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BackgroundThe optimal treatment of sleeve strictures has not been agreed upon at the current time. At our institution, we began using pneumatic balloon dilation to help resolve these obstructions in 2010. Herein we report our experience with pneumatic balloon dilation for the treatment of sleeve strictures.MethodsFrom Jan 2010 to Dec 2016 we retrospectively reviewed our prospectively kept database for patients who developed a Laparoscopic Sleeve Gastrectomy (LSG) stricture within 90 days of surgery. If the stricture was found, then we dilated all our patients initially at 30 mm at 10 PSI for 10-20 min (14.5 min average) and increased the balloon size (30-40 mm) and duration (10-30 min) in subsequent sessions if the first session was unsuccessful.ResultsThe review found that 1756 patients underwent either LSG or the first step of a Laparoscopic Duodenal Switch (LDS) (1409 LSG & 356 LDS). Of the 1756 patient 33 patients (24 underwent LSG, and 9 underwent LDS) developed a stricture as a complication of LSG. The average age of the patients was 46.4 (±9.6) years, and the average BMI was 43.7 (±6.4). The most common location for stricture was mid-body of the sleeve (54.5%). The average time from the primary surgery to diagnosis and first pneumatic dilation was 5.6 months (± 6.8) and 5.9 months (± 6.6) respectively. We successfully used pneumatic dilation in 31 (93.9%) of these patients to relieve the stricture.ConclusionWe conclude that pneumatic dilation is an effective procedure in patients with post sleeve gastrectomy stricture.

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BACKGROUND Non-alcoholic fatty liver disease (NAFLD) is a systemic disease with bidirectional relationships with cardiovascular disease (CVD). Non-alcoholic steatohepatitis (NASH) is a more severe subtype of NAFLD. Patients with NASH exhibit more intra and extrahepatic inflammation, procoagulant imbalances and proatherogenic lipid profiles. Whether NASH increases the risk of ischemic heart disease is currently unclear. AIM To investigate the relationship between acute myocardial infarction (MI) and NASH in a large cohort of subjects in the United States. METHODS We reviewed data from a large commercial database (Explorys IBM) that aggregates electronic health records from 26 large nationwide healthcare systems. Using systemized nomenclature of clinical medical terms (SNOMED CT), we identified adult with the diagnosis of NASH from 1999-2019. We included patients with the diagnosis of acute MI from 2018-2019. Comorbidities known to be associated with NASH and MI such as obesity, diabetes mellitus, hyperlipidemia, smoking, male gender, and hypertension were collected. Univariable and multivariable analyses were performed to investigate whether NASH is independently associated with the risk of MI. RESULTS Out of 55099280 patients, 43170 were diagnosed with NASH (0.08%) and 107000 (0.194%) had a MI within 2018-2019. After adjusting for traditional risk factors, NASH conferred greater odds of MI odds ratio (OR) 1.5 [95% confidence interval (CI): 1.40-1.62]. Hyperlipidemia had the strongest association with MI OR 8.39 (95%CI: 8.21-8.58) followed by hypertension OR 3.11 (95%CI: 3.05-3.17) and smoking OR 2.83 (95%CI: 2.79-2.87). NASH had a similar association with MI as the following traditional risk factors like age above 65 years OR 1.47 (95%CI: 1.45-1.49), male gender OR 1.53 (95%CI: 1.51-1.55) diabetes mellitus OR 1.89 (95%CI: 1.86-1.91). CONCLUSION MI appears to be a prevalent disease in NASH. Patients with NASH may need early identification and aggressive cardiovascular risk modification.

Background: Inflammatory bowel disease (IBD) has been associated with an increased risk of cardiovascular events, but the risk of cerebrovascular accidents (CVA) remains unknown. Hypercoagulability and systemic inflammation are two proposed mechanisms by which the presence of IBD might lead to the development of CVA. Objective: To assess the risk of CVA in patients with IBD compared to those without IBD with known traditional risk factors for CVA. Methods: We reviewed data from a large commercial database (Explorys, IBM) that aggregated records from 26 health-care systems nationwide. Using systemized nomenclature of medicineclinical terms, we identified adult patients diagnosed with IBD (ulcerative colitis or Crohn's disease) between September 1994 and September 2019. We then examined the risk of CVA in these patients. Known risk factors such as age ≥65-years old, diabetes mellitus (DM), hypertension (HTN), female gender, atrial fibrillation (Afib) were collected. A univariate binary logistic model was constructed using CVA as the dependent variable and other variables as independent variables. To adjust for possible confounding, a multivariable model adjusting for all covariates was created to test for CVA. Results: A total of 52,176,550 patients were included in this analysis, and 261,890 had IBD. The prevalence of CVA was higher in IBD patients compared to non-IBD patients (6.24% versus 0.48%, p <0.0001). The univariate binary logistic regression showed 13.7 times higher odds of having CVA in IBD patients than without IBD (odds ratio (OR) 13.74, p <0.0001). In multivariate binary logistic regression, after adjusting for traditional risk factors for CVA (Afib, HTN, female gender, DM, age ≥65 years), odds ratio of CVA in IBD patients remained significantly higher (OR 8.07, 95% CI: 7.9-8.2, p<0.0001). Conclusion:In our large cohort of patients, IBD appears to be an independent risk factor for CVA. Further prospective studies are needed to understand the underlying mechanisms by which IBD increases the risk of CVA. This may lead to early identification and intervention to reduce the risk of CVA in this highly heterogeneous group of patients.

 Cardiometabolic syndrome is a constellation of metabolic abnormalities, characterized by insulin resistance, impaired glucose tolerance, dyslipidemia, hypertension, and central adiposity.  The role of inflammation in cardiometabolic diseases is well recognized.  Canakinumab is a human monoclonal antibody against IL-1β.  The Canakinumab Anti-inflammatory Thrombosis Outcome Study (CANTOS) showed a significant reduction in cardiovascular events in patients on canakinumab.  Canakinumab in higher doses led to a reduction in the incidence of lung cancer.

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Heart failure with preserved ejection fraction is a growing epidemic and accounts for half of all patients with heart failure. Increasing prevalence, morbidity, and clinical inertia have spurred a rethinking of the pathophysiology of heart failure with preserved ejection fraction. Unlike heart failure with reduced ejection fraction, heart failure with preserved ejection fraction has distinct clinical phenotypes. The obese-diabetic phenotype is the most often encountered phenotype in clinical practice and shares the greatest burden of morbidity and mortality. Left ventricular remodeling plays a major role in its pathophysiology. Understanding the interplay of obesity, diabetes mellitus, and inflammation in the pathophysiology of left ventricular remodeling may help in the discovery of new therapeutic targets to improve clinical outcomes in heart failure with preserved ejection fraction. Anti-diabetic agents like glucagon-like-peptide 1 analogs and sodium-glucose co-transporter 2 are promising therapeutic modalities for the obese-diabetic phenotype of heart failure with preserved ejection fraction and aggressive weight loss via lifestyle or bariatric surgery is still key to reverse adverse left ventricular remodeling. This review focuses on the obese-diabetic phenotype of heart failure with preserved ejection fraction highlighting the interaction between obesity, diabetes, and coronary microvascular dysfunction in the development and progression of left ventricular remodeling. Recent therapeutic advances are reviewed.