. 33 patients (67%) underwent LRYGB in one stage. 14 patients (29%) underwent conversion to LSG in one stage. One patient (2%) underwent removal of the band only without conversion to LSG due to esophageal injury. Another patient (2%) underwent conversion to LSG with duodeno-jejunal bypass (DJB). We had no mortalities. No leaks were encountered in the LRYGB patients. One anastomotic stenosis (1/34: 3%) required endoscopic dilatation. In LSG conversions, one leak (1/14: 7%) that required operative conversion to laparoscopic bypass after failed stenting. No other complications were noted. Mean EWL% for LRYGB at 12 months was 69.1% (41-83), while for LSG at 12 months was 49.3% (1-72). Comparing EWL % to our primary cases at 12 months: LRYGB 83.1% (59-115), LSG 84.9% (61-103).
Conclusion: Conversion of failed LAGB to LRYGB or LSG is safe, however, LRYGB appears to achieve better EWL%. Both fail to achieve EWL% observed in our primary series.
| Re-do in bariatric surgery, experience from Saudi Arabia|| |
Introduction: Bariatric surgery is the most effective treatment for severe obesity, producing durable weight loss, improvement of co-morbid conditions, and longer life. In Revision (RE-Do) Bariatric Surgery the results can vary widely depending on the original procedure and the reason for the revision. Bariatric surgery revisions are usually successful in resolving the associated problems and promoting further weight loss, which is usually not as dramatic as the initial bariatric procedure, but it can be substantial over time. As revision surgery can be more complex, it is important to perform in Center of Excellence for Bariatric surgery. We do Re-Do bariatric surgery because failure to lose weight, recidivism, and complications.
Method : This is a retrospective study for cases underwent re-do bariatric surgery from April 2005 to January 2013 in three hospitals (King Fahad Medical Military Complex, Saad specialist Hospital and Procare hospital - Alkhobar), the study include the type of the revision bariatric surgery, high-light the reasons to do revision bariatric surgery, describe the expected difficulties and the un-expected challenges, and describe techniques used in revision surgery and the outcome.
Results: Cases underwent Bariatric surgery in this period by single surgeon ( the author ) 1650 cases out of it 290 had a re-do (revision) bariatric surgery equivalent to 17.5% of the total cases, 268 cases conversion from Laparoscopic Gastric Banding LGB to laparoscopic R-Y gastric bypass LRYGBP 92.4%. 3 cases conversion from LGB to laparoscopic biliopancreatic diversion. 7 cases conversion from LGB to laparoscopic sleeve gastrectomy LSG. 8 cases from vertical banded gastroplasty to LRYGBP. 4 cases from sleeve gastrectomy to LRYGBP. The most common re-do bariatric surgery in our experience is conversion from gastric banding to laparoscopic R-Y gastric bypass the male patients 34.6% and the female patients 65.4%. Removal of Gastric band and LRYGBP in same procedure (one step) 265/290 = 91.3%. Two steps or delayed LRYGBP 25/290 = 8.7%, the average weight reduction post conversion of LGB to LRYGBP 45% to 80% of their access body weight with the mean 60% over 1-4 years, while VBG to LRYGBP less weight reduction about 45% of their access body weight.
Conclusion: Re-Do in Bariatric Surgery is challenging need expert and Excellence Center for Bariatric Surgery. To obtain good results all efforts to decrease the number of failed weight loss cases which will decrease the revision bariatric surgery by good selection of the best procedure for the patient, education for the patients and good follow up.
| Video clips in the presentation revisionary bariatric surgery - Re-Do|| |
All bariatric procedures are subject to possible failure even as all appropriate steps are taken preoperatively, intraoperatively, and postoperatively, procedures will sometimes fail and surgeons must become skilled at both repairing complications and in converting to other procedures when the need arises. Around 10 to 25% of patients undergoing bariatric surgery will require a revision, either for unsatisfactory weight loss or for complications.  Reoperation is associated with a higher morbidity and has traditionally been done in open fashion. Expertise in performing reoperations is an essential part of any bariatric surgery practice. Patients with failed previous bariatric procedure deserve special consideration. Therefore, it is imperative that the surgeon fully understands the anatomic reasons for failure in each patient. In addition to undergoing the same type of preoperative evaluation as for a primary bariatric procedure, including counseling with a nutritionist and a psychologist patients should undergo evaluation of the causes and con sequences of the failed operation. Patient selection for revision is essential, though feasible, Revisional bariatric surgery is technically complicated, whether performed open or laparoscopic, and has a higher complication rate than primary bariatric surgery. Revisionary bariatric surgery carries a 28 to 50% morbidity rate and 1 to 2% mortality rate.
| Role of proximal gut exclusion from food by implanting linear device (endobarrier) on glucose homeostasis and weight reduction in obese patients with type 2 diabetes|| |
Salem M Bazarah, Mazen Fakeeh
Fakeeh Hospital, Jeddah, Saudi Arabia
Aims: To report weight reduction and control of Type 2 diabetes after the implantation of a duodenal-jejunal bypass liner device (Endobarrier) and to investigate the role of proximal gut exclusion from food in weight reduction and glucose homeostasis using the model of this device.
Methods: 25 patients with Type 2 diabetes with HbA1c between 8.0% to 12% and BMI between 30 to 45 kg/m 2 were evaluated before and 1, 12 and 24 weeks after duodenal-jejunal bypass liner (Endobarrier) implantation. BMI and HbA1c as well as other metabolic indicators were measured for each patient at 0, 1, 12 and 24 weeks of implantation.
Results: Mean Body weight reduction was by 6 kg after 1 week 25 kg after 24 weeks (P < 0.001). The mean HbA1c level reduction was 2% at 12 weeks and 4.5% by 24 weeks (P < 0.001). Fasting blood sugar (FBS) also showed mean reduction of 70 mg/dl at 12 weeks and 130 mg/dl at 24 weeks. Mean reduction in Insulin requirements in those using Insulin was 60% at 12 weeks and 90% at 24 weeks. Patients on oral hypoglycemic medications only 80% of them were able to achieve very good glycemic control on Metformin only and stop other glycemic medications.
Conclusions: The duodenal-jejunal bypass liner (Endobarrier) device helps to achieve significant weight reduction as well as significantly improves glycemic control in overweight and obese patients with Type 2 diabetes probably, by improving insulin sensitivity.
The study is still on going to complete 48 weeks prior to device explant.
| Obstacles to starting a bariatric surgery multidisciplinary team: Experience after 1000 complex bariatric surgery operations|| |
Abdelrahman Nimeri, Ahmed Maasher, Elnazeer Salim, Maha Ibrahim, Bisher Mustafa, Rami Al Shihabi, Abdul Razzak Al Kaddour, Peter Kelsel, Nour Al Mehairi, Maria Margarita, Biji Koshi, Mohammed Al Hadad
1 BMI Abu Dhabi, 2 Sheikh Khalifa Medical City, Abu Dhabi UAE
Introduction: Bariatric surgery is the most effective method for morbid obesity. However, to achieve safe and effective bariatric surgery, a multi-disciplinary team is needed to evaluate and assess patients before surgery and follow up their outcomes after surgery.
Aim: To describe the set-up of a multidisciplinary bariatric surgery team and the obstacles to initiating such practice in the UAE.
Methods: Bariatric & Metabolic Institute (BMI) Abu Dhabi is a comprehensive multidisciplinary team that was started in June 2009. We reviewed our pathways number of procedures performed and outcomes from 2009-2015. Our aim when we started our team was to establish a multidisciplinary group to evaluate and manage patients with Obesity & the metabolic syndrome in Abu Dhabi, UAE, and the entire region. In addition, to establish BMI Abu Dhabi as a major referral center for Obesity, Bariatric surgery. Furthermore, to establish training curriculum for bariatric surgery fellowship and short CME training courses for bariatric surgery teams. Finally, to help in public outreach and education of the school children and the public about the dangers of obesity, type II DM and the options of Bariatric & Metabolic Surgery.
Results: During the study period we performed 1000 complex bariatric surgery operations (58% LRYGB, 41% LSG and 1% LAGB) Revisional bariatric surgery represents 18% of our operative volume. We have established a 2 year fellowship for bariatric surgery and have graduated our first fellow and he joined our program as a partner in 2013; our first fellow performed 167 bariatric surgery operations and published 5 peer reviewed articles during his fellowship and participated in several accepted presentations at SAGES, IFSO and ASMBS. Our program has several pathways including an outpatient, inpatient, anesthesia, emergency room pathways. In addition, we are a training site for bariatric surgery teams interested to learn about our set up and we have conducted 8 comprehensive 2 day courses including live surgery during the study period. Our program was ranked 3rd by the Arab health in 2011. Our program conducted more than 60 monthly public lectures with more than 4000 participants and have conducted 8 school educational sessions. Our outcomes were published 7 publications about our patient outcomes in peer reviewed journal; in summary we have 0 mortality and less than 1% leak and stenosis rate. The main obstacles we have found in setting up a robust comprehensive bariatric surgery program is bariatric psychology, patient education and expectation and institution support.
Conclusion: Bariatric surgery can be practiced with a multi-disciplinary team set up in our region with excellent results.
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