Non-alcoholic fatty liver disease (NAFLD), as a metabolic disease, has shown a constant upward trend in prevalence among the people in recent years. In addition to changing lifestyles and conventional drug treatment, bariatric surgery, represented by Roux-en-Y gastric bypass surgery and sleeve gastrectomy, has gradually become one of the treatment options for NAFLD. However, the mechanism of bariatric surgery in treating NAFLD remains to be studied. The "multiple-hit theory", which has gradually been recognized in recent years, believes that NAFLD is formed by the combined effect of multiple mechanisms such as insulin resistance, bile acid metabolism pathway, and intestinal flora. Based on relevant literatures and clinical practices, the authors explore the relevant mechanisms of bariatric surgery for direct or indirect treatment of NAFLD.

BACKGROUND: Management of gastric leak after sleeve gastrectomy (SG) is challenging due to its unpredictable outcomes. We aimed to summarize the characteristics of SG leaks and analyze interventions and corresponding outcomes in a real-world setting. METHODS: To retrospectively review of 15,721 SG procedures from 2010 to 2020 based on a national registry. A cumulative sum analysis was used to identify a fitting curve of gastric leak rate. The Kaplan-Meier method and log-rank tests were performed to calculate and compare the probabilities of relevant outcomes. The logistic regression analysis was conducted to determine the predictors of acute leaks. RESULTS: A total of 78 cases of SG leaks were collected with an incidence of 0.5% (78/15,721) from this registry (6 patients who had the primary SG in non-participating centers). After accumulating 260 cases in a bariatric surgery center, the leak rate decreased to a stably low value of under 1.17%. The significant differences presented in sex, waist circumference, and the proportion of hypoproteinemia and type 2 diabetes at baseline between patients with SG leak and the whole registry population ( P = 0.005, = 0.026, <0.001, and = 0.001, respectively). Moreover, 83.1% (59/71) of the leakage was near the esophagogastric junction region. Leakage healed in 64 (88.9%, 64/72) patients. The median healing time of acute and non-acute leaks was 5.93 months and 8.12 months, respectively. Acute leak (38/72, 52.8%) was the predominant type with a cumulative reoperation rate >50%, whereas the cumulative healing probability in the patients who required surgical treatment was significantly lower than those requring non-surgical treatment ( P = 0.013). Precise dissection in the His angle area was independently associated with a lower acute leak rate, whereas preservation ≥2 cm distance from the His angle area was an independent risk factor. CONCLUSIONS Male sex, elevated waist circumference, hypoproteinaemia, and type 2 diabetes are risk factors of gastric leaks after SG. Optimizing surgical techniques, including precise dissection of His angle area and preservation of smaller gastric fundus, should be suggested to prevent acute leaks.
Humans ; Male ; Retrospective Studies ; Diabetes Mellitus, Type 2/complications* ; Obesity, Morbid ; Anastomotic Leak/epidemiology* ; Gastrectomy/methods* ; Reoperation/methods* ; Registries ; Laparoscopy/methods* ; Treatment Outcome

Objective:To systematically evaluate the effect of bariatric and metabolic surgery on bone metabolism in obese patients.Methods:Search terms for the present meta-analysis included "bariatric surgery, metabolic surgery, sleeve gastrectomy, gastric bypass, bone metabolic indicators, bone mineral density", both in English and corresponding Chinese. PubMed, WOS, Cochrane, CNKI, and VIP databases were searched for longitudinal studies from the establishment of the database to September 20, 2022. The data on bone mineral density and bone metabolic markers in obese patients before and after bariatric surgery were extracted. RevMan5.4 and Stata17.0 software were used for Meta-analysis.Results:A total of 8 clinical studies with 420 patients were included. The results of the meta-analysis showed that compared with the preoperative baseline, lumbar spine bone mineral density ( WMD=0.05, 95% CI: -0.00~0.1), femoral neck bone mineral density( WMD=0.10, 95% CI: 0.05-0.15), hip bone mineral density( WMD=0.14, 95% CI: 0.10-0.17), and serum vitamin D 3 ( WMD=-4.87, 95% CI: -6.34--3.40)were decreased, while parathyroid hormone ( WMD=10.04, 95% CI: 5.32-14.76) was elevated after surgery. Conclusions:Current evidence demonstrates that metabolic and bariatric surgery can lead to decreased bone mineral density and impairs in bone metabolic markers early after surgery. Roux-en-Y gastric bypass surgery cause more adverse effects on bone metabolism than sleeve gastrectomy. The results imply that all patients undergoing metabolic and bariatric surgery should be monitored for bone metabolism and routinely take vitamin D and calcium supplements.

Objective:To analyze the incidence of gallstone formation after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) by meta-analysis.Methods:English terms for this meta-analysis included "bariatric surgery, gastric bypass, Roux-n-Y gastric bypass, RYGB, sleeve gastrectomy, SG, cholelithiasis, cholecystectomy, gallstone". Researched articles in Pubmed, Medline and Embase databases were searched up to February 2023 and retrieved for further analysis. The quality of each article was evaluated with Newcastle-Ottawa Scale (NOS). Generated data were analyzed with Revman 5.4.Results:Nine relevant cohort studies were retrieved for this meta-analysis, including a total of 24 255 RYGB patients and 4 500 SG patients. All articles met the requirements after the quality evaluation of NOS. The meta-analysis results showed that the incidence of postoperative gallstones in RYGB group was higher than that in SG group ( P<0.001). In subgroup analysis, by administering ursodeoxycholic acid (UDCA) for gallstone prevention, the incidence had no difference between the two groups ( P=0.090), while in the study without UDCA, the incidence of gallstones after RYGB was higher than SG ( P=0.005). In the studies with follow-up time no more than 24 months, the incidence of postoperative gallstones in RYGB group was higher than that in SG group ( P=0.050), but there was no statistical difference when following-up beyond 24 months ( P=0.240). Conclusions:Within 2 years after surgery, RYGB patients have more chances to develop gallstones than SG patients. However, beyond 2-year follow-up, there is no difference between the two procedures. Prophylactical utilization of UDCA after RYGB can effectively reduce the incidence of gallstone formation.

Objective:To compare the effect of age on clinical outcome of laparoscopic sleeve gastrectomy (LSG) in the obese patients.Methods:A total of 113 patients who underwent LSG due to obesity and metabolic disorders between 2013 and 2018 at Fudan University Pudong Hospital, and completed the scheduled follow-up (1, 3, 6, and 12 months after surgery) were included for the retrospective analysis. The patients were divided into three groups based upon pre-operative age, including 15 to 30 year-old group ( n=58), 31 to 45 year-old group ( n=32), and 45 to 65 year-old group ( n=23). The body weight related parameters, glycemic and metabolic related parameters, lipid panel as well as arterial blood pressure were compared at pre-operative baseline, 1, 3, 6, and 12 months after surgery. The quantitative data were analyzed by repeated measurement ANOVA, and the P value was corrected by Bonferroni method. And the categorical variables were analyzed by chi square test. Results:The preoperative baseline data showed that with the increase of age, the preoperative body mass index gradually decreased, which were (40.1±5.9) kg/m 2, (37.1±6.6) kg/m 2 and (35.3±7.4) kg/m 2 in 16 to 30, 31 to 45 and 46 to 65 year-old groups, respectively. Otherwise, other metabolic related parameters were comparable. At 12 months after LSG, there was no significant difference in the amount of weight loss among the groups, but the percentage of total weight loss (% TWL) and the percentage of total BMI loss (%TBMIL) decreased significantly with age increasing. The %TBMIL in 16 to 30, 31 to 45 and 46 to 65 year-old groups were 32.3±7.5%, 28.4±8.4% ( P<005 compared with 16 to 30 year-old group) and 25.7±8.2% (compared with 16 to 30 year-old group P<0.001), respectively. In the patients with preoperative HbA1c>7%, HbA1c reduction in the three groups at 12 months after operation were 3.20% (compared with 46-65 year-old group P<0.001), 2.64% (compared with 46-65 year-old group P<0.05) and 1.34%, respectively. The proportions of patients with HbA1c < 6.5% were 95.8%, 88.9% and 50.0%, respectively. LDL, triglyceride and arterial blood pressure in all groups decreased and HDL increased rapidly within 3 months after operation, but there was no significant difference among the three groups. Conclusions:The improvement of blood glucose metabolism and the remission rate of type 2 diabetes mellitus (T2DM) in the patients with older age were worse than those in the younger patients, and the T2DM in the younger patients tends to obtain better clinical remission after LSG; in terms of weight loss, with the increase of age, %TWL and %TBMIL also showed a decreasing trend; however, the improvement of blood lipid and blood pressure after LSG was not affected by the factor of age. This study implies that patients who meet the indications of metabolic and bariatric surgery should be suggested to receive surgical treatment early in order to achieve better clinical outcomes.

Objective:To investigate the relationship of glycated hemoglobin(HbA1c)and brain natriuretic peptide(BNP)levels with clinical prognosis of acute myocardial infarction.Methods:A total of 108 patients with acute myocardial infarction combined with diabetes mellitus, who underwent percutaneous coronary intervention(PCI)from March 2016 to June 2017 in our hospital, were enrolled.According to the HbA1c level, patients were divided into three groups: Group A(HbA1c≤6.9%, n=36), Group B(7%≤HbA1c≤7.9%, n=31)and Group C(HbA1c≥8%, n=41). HbA1c and NT-proBNP levels, cardiac function classification at admission and discharge, the incidence of adverse cardiac events during hospitalization and left ventricular ejection fraction(LVEF)at admission, discharge and 3 months after discharge were analyzed.Results:Among the three groups, plasma NT-proBNP levels were higher in Group C than in Group B and Group A( P<0.05), and there was no significant difference between Group B and Group C( P<0.05). Furthermore, HbA1c levels were positively correlated with NT-proBNP levels in Group C( P<0.05). Cardiac function grading was better in Group A and Group B than in Group C at discharge.During hospitalization, the incidence of adverse cardiac events in Group C was 29.3%, which was higher than in Group A(8.3%)and Group B(9.7%)( P<0.05). LVEF levels were significantly improved in Group A and Group B at discharge and 3 months after discharge, compared with those at admission, while Group C had no significant improvement in LVEF levels and had lower LVEF than Group A and Group B( P<0.05). Conclusions:HbA1c and NT proBNP levels can be used as a joint monitoring indicator in patients with acute myocardial infarctions after PCI, to help prevent and reduce the incidence of complications and mortality in patients with acute myocardial infarction after PCI and improve clinical prognosis.

Objective To compare laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy for the treatment of obese patients with type 2 diabetes mellitus.Methods A retrospective analysis of T2DM patients with LRYGB (28 cases) and LSG (35 cases) was enrolled from Jan 2010 to Jun 2013.Results The indicator such as BMI,fasting glucose,fasting insulin,HbA1c,and insulin resistance were significantly lower in 1 year,3 years and 5 years after operation [LRYGB group:(37.3 ±3.7) kg/m2 to (32.3 ± 3.4) kg/m2 to (28.8 ± 3.0) kg/m2 to (25.5 ± 2.8) kg/m2,t =13.670,15.499,21.710,P=0.000,0.000,0.000;(8.2 ± 1.8) mmol/L to (6.0 ± 1.3) mmol/L to (5.2 ±0.9) mmol/L to (4.7±0.5) mmol/L,t =6.664,8.723,10.282,P=0.000,0.000,0.000;(32.2±17.0) μ IU/ml to (16.1 ± 12.1) μIU/ml to (8.6 ±5.2) μ IU/ml to (5.2 ±2.8) μIU/ml,t =7.453,8.218,8.687,P =0.000,0.000,0.000;(7.4％ ±0.6％) to (6.2％ ±0.7％) to (5.7％ ±0.7％) to (5.1％ ±0.6％),t =11.362,18.771,21.186,P=0.000,0.000,0.000;(12.0±7.3) to (4.6±4.3) to (2.1 ±1.7) to (1.1 ±0.7),t =6.455,7.667,8.050,P=0.000,0.000,0.000;LSG group:(39.2±5.2) kg/m2 to (34.1 ±4.5) kg/m2to (29.3±4.0) kg/m2to (25.1 ±2.3) kg/m2,t=11.676,13.680,19.161,P=0.000,0.000,0.000;(8.0±2.9) mmol/L to (5.8±1.5) mmol/L to (5.1 ±0.9) mmol/L to (4.6 ±0.5) mmoL/L,t=5.467,6.921,7.741,P=0.000,0.000,0.000;(29.1 ±25.2) μIU/ml to (16.4±10.6) μ IU/ml to (8.8±5.5) μ IU/ml to (5.5 ±2.0) μIU/ml,t =3.512,5.232,5.702,P=0.001,0.000,0.000;(7.7％ ±1.3％) to (6.3％ ±0.6％) to (5.8％ ±0.6％) to (5.2％ ±0.6％),t=8.001,10.106,11.922,P =0.000,0.000,0.000;(9.8 ±9.6) to (3.9 ±2.2) to (1.9 ±1.0) to (1.1 ± 0.4),t =3.733,4.972,5.404,P =0.001,0.000,0.000].There was no significant difference between the two groups in 1 year,3 year and 5 year post-operation (DM remission:71％ to 69％,89％ to 80％,93％ to 89％) (P ＞ 0.05).Conclusion LRYGB and LSG have the same long-term efficacy for T2DM patients.

Objective To study the treatment principles and surgical skills in laparoscopic subtotal cholecystectomy (LSC) for acute cholecystitis.Methods We retrospectively analyzed the clinical data of patients who underwent LSC for acute cholecystitis from Jan.2006 to Dec.2015 at the Beijing Shijitan Hospital,Capital Medical University.We dissected any serious pericholecystic adhesions according to the principle that "It is better that the gallbladder rather than other tissue is injured",and the technique that "After the gallbladder anterior wall is excised,the gallbladder ampulla and duct are split along the longitudinal direction of the cholecystic duct,then the opened cholecystic duct is sutured inside the gallbladder".Results LSC was completed successfully in 96 patients.There were no conversion to open surgery,and no bile duct injury.The mean surgery time was (108.0 ± 37.0) min,the mean blood loss was (121.0 ± 62.0) ml,the mean peritoneal drainage was (105.0 ± 32.0) ml.The drainage tube was removed at a mean of (3.4 ±1.2) d after surgery.The mean hospitalization time after surgery was (6.1 ± 2.2) d.Surgical complications occurred in 2 patients with bleeding after surgery.One patient underwent laparoscopic exploration to stop bleeding.Another patient underwent conservative treatment and the bleeding stopped spontaneously.There were 3 patients who had mild bile leakage.All these patients recovered well after drainage.No patient developed bile duct stenosis or obstructive jaundice on follow-up.Conclusions LSC for acute cholecystitis was safe.Bile duct injuries could be avoided if we follow the principle of "It is better that the gallbladder rather than other tissue is injured" and the technique of "After the gallbladder anterior wall is excised,the gallbladder ampulla and duct are split along the longitudinal direction of the gallbladder,then the opened cholecystic duct is sutured inside the gallbladder".

Objective:To compare the clinical effects of rapid maxillary expansion between tooth-borne and hybrid-borne expanders.Methods:PubMed,Cochrane Library,EMbase,CBM,CNKI,VIP and WanFang Data were searched from the date of their establishment to October 31,2015,to find clinical trials about comparison of rapid maxillary expansion by tooth tissue-borne versus hybrid-borne expanders.The quality of the included studies was evaluated by 2 independent reviewers,and Meta-analysis was performed by using RevMan 5.3 software.Results:8 articles with 206 cases were included.The results of Meta-analysis showed that:there were significant differences between the 2 groups in the changes of the right first molar dental inclination [MD =-1.62,95 ％ CI (-3.18,-0.07)],inter first premolar width [SMD =-0.86,95％ CI(-1.47,0.25)] and molar alveolar inclination [SMD =-0.86,95％ CI(-1.10,-0.20)].There was no significant difference between the 2 groups in the changes of inter first molar ~dth [SMD =-0.08,95％ CI (-0.6l,0.45)],the left first molar dental inclination [MD =-1.12,95％ CI(-2.57,0.33)],maxillary width [SMD =-0.30,95％ CI(-1.08,0.47)].Conclusion:The effect between tooth-borne and hybrid-borne expanders in the expansion of maxillary dental arch is similar.However,tooth-borne expanders may cause greater inclination of first molar and alveolar process.

Primary failure of eruption(PFE) is an unusual dental disease.Clinically,it is difficult to distinguish PFE from Mechanical failure of eruption (MFE),and the diagnosis is especially challenging since misdiagnosis and mistreatment always take place.The present paper reports the treatment experience of a case of PFE.