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Comparison of Simultaneous Pharyngeal and Distal Esophageal pH Monitoring Studies
BARIATRIC AND FOREGUT A Peroxisome Proliferator-Activated Receptor (PPAR) Isoform Switch Links Partitioning of Adipose Lipid Metabolism after Bariatric Surgery Scott Kizy, MD, Cyrus Jahansouz, MD, Hongliang Xu, PhD, Daniel B Leslie, MD, FACS, David A Bernlohr, PhD, Sayeed Ikramuddin, MD, FACS University of Minnesota, Minneapolis, MN
METHODS: Non-obese, C57Bl/6J mice fed a normal rodent chow underwent SG (n ¼ 8) or sham operation (short gastric vessel ligation, n ¼ 7). Oral glucose tolerance tests (OGTT) and insulin tolerance tests (ITT) were performed at 2 and 4 weeks postoperatively. Hepatic tissue was harvested for quantitative polymerase chain reaction (PCR) and single-cell, quantitative, immunologic profiling by mass cytometry time-of-flight analysis (CyTOF).
INTRODUCTION: Bariatric surgery remains the most effective treatment for reducing adiposity and eliminating type 2 diabetes; however, the mechanism(s) responsible have remained elusive. As an endocrine organ, adipose tissue plays an important role in the pathogenesis of obesity and T2DM. The peroxisome proliferatoractivated receptor g (PPARg) nuclear receptor plays a major role in controlling adipocyte lipid storage and insulin sensitivity. PPARd is also abundantly expressed in adipose tissue and promotes lipid utilization by up-regulating genes involved in fatty acid oxidation. We explored the role of PPAR in adipose tissue after bariatric surgery.
RESULTS: There were no differences between the weights or daily food intake of SG and sham animals. However, SG mice showed improved glucose handling by OGTT and ITT as early as 2 weeks postoperatively. A 17-antibody cell surface and intra-cellular transcription factor panel was used to quantitate major hepatic innate and adaptive lymphocyte populations by CyTOF. This revealed a significant reduction of TH17 lymphocytes, TH17-activating dendritic cells, and type-2-innate lymphoid cells. Further, after SG, there was a 2.5-fold reduction in TNF-alpha expression (p < 0.01). CONCLUSIONS: We present a model of SG with weight-independent improvements in glucose tolerance associated with reduced hepatic pro-inflammatory TH17 lymphocytes and cytokines. Further studies are needed to define the interplay between innate lymphoid cells, TH17 lymphocytes, and hepatic metabolism after SG.
METHODS: Patients undergoing vertical sleeve gastrectomy, Roux-en-Y gastric bypass, or hypocaloric restriction underwent subcutaneous adipose tissue (SAT) biopsies at the time of surgery and on postoperative day 7. SAT was analyzed for gene expression, protein levels, and lipid oxidation and lipolysis. RESULTS: Expression of PPARg decreases, while that of PPARd increases acutely after bariatric surgery in SAT, independently from hypocaloric restriction. This unique metabolic alteration leads to changes in downstream PPARg/d targets, including decreased expression of FABP4, with increased expression of carnitine palmitoyl transferase 1 (CPT1) and uncoupling protein 2 (UCP2). Increased expression of UCP2 not only facilitates fatty acid oxidation (increased 15-fold after surgery) but also regulates the SAT redoxome by attenuating protein cysteine oxidation and reducing oxidative stress.
Comparison of Simultaneous Pharyngeal and Distal Esophageal pH Monitoring Studies Ezra N Teitelbaum, MD, Christy M Dunst, MD, FACS, Marc A Ward, MD, Kevin M Reavis, MD, FACS, Lee L Swanstrom, MD, FACS, Steven R DeMeester, MD, FACS Providence Portland Medical Center, Portland, OR; The Oregon Clinic, Portland, OR INTRODUCTION: Assessment of pharyngeal acid exposure with the Restech probe has been used in an effort to associate extraesophageal symptoms such as cough, hoarseness, and sore throat with gastroesophageal reflux disease (GERD); however, the correlation between simultaneous pharyngeal and distal esophageal pH has not been well studied. The aim of this study was to compare pharyngeal and esophageal pH when measured concurrently in symptomatic patients.
CONCLUSIONS: These results suggest that bariatric surgery, independent from hypocaloric restriction, introduces a novel metabolic potential of SAT to utilize excess fatty acids through regulation of PPAR isoform switching. This may have important implications in energy metabolism after bariatric surgery.
METHODS: We reviewed the records of all patients at a single institution who had simultaneous Restech and distal esophageal pH monitoring to evaluate extra-esophageal reflux symptoms. Abnormal esophageal and pharyngeal pH were determined based on the DeMeester and RYAN scores, respectively.
Changes in Hepatic Immune Phenotype Associated with Improved Glucose Tolerance after Sleeve Gastrectomy David A Harris, MD, Renuka Subramaniam, PhD, Eleanor JM Rudge, MBChB, Thomas C Mielewczyk, Hassan Aliakbarian, MD, Ali Tavakkoli, MBBS, FACS, Eric G Sheu, MD, FACS Brigham and Women’s Hospital, Boston, MA
RESULTS: Twenty-seven patients (19 female), with a median age of 57 years, were studied. All had simultaneous pharyngeal pH (Restech) and distal esophageal pH monitoring (with either transnasal catheter [n ¼ 14] or Bravo capsule [n ¼ 13]). Increased acid exposure was present in the distal esophagus in 11 patients (41%) and in the pharynx in 18 (67%). Overall agreement between distal esophageal and pharyngeal pH was 67%, with 100% agreement in patients tested with Bravo as opposed to 50% with catheter studies (Table).
INTRODUCTION: Sleeve gastrectomy (SG) leads to improvement in type 2 diabetes and hepatic insulin resistance. Dysregulation of pro-inflammatory, adaptive, and innate lymphocytes is seen in diabetes. Therefore, we hypothesized that SG induces changes in hepatic adaptive and innate immunity, leading to improved glucose tolerance.
S13
http://dx.doi.org/10.1016/j.jamcollsurg.2017.07.004 ISSN 1072-7515/17
S14
J Am Coll Surg
Scientific Forum Abstracts
(0.6% vs 0.29%, p < 0.001), and operative time (p < 0.001) were higher with fellow presence.
Table. Distal esophageal pH
Bravo capsule (n ¼ 13) Abnormal Normal Transnasal catheter (n ¼ 14) Abnormal Normal
Restech abnormal Restech normal
9 0
0 4
2 7
0 5
CONCLUSIONS: Restech detected all patients with pathologic GERD based on abnormal distal esophageal pH monitoring with either transnasal catheter or Bravo capsule. However, pharyngeal pH was abnormal in 58% of patients who had normal distal esophageal pH by catheter. We recommend either Bravo or Restech for patients with extra-esophageal reflux symptoms given the increased sensitivity of these tests compared with catheter pH monitoring. Effects of Resident or Fellow Participation in Sleeve Gastrectomy and Gastric Bypass: Results from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Marko Martinovski, MD, Abby L Navratil, MD, Tallal Zeni, MD, Mark Jonker, MD, Jane Ferraro, Jeremy Albright, Robert K Cleary, MD, FACS St Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI INTRODUCTION: Resident participation has been shown to be safe for many laparoscopic procedures. However, patient outcomes associated with complex laparoscopic operations with resident involvement have been mixed. We evaluated the impact of resident and fellow participation on outcomes after bariatric surgery using a national clinical registry. METHODS: Using the MBSAQIP, we analyzed 134,011 patients undergoing laparoscopic/robotic sleeve gastrectomy or gastric bypass. Resident/fellow involvement was characterized at the first assistant level. Baseline characteristics and 30-day perioperative outcomes were analyzed and adjusted using logistic regressions. RESULTS: Risk-adjusted 30-day complication rates comparing residents with fellows were 6.71% vs 7.21% (p ¼ 0.245), respectively. The complication rate was reduced to 5.85% (p < 0.001) when neither residents nor fellows were involved. Comparing residents with fellows, surgical site infection (SSI) rates were 0.86% and 1.17% (p ¼ 0.019), respectively, and median operative time was significant (p < 0.001). Comparing resident with noninvolvement, readmissions (4.82% vs 4.2% p < 0.001), cardiac complications (0.14% vs 0.07%, p ¼ 0.013), urinary tract infection (UTI) (0.52% vs 0.29%, p < 0.001), and operative time (p < 0.001), were higher with resident participation. Comparing fellow with noninvolvement, sepsis (0.24% vs 0.13%, p < 0.001), readmissions (4.81% vs 4.2%, p < 0.001), SSI (1.17% vs 0.75%, p < 0.001), pulmonary embolus (0.2% vs 0.11%, p ¼ 0.012), UTI
CONCLUSIONS: Resident and fellow participation in gastric bypass and sleeve gastrectomy had comparable outcomes. Their involvement was associated with higher readmissions, UTIs, SSIs, pulmonary embolus, and operative times. Despite statistical significance, the true effect size may be small. Nonetheless, strategies to improve technical competence during surgical training are needed.
Factors Associated with Prolonged Length of Stay after Laparoscopic Roux-en-Y Gastric Bypass: A Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Database Analysis Eric S Wise, MD, Jessica Felton, MD, Rami S Kantar, MD, Mark D Kligman, MD University of Maryland, Baltimore, MD INTRODUCTION: Prompt and successful postoperative discharge after laparoscopic Roux-en-Y gastric bypass (LRYGB) reflects achievement of an important quality measure, particularly as there is a trend toward this operation becoming an ambulatory procedure. As such, we utilized a recent national database to define and validate risk factors portending a prolonged length of stay (LOS) after LRYGB. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015 national database was queried for patients who underwent LRYGB with successful discharge, defined as freedom from 30-day readmission, reintervention, or mortality. Bivariate and multivariate analyses were conducted to identify independent predictors of prolonged LOS, defined as discharge after the second postoperative day. The 1,910 patients with prolonged LOS were further interrogated to determine rates of specific postoperative morbidities potentially contributing to extended hospitalization. RESULTS: Of the 10,693 patients, there were 2,924, 5,859, and 1,910 discharges on the first, second, and third or greater postoperative days, respectively. Bivariate analysis revealed 20 patient variables associated with prolonged LOS (p < 0.1). Variables independently predictive of prolonged LOS included advanced age (odds ratio [OR] 1.008 [1.003e1.01], p ¼ 0.005), female sex (OR 1.2 [1.03e1.4], p ¼ 0.02), black race (OR 1.3 [1.09e1.5], p ¼ 0.004), higher preoperative BMI (OR 1.008 [1.0008e1.02], p ¼ 0.03), and previous foregut operation (OR 1.5 [1.1e2.0], p ¼ 0.01). Among patients with prolonged LOS, rates of morbidities including renal failure, cardiac events, pneumonia, sepsis, and transfusion requirement were acceptably low (<2%). CONCLUSIONS: This study identified several critical factors associated with prolonged LOS after LRYGB, allowing characterization of the bariatric patient most prone to delayed discharge.
METHODS: Non-obese, C57Bl/6J mice fed a normal rodent chow underwent SG (n ¼ 8) or sham operation (short gastric vessel ligation, n ¼ 7). Oral glucose tolerance tests (OGTT) and insulin tolerance tests (ITT) were performed at 2 and 4 weeks postoperatively. Hepatic tissue was harvested for quantitative polymerase chain reaction (PCR) and single-cell, quantitative, immunologic profiling by mass cytometry time-of-flight analysis (CyTOF).
INTRODUCTION: Bariatric surgery remains the most effective treatment for reducing adiposity and eliminating type 2 diabetes; however, the mechanism(s) responsible have remained elusive. As an endocrine organ, adipose tissue plays an important role in the pathogenesis of obesity and T2DM. The peroxisome proliferatoractivated receptor g (PPARg) nuclear receptor plays a major role in controlling adipocyte lipid storage and insulin sensitivity. PPARd is also abundantly expressed in adipose tissue and promotes lipid utilization by up-regulating genes involved in fatty acid oxidation. We explored the role of PPAR in adipose tissue after bariatric surgery.
RESULTS: There were no differences between the weights or daily food intake of SG and sham animals. However, SG mice showed improved glucose handling by OGTT and ITT as early as 2 weeks postoperatively. A 17-antibody cell surface and intra-cellular transcription factor panel was used to quantitate major hepatic innate and adaptive lymphocyte populations by CyTOF. This revealed a significant reduction of TH17 lymphocytes, TH17-activating dendritic cells, and type-2-innate lymphoid cells. Further, after SG, there was a 2.5-fold reduction in TNF-alpha expression (p < 0.01). CONCLUSIONS: We present a model of SG with weight-independent improvements in glucose tolerance associated with reduced hepatic pro-inflammatory TH17 lymphocytes and cytokines. Further studies are needed to define the interplay between innate lymphoid cells, TH17 lymphocytes, and hepatic metabolism after SG.
METHODS: Patients undergoing vertical sleeve gastrectomy, Roux-en-Y gastric bypass, or hypocaloric restriction underwent subcutaneous adipose tissue (SAT) biopsies at the time of surgery and on postoperative day 7. SAT was analyzed for gene expression, protein levels, and lipid oxidation and lipolysis. RESULTS: Expression of PPARg decreases, while that of PPARd increases acutely after bariatric surgery in SAT, independently from hypocaloric restriction. This unique metabolic alteration leads to changes in downstream PPARg/d targets, including decreased expression of FABP4, with increased expression of carnitine palmitoyl transferase 1 (CPT1) and uncoupling protein 2 (UCP2). Increased expression of UCP2 not only facilitates fatty acid oxidation (increased 15-fold after surgery) but also regulates the SAT redoxome by attenuating protein cysteine oxidation and reducing oxidative stress.
Comparison of Simultaneous Pharyngeal and Distal Esophageal pH Monitoring Studies Ezra N Teitelbaum, MD, Christy M Dunst, MD, FACS, Marc A Ward, MD, Kevin M Reavis, MD, FACS, Lee L Swanstrom, MD, FACS, Steven R DeMeester, MD, FACS Providence Portland Medical Center, Portland, OR; The Oregon Clinic, Portland, OR INTRODUCTION: Assessment of pharyngeal acid exposure with the Restech probe has been used in an effort to associate extraesophageal symptoms such as cough, hoarseness, and sore throat with gastroesophageal reflux disease (GERD); however, the correlation between simultaneous pharyngeal and distal esophageal pH has not been well studied. The aim of this study was to compare pharyngeal and esophageal pH when measured concurrently in symptomatic patients.
CONCLUSIONS: These results suggest that bariatric surgery, independent from hypocaloric restriction, introduces a novel metabolic potential of SAT to utilize excess fatty acids through regulation of PPAR isoform switching. This may have important implications in energy metabolism after bariatric surgery.
METHODS: We reviewed the records of all patients at a single institution who had simultaneous Restech and distal esophageal pH monitoring to evaluate extra-esophageal reflux symptoms. Abnormal esophageal and pharyngeal pH were determined based on the DeMeester and RYAN scores, respectively.
Changes in Hepatic Immune Phenotype Associated with Improved Glucose Tolerance after Sleeve Gastrectomy David A Harris, MD, Renuka Subramaniam, PhD, Eleanor JM Rudge, MBChB, Thomas C Mielewczyk, Hassan Aliakbarian, MD, Ali Tavakkoli, MBBS, FACS, Eric G Sheu, MD, FACS Brigham and Women’s Hospital, Boston, MA
RESULTS: Twenty-seven patients (19 female), with a median age of 57 years, were studied. All had simultaneous pharyngeal pH (Restech) and distal esophageal pH monitoring (with either transnasal catheter [n ¼ 14] or Bravo capsule [n ¼ 13]). Increased acid exposure was present in the distal esophagus in 11 patients (41%) and in the pharynx in 18 (67%). Overall agreement between distal esophageal and pharyngeal pH was 67%, with 100% agreement in patients tested with Bravo as opposed to 50% with catheter studies (Table).
INTRODUCTION: Sleeve gastrectomy (SG) leads to improvement in type 2 diabetes and hepatic insulin resistance. Dysregulation of pro-inflammatory, adaptive, and innate lymphocytes is seen in diabetes. Therefore, we hypothesized that SG induces changes in hepatic adaptive and innate immunity, leading to improved glucose tolerance.
S13
http://dx.doi.org/10.1016/j.jamcollsurg.2017.07.004 ISSN 1072-7515/17
S14
J Am Coll Surg
Scientific Forum Abstracts
(0.6% vs 0.29%, p < 0.001), and operative time (p < 0.001) were higher with fellow presence.
Table. Distal esophageal pH
Bravo capsule (n ¼ 13) Abnormal Normal Transnasal catheter (n ¼ 14) Abnormal Normal
Restech abnormal Restech normal
9 0
0 4
2 7
0 5
CONCLUSIONS: Restech detected all patients with pathologic GERD based on abnormal distal esophageal pH monitoring with either transnasal catheter or Bravo capsule. However, pharyngeal pH was abnormal in 58% of patients who had normal distal esophageal pH by catheter. We recommend either Bravo or Restech for patients with extra-esophageal reflux symptoms given the increased sensitivity of these tests compared with catheter pH monitoring. Effects of Resident or Fellow Participation in Sleeve Gastrectomy and Gastric Bypass: Results from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Marko Martinovski, MD, Abby L Navratil, MD, Tallal Zeni, MD, Mark Jonker, MD, Jane Ferraro, Jeremy Albright, Robert K Cleary, MD, FACS St Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI INTRODUCTION: Resident participation has been shown to be safe for many laparoscopic procedures. However, patient outcomes associated with complex laparoscopic operations with resident involvement have been mixed. We evaluated the impact of resident and fellow participation on outcomes after bariatric surgery using a national clinical registry. METHODS: Using the MBSAQIP, we analyzed 134,011 patients undergoing laparoscopic/robotic sleeve gastrectomy or gastric bypass. Resident/fellow involvement was characterized at the first assistant level. Baseline characteristics and 30-day perioperative outcomes were analyzed and adjusted using logistic regressions. RESULTS: Risk-adjusted 30-day complication rates comparing residents with fellows were 6.71% vs 7.21% (p ¼ 0.245), respectively. The complication rate was reduced to 5.85% (p < 0.001) when neither residents nor fellows were involved. Comparing residents with fellows, surgical site infection (SSI) rates were 0.86% and 1.17% (p ¼ 0.019), respectively, and median operative time was significant (p < 0.001). Comparing resident with noninvolvement, readmissions (4.82% vs 4.2% p < 0.001), cardiac complications (0.14% vs 0.07%, p ¼ 0.013), urinary tract infection (UTI) (0.52% vs 0.29%, p < 0.001), and operative time (p < 0.001), were higher with resident participation. Comparing fellow with noninvolvement, sepsis (0.24% vs 0.13%, p < 0.001), readmissions (4.81% vs 4.2%, p < 0.001), SSI (1.17% vs 0.75%, p < 0.001), pulmonary embolus (0.2% vs 0.11%, p ¼ 0.012), UTI
CONCLUSIONS: Resident and fellow participation in gastric bypass and sleeve gastrectomy had comparable outcomes. Their involvement was associated with higher readmissions, UTIs, SSIs, pulmonary embolus, and operative times. Despite statistical significance, the true effect size may be small. Nonetheless, strategies to improve technical competence during surgical training are needed.
Factors Associated with Prolonged Length of Stay after Laparoscopic Roux-en-Y Gastric Bypass: A Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Database Analysis Eric S Wise, MD, Jessica Felton, MD, Rami S Kantar, MD, Mark D Kligman, MD University of Maryland, Baltimore, MD INTRODUCTION: Prompt and successful postoperative discharge after laparoscopic Roux-en-Y gastric bypass (LRYGB) reflects achievement of an important quality measure, particularly as there is a trend toward this operation becoming an ambulatory procedure. As such, we utilized a recent national database to define and validate risk factors portending a prolonged length of stay (LOS) after LRYGB. METHODS: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) 2015 national database was queried for patients who underwent LRYGB with successful discharge, defined as freedom from 30-day readmission, reintervention, or mortality. Bivariate and multivariate analyses were conducted to identify independent predictors of prolonged LOS, defined as discharge after the second postoperative day. The 1,910 patients with prolonged LOS were further interrogated to determine rates of specific postoperative morbidities potentially contributing to extended hospitalization. RESULTS: Of the 10,693 patients, there were 2,924, 5,859, and 1,910 discharges on the first, second, and third or greater postoperative days, respectively. Bivariate analysis revealed 20 patient variables associated with prolonged LOS (p < 0.1). Variables independently predictive of prolonged LOS included advanced age (odds ratio [OR] 1.008 [1.003e1.01], p ¼ 0.005), female sex (OR 1.2 [1.03e1.4], p ¼ 0.02), black race (OR 1.3 [1.09e1.5], p ¼ 0.004), higher preoperative BMI (OR 1.008 [1.0008e1.02], p ¼ 0.03), and previous foregut operation (OR 1.5 [1.1e2.0], p ¼ 0.01). Among patients with prolonged LOS, rates of morbidities including renal failure, cardiac events, pneumonia, sepsis, and transfusion requirement were acceptably low (<2%). CONCLUSIONS: This study identified several critical factors associated with prolonged LOS after LRYGB, allowing characterization of the bariatric patient most prone to delayed discharge.