Showing papers in "Obesity Surgery in 2019"
TL;DR: All current procedures are associated with substantial and durable weight loss and reoperation rate was initially high but reduced markedly with improved band and surgical and aftercare techniques.
Abstract: Durability is a key requirement for the broad acceptance of bariatric surgery. We report on durability at and beyond 10 years with a systematic review and meta-analysis of all reports providing data at 10 or more years and a single-centre study of laparoscopic adjustable gastric banding (LAGB) with 20 years of follow-up. Systematic review with meta-analysis was performed on all eligble reports containing 10 or more years of follow-up data on weight loss after bariatric surgery. In addition, a prospective cohort study of LAGB patients measuring weight loss and reoperation at up to 20 years is presented. Systematic review identified 57 datasets of which 33 were eligible for meta-analysis. Weighted means of the percentage of excess weight loss (%EWL) were calculated for all papers included in the systematic review. Eighteen reports of gastric bypass showed a weighted mean of 56.7%EWL, 17 reports of LAGB showed 45.9%EWL, 9 reports of biliopancreatic bypass +/− duodenal switch showed 74.1%EWL and 2 reports of sleeve gastrectomy showed 58.3%EWL. Meta-analyses of eligible studies demonstrated comparable results. Reoperations were common in all groups. At a single centre, 8378 LAGB patients were followed for up to 20 years with an overall follow-up rate of 54%. No surgical deaths occurred. Weight loss at 20 years (N = 35) was 30.1 kg, 48.9%EWL and 22.2% total weight loss (%TWL). Reoperation rate was initially high but reduced markedly with improved band and surgical and aftercare techniques. All current procedures are associated with substantial and durable weight loss. More long-term data are needed for one-anastomosis gastric bypass and sleeve gastrectomy. Reoperation is likely to remain common across all procedures.
433 citations
TL;DR: This multicenter study show a high rate of BE at least 5 years after SG in patients who underwent SG in different bariatric centers of two countries: France and Italy and suggests to provide systematic endoscopy in these patients to rule out this condition.
Abstract: Recent evidence has indicated an increased risk of Barrett’s esophagus (BE) in the long term after sleeve gastrectomy (SG). The aim of the study is to investigate the spectrum of gastroesophageal reflux disease (GERD) symptoms as well as the prevalence of BE, at minimum 5 years after SG in patients who underwent SG in different bariatric centers of two countries: France and Italy. Five high volume outpatient centers dedicated to bariatric surgery that routinely perform upper GI endoscopy before any bariatric procedures were invited to participate in the study. From January 2017 to June 2018, each center during scheduled postoperative evaluation after surgery asked a minimum 10 consecutive patients, which had performed SG at least 5 years before and with no evidence of BE preoperatively, to undergo another upper GI endoscopy. Ninety (66 F) consecutive patients were enrolled. The mean follow-up was 78 ± 15 months, and the mean total body weight loss was 25 ± 12%. The prevalence of BE was 18.8% with no significant difference among centers. Weight loss failure was significantly associated with BE (p < 0.01). The prevalence of GERD symptoms, erosive esophagitis, and the usage of PPIs increased from 22%, 10%, and 22% before the SG to 76%, 41%, and 52% at the time of follow-up, respectively (p < 0.05). This multicenter study show a high rate of BE at least 5 years after SG. Weight loss failure was significantly associated with BE. We suggest to provide systematic endoscopy in these patients to rule out this condition.
157 citations
TL;DR: Online information on sleeve gastrectomy is of low quality, and its contents are of unknown source and accuracy, however, educational potential of YouTube® cannot be ignored.
Abstract: The internet is a widely used source for obtaining medical information both by patients and physicians. YouTube® is a valuable information resource which can improve the learning experience of both public and medical professionals if appropriately used. In this study, we want to evaluate quality and accuracy of videos about sleeve gastrectomy procedure. We included the first 100 videos returned by YouTube® search engine in response to “sleeve gastrectomy” keyword query to the study. The popularity of the videos was evaluated with an index called the video power index (VPI). Educational quality of videos was measured using the DISCERN score (DISCERN), Journal of American Medical Association (JAMAS) benchmark criteria, and Global Quality Scores (GQS). The technical quality was measured by Sleeve Gastrectomy Scoring System (SGSS) which was utilized by three bariatric surgeons. The source in 31% of the videos was a patient. The content in 53% of the videos was surgical technique. According to sources, videos uploaded by a university-affiliated physician had significantly higher DISCERN, JAMAS, GQS, and SGSS scores. Videos uploaded by a university-affiliated physician also had lower video power index than videos uploaded by patients. Surgical technique videos had significantly higher DISCERN, JAMAS, GQS, and SGSS scores. Patient experiences and advertisement videos had higher VPI scores. Also, negative correlations were found between video power index and JAMAS, GQS, and SGSS scores. Online information on sleeve gastrectomy is of low quality, and its contents are of unknown source and accuracy. However, educational potential of YouTube® cannot be ignored.
106 citations
TL;DR: Post-bariatric surgery patients had higher self-harm/suicide attempt risk compared to age-, sex-, and BMI-matched controls, and various pre- and post-surgical psychosocial, pharmacokinetic, physiologic, and medical factors may be involved.
Abstract: Bariatric surgery is endorsed by multiple societies as the most effective treatment for obesity. Psychosocial functioning has also been noted to improve for most patients after bariatric surgery. However, some studies have shown an increase in post-operative suicide risk. The aim of this study was to review the published literature and evaluate the association of bariatric surgery with suicide events and suicide/self-harm attempts in patients who have undergone weight loss surgery. MEDLINE and Embase were searched from inception through January 2018 for retrospective or prospective studies reporting mortality outcomes and self-harm or suicide rates after bariatric procedures. The primary outcome was the pooled event rate with 95% confidence interval (95% CI) for suicide. Secondary outcomes were suicide/self-harm attempts after bariatric surgery compared to same population prior to surgery and to matched control subjects, with the respective calculated odds ratios (OR) and 95% CI. From 227 citations, 32 studies with 148,643 subjects were eligible for inclusion. The patients were predominantly females (76.9%). Roux-en-Y gastric bypass (RYGB) was the most commonly performed procedure (58.9%). The post-bariatric suicide event rate was 2.7/1000 patients (95% CI 0.0019–0.0038), while the suicide/self-harm attempt event rate was 17/1000 patients (95% CI 0.01–0.03). The self-harm/suicide attempt risk was higher after bariatric surgery within the same population with OR of 1.9 (95% CI 1.23–2.95), and compared to matched control subjects, OR 3.8 (95% CI, 2.19–6.59). Post-bariatric surgery patients had higher self-harm/suicide attempt risk compared to age-, sex-, and BMI-matched controls. Various pre- and post-surgical psychosocial, pharmacokinetic, physiologic, and medical factors may be involved.
93 citations
TL;DR: Standard versions of the finished anatomic configurations of 22 surgical procedures were established by expert consensus, as a first step in developing evidence-based standard bariatric metabolic surgical procedures with the aim of improving consistency in surgery, data collection, comparison of procedures, and outcome reporting.
Abstract: Standardization of the key measurements of a procedure’s finished anatomic configuration strengthens surgical practice, research, and patient outcomes A consensus meeting was organized to define standard versions of 25 bariatric metabolic procedures A panel of experts in bariatric metabolic surgery from multiple continents was invited to present technique descriptions and outcomes for 4 classic, or conventional, and 21 variant and emerging procedures Expert panel and audience discussion was followed by electronic voting on proposed standard dimensions and volumes for each procedure’s key anatomic alterations Consensus was defined as ≥ 70% agreement The Bariatric Metabolic Surgery Standardization World Consensus Meeting (BMSS-WOCOM) was convened March 22–24, 2018, in New Delhi, India Discussion confirmed heterogeneity in procedure measurements in the literature A set of anatomic measurements to serve as the standard version of each procedure was proposed After two voting rounds, 22/25 (880%) configurations posed for consideration as procedure standards achieved voting consensus by the expert panel, 1 did not attain consensus, and 2 were not voted on All configurations were voted on by ≥ 50% of 50 expert panelists The Consensus Statement was developed from scientific evidence collated from presenters’ slides and a separate literature review, meeting video, and transcripts Review and input was provided by consensus panel members Standard versions of the finished anatomic configurations of 22 surgical procedures were established by expert consensus The BMSS process was undertaken as a first step in developing evidence-based standard bariatric metabolic surgical procedures with the aim of improving consistency in surgery, data collection, comparison of procedures, and outcome reporting
85 citations
TL;DR: A standardized definition for identifying good responders following bariatric surgery to be ≥ 20% TWL is proposed, as this measure is least influenced by preoperative BMI.
Abstract: Some weight regain is expected after bariatric surgery; however, this concept is not well defined. A favorable weight loss response has commonly been defined as 50% excess weight loss (EWL). The medical literature uses %total weight loss (%TWL), which has recently been adopted in some surgical literature. To demonstrate variability in bariatric surgery outcomes based on the definition applied and propose a standardized definition. A retrospective review of patients who underwent bariatric surgery from 2001 to 2016 with ≥ 1 year follow-up was completed. Several previously proposed definitions of weight regain were analyzed. One thousand five hundred seventy-four patients met inclusion criteria. Preoperative mean body mass index (BMI) was 47.6 ± 6.4 kg/m2. Increased preoperative BMI was associated with increased mean %TWL at 2 years postoperative (29.3 ± 9.1% for BMI 60; P 90%) of patients achieve ≥ 20% TWL and ≥ 50% EWL. Increased preoperative BMI was associated with increased %TWL and decreased %EWL at 2 years postoperative. The incidence of weight regain varies depending on the definition. We propose a standardized definition for identifying good responders following bariatric surgery to be ≥ 20% TWL, as this measure is least influenced by preoperative BMI.
81 citations
TL;DR: In this paper, the authors investigated the relationship between bariatric surgery (laparoscopic sleeve gastrectomy [LSG] and laparoscopic Roux-en-Y gastric bypass [LRYGB]) and gastroesophageal reflux disease (GERD).
Abstract: The purpose of this study was to investigate the relationship between bariatric surgery (laparoscopic sleeve gastrectomy [LSG] and laparoscopic Roux-en-Y gastric bypass [LRYGB]) and gastroesophageal reflux disease (GERD). The number of obese patients with newly onset, worsened, or improved GERD after bariatric surgery in each article were extracted. In the pooled analysis, LSG was associated with a higher risk of GERD than LRYGB (odds ratio [OR] = 5.10, 95% confidence interval [CI] 3.60–7.23, p < 0.001). Compared with LSG, LRYGB had a better effect on GERD (OR = 0.19, 95% CI 0.12–0.30, p < 0.001). LRYGB was more effective for treating GERD in obese patients than LSG and the incidence of newly onset GERD after LRYGB was lower.
81 citations
TL;DR: Bariatric surgery appears to be associated with a reduction in cancer incidence at a population-based level.
Abstract: This study has analyzed results from registry-based population studies to assess the effect of bariatric surgery upon cancer incidence at a population level. Relevant studies were identified and meta-analysis was used to calculate pooled odds ratios (POR) for the incidence of cancer after bariatric surgery compared to controls. Eight population-based studies were included with 635,642 total patients. Bariatric surgery was associated with a significant reduction in overall cancer incidence (POR = 0.72; 95% CI 0.59 to 0.87; p = 0.0007) and incidence of obesity-related cancer (POR = 0.55; 95% CI 0.31 to 0.96; p = 0.04). Bariatric surgery was also protective for breast cancer development (POR = 0.50; 95% CI 0.25 to 0.99; p = 0.045). Bariatric surgery appears to be associated with a reduction in cancer incidence at a population-based level.
72 citations
TL;DR: Clinical practice recommendations for pregnancy management following bariatric surgery are proposed, derived from a comprehensive review of the literature, existing guidelines, and expert opinion.
Abstract: Emerging evidence suggests that bariatric surgery improves pregnancy outcomes of women with obesity by reducing the rates of gestational diabetes, pregnancy-induced hypertension, and macrosomia. However, it is associated with an increased risk of a small-for-gestational-age fetus and prematurity. Based on the work of a multidisciplinary task force, we propose clinical practice recommendations for pregnancy management following bariatric surgery. They are derived from a comprehensive review of the literature, existing guidelines, and expert opinion covering the preferred type of surgery for women of childbearing age, timing between surgery and pregnancy, contraception, systematic nutritional support and management of nutritional deficiencies, screening and management of gestational diabetes, weight gain during pregnancy, gastric banding management, surgical emergencies, obstetrical management, and specific care in the postpartum period and for newborns.
72 citations
TL;DR: The present meta-analysis demonstrates the superiority of OAGB compared with RYGB, in terms of weight loss and diabetes remission and was associated with a significantly higher incidence of malnutrition, thus indicating the significant malabsorptive traits of this operation.
Abstract: We aim to review the available literature on morbidly obese patients treated with one anastomosis gastric bypass (OAGB) or Roux-en-Y gastric bypass (RYGB) in order to compare the clinical outcomes of the two methods. A literature search was performed in PubMed, Cochrane Library, and Scopus, in accordance with the PRISMA guidelines. Sixteen studies were included in the qualitative analysis, and 11 studies were included in the quantitative analysis (meta-analysis), incorporating 12,445 patients. OAGB was associated with shorter mean operative time. The length of hospital stay was comparable between the two procedures. The incidence of leaks, marginal ulcer, dumping, bowel obstruction, revisions, and mortality was similar between the two approaches. The incidence of malnutrition was increased in patients treated with OAGB, while the incidence of internal hernia and bowel obstruction was greater in the RYGB group. In addition, the OAGB was associated with greater % excess weight loss (%EWL) at 1, 2, and 5 years postoperatively. The rate of diabetes remission was greater in the OAGB group. Nonetheless, the rate of hypertension and dyslipidemia remission was similar between OAGB and RYGB. The present meta-analysis is the best currently available evidence on the topic and demonstrates the superiority of OAGB compared with RYGB, in terms of weight loss and diabetes remission. However, the OAGB was associated with a significantly higher incidence of malnutrition, thus indicating the significant malabsorptive traits of this operation.
71 citations
TL;DR: In the first comparative study of WR, OAGB had lesser WR in comparison to SG and RYGB but had the most impact on Hb and albumin levels in the long term and there is a need for standardising the reporting of WR in bariatric literature.
Abstract: There is little robust data on weight regain (WR) after bariatric surgery making it difficult to counsel patients regarding long-term outcomes of different bariatric procedures. The purpose of this study was to see WR in medium and long term after SG, RYGB, and OAGB in Indian population. In a multicentre study, data on preoperative and postoperative weights over 5 years were collected. Multiple definitions were applied to find the proportion of patients with significant WR increase of 25% of lost weight from nadir (definition 1), weight gain of > 10 kg from nadir (definition 2), and BMI gain of > 5 kg/m2 from nadir (definition 3). The proportion of those with significant WR was compared across sub-groups. A total of 9617 patients were included. Median WR at 5 years was 14.1% of lost weight, 1.92 kg/m2, and 5 kg. Significant WR using definition 1 was 35.1%, 14.6%, and 3% after sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and mini-one anastomosis gastric bypass (OAGB) respectively. Severe albumin deficiency was highest in OAGB (5.9%) patients followed by SG (2.9%) and RYGB (2.2%) at 5 years(p = 0.023). Haemoglobin levels < 10 g/dL were seen in 8.2%, 9.0%, and 13.9% of SG, RYGB, and OAGB patients respectively (p = 0.041). In the first comparative study of WR, OAGB had lesser WR in comparison to SG and RYGB but had the most impact on Hb and albumin levels in the long term. Definition selection for reporting WR has a significant impact on the results. There is a need for standardising the reporting of WR in bariatric literature.
TL;DR: It is suggested that LOCE and binge eating are clinically relevant behaviors that may impede weight loss, and findings highlight the importance of ongoing assessment of maladaptive eating following surgery.
Abstract: Although bariatric surgery is an effective intervention for severe obesity, a subset of patients demonstrates suboptimal weight outcomes. Postoperative loss of control eating (LOCE) and binge eating may influence weight outcomes, though research has not examined differences by surgical procedure, or factors that predict postoperative LOCE. This study aimed to [1] characterize LOCE and binge eating disorder (BED) over a 7-year period following bariatric surgery; [2] examine concurrent, prospective, and cumulative relationships between LOCE and weight loss; [3] assess whether these associations are moderated by surgery type; and [4] evaluate predictors of LOCE. Participants were 2156 patients who underwent laparoscopic adjustable gastric banding (LAGB) or Roux-n-Y gastric bypass (RYGB) in the multi-center Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study. Generalized linear mixed models examined relationships between LOCE and percent weight loss and predictors of LOCE. LOCE and BED initially declined then increased after surgery, with a notable number of de-novo cases (25.6% and 4.8%, respectively). LOCE was related to less concurrent but not prospective or cumulative percent weight loss. Self-monitoring of eating, higher daily eating frequency, older age, male gender, and higher self-esteem were associated with a lower likelihood of LOCE. Results suggest that LOCE and binge eating are clinically relevant behaviors that may impede weight loss, and findings highlight the importance of ongoing assessment of maladaptive eating following surgery.
TL;DR: This meta-analysis shows a superior and persistent effect of bariatric surgery versus MM for inducement of remission of T2D and was significant at 2 years and superior to MM even after 5 years.
Abstract: Bariatric surgery improves type 2 diabetes (T2D) in obese patients. The sustainability of these effects and the long-term results have been under question. To compare bariatric surgery versus medical management (MM) for T2D based on a meta-analysis of randomized controlled trials (RCTs) with 2 years of follow-up. Seven RCTs with at least 2-year follow-up were identified. The primary endpoint was remission of T2D (full or partial). Four hundred sixty-three patients with T2D and body mass index > 25 kg/m2 were evaluated. After 2 years, T2D remission was observed in 138 of 263 patients (52.5%) with bariatric surgery compared to seven of 200 patients (3.5%) with MM (risk ratio (RR) = 10, 95% CI 5.5–17.9, p < 0.001). Subgroup analysis of the Roux-en-Y gastric bypass (RYGB) showed a significant effect size at 2 years in favor of RYGB over MM for a higher decrease of HbA1C (0.9 percentage points, 95% CI 0.6–1.1, p < 0.001), decrease of fasting blood glucose (35.3 mg/dl, 95% CI 13.3–57.3, p = 0.002), increase of high-density lipoprotein (HDL) (12.2 mg/dl, 95% CI 7.6–16.8, p < 0.001), and decrease of triglycerides (32.4 mg/dl, 95% CI 4.5–60.3, p = 0.02). Four studies followed patients up to 5 years and showed 62 of 225 patients (27.5%) with remission after surgery, compared to six of 156 patients (3.8%) with MM (RR = 6, 95% CI 2.7–13, p < 0.001). This meta-analysis shows a superior and persistent effect of bariatric surgery versus MM for inducement of remission of T2D. This benefit of bariatric surgery was significant at 2 years and superior to MM even after 5 years. Compared with MM, patients with RYGB had better glycemic control and improved levels of HDL and triglycerides.
TL;DR: The objective of the present narrative review was to categorize the guidelines related to nutrition, physical activity, and supplement prescription before and after bariatric surgery to help medical teams, including bariatric surgeons, nutritionists, and sports medicine specialists, with proper management.
Abstract: According to ASMBS, the rate of bariatric surgery increased from 158,000 in 2011 to 196,000 in 2015. Nevertheless, this growth in invasive techniques does not eliminate unhealthy habits, so lifestyle modification such as healthy nutrition and correct physical activity programs may improve surgical results. The objective of the present narrative review was to categorize the guidelines related to nutrition, physical activity, and supplement prescription before and after bariatric surgery. The main key words including nutrition, diet, physical activity, exercise, supplements, macronutrients, micronutrients, weight reduction, bariatric surgery, Roux-en-Y gastric bypass, sleeve gastrostomy, laparoscopic adjustable gastric banding, and biliopancreatic diversion with duodenal switch were searched in databases including PubMed/Medline, Cochrane, and some other sources such as Google scholar. The recommendations are classified based on the type of surgery. The indications for surgery and the type of bariatric surgery are not included in this review. This review helps medical teams, including bariatric surgeons, nutritionists, and sports medicine specialists, with proper management before and after bariatric surgery.
TL;DR: Bariatric surgery significantly lowered inflammatory factors; however, baseline BMI, follow-up duration and type of surgery could impact the extent of observed effects.
Abstract: Obesity is one of the main causes of inflammation. Previous studies have reported inconclusive results regarding the effect of bariatric surgery on inflammatory markers. This systematic review and meta-analysis is aimed at describing the effect of bariatric surgery on C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α). PubMed/Medline and Scopus were systematically searched for all eligible studies from inception to June 2018. Results are expressed as weighted mean difference (MD) with 95% confidence intervals (CI) using a random effects model. Overall, 116 studies which evaluated serum CRP, IL-6, and TNF-α after bariatric surgery were included. Pooled effect size showed significant reduction in serum CRP (− 5.30 mg/l, 95% CI − 5.46, − 5.15, P 95% for all factors). Bariatric surgery significantly lowered inflammatory factors; however, baseline BMI, follow-up duration and type of surgery could impact the extent of observed effects.
TL;DR: RYGB and SG had excellent long-term outcomes for both the %EWL and DM remission rates and had a relatively lower risk of adverse events than RYGB.
Abstract: The comparative efficacy of various bariatric procedures has not been completely elucidated. We aimed to evaluate efficacy and safety of various bariatric procedures comprehensively. We searched for randomized controlled trials investigating the efficacy of bariatric surgery. Network meta-analyses were performed to determine the percentage of excess weight loss (%EWL) and remission of diabetes mellitus (DM). Of 45 studies, 33 and 24 provided the data for %EWL and DM remission rates, respectively. Six months after surgery, biliopancreatic diversion with duodenal switch (BPD-DS), Roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (SG) showed superior efficacy for %EWL compared to the standard-of-care (mean difference [MD], [95% confidence interval [CI]]: BPD-DS, 38.2% [7.3%, 69.1%]; RYGB, 32.1% [3.1%, 61.1%]; SG, 32.5% [5.5%, 59.5%]). However, adjustable gastric banding was not superior to standard-of-care (MD [95% CI] = − 0.2% [− 19.6%, 19.2%]). At 1 year, all bariatric procedures were superior to standard-of-care. At 3 years, RYGB and SG showed superior efficacy when compared to standard-of-care (MD [95% CI]: RYGB, 45.0% [21.8%, 68.2%]; SG, 39.2% [15.2%, 63.3%]). With respect to DM remission 3–5 years after surgery, BPD-DS, RYGB, and SG were superior to standard-of-care. Hernias, obstruction/stricture, bleeding, and ulcers were less common in patients who underwent SG than in those who underwent RYGB. RYGB and SG had excellent long-term outcomes for both the %EWL and DM remission rates. Additionally, SG had a relatively lower risk of adverse events than RYGB.
TL;DR: EDGE is an effective modality for performing ERCP in patients with RYGB anatomy and can be performed via gastrogastric or jejunogastric approaches.
Abstract: Endoscopic ultrasound-directed transgastric ERCP (EDGE) by creating an anastomosis from the gastric pouch or jejunum to the excluded stomach allows performance of ERCP in Roux-en-Y gastric bypass (RYGB) anatomy. Concern for persistent fistula following stent removal and sparse data limit adoption. Retrospective review of consecutive patients undergoing EDGE over a 2-year period. Nineteen RYGB patients underwent EDGE; three had previously failed ERCP by the device-assisted method. Indications for ERCP were choledocholithiasis (8), recurrent acute pancreatitis (6), benign post-surgical stricture (3), elevated bilirubin, and papillary stenosis (1 each). EDGE was technically successful in all 19 patients with jejunogastric anastomosis in 11 patients and gastrogastric in 8 using a 15-mm lumen-apposing metal stent. Stent malposition occurred in six and was managed by rescue maneuvers. ERCP was performed in the same session in four patients; the remainder were delayed after a mean of 48 days. Diagnostic endoscopic ultrasound (EUS) was performed in four patients. No severe adverse events occurred; clinical success was 100%. Stents were removed after a mean dwell time of 182 days. Argon plasma coagulation (APC) was used to promote fistula closure in 12 patients. Upper GI series to assess fistula closure was obtained in 11 patients after a mean of 182 days following stent removal. One persistent fistula was identified and closed endoscopically. EDGE is an effective modality for performing ERCP in patients with RYGB anatomy and can be performed via gastrogastric or jejunogastric approaches. Persistent fistula is uncommon and can be managed endoscopically. APC may promote fistula closure.
TL;DR: OAGB after failed SG was found to be a quicker procedure with less perioperative complications and still long-term FU including the risk of malnutrition is needed to have a complete evaluation of OAGB as a RBS for the future.
Abstract: Whether one anastomosis gastric bypass (OAGB) or Roux-en-Y gastric bypass (RYGB) is a better revisional bariatric surgery (RBS) after sleeve gastrectomy (SG) is still under debate. The aim is to compare short-term outcomes of RYGB and OAGB as a RBS after SG, pertaining to their effects on weight loss, resolution of comorbidities, and complications. We performed a single-center analysis of 55 patients (n = 34 OAGB, n = 21 RYGB). Indications for revisional surgery included weight regain/loss failure (67%) and intractable gastroesophageal reflux disease (33%). Data were collected up to 1-year follow-up (FU) and included time of revisional surgery, operation time, weight, body mass index, excess weight loss, and total weight loss (TWL), both in percent, complications and resolution of comorbidities. Operation time was 79 ± 36 (OAGB-MGB) and 98 ± 24 min (RYGB) (p = 0.03). In the first 30 postoperative days, three patients in the RYGB group, and no patient in the OAGB group, had postoperative complications. FU was 100%. Minor complication rates at 12 months were 33.3% (RYGB) and 35.3% (OAGB). At 12 months, mean % TWL was 10.3 ± 7.6% (RYGB) and 15.8 ± 7.8% (OAGB) (p = 0.0132). OAGB after failed SG was found to be a quicker procedure with less perioperative complications. At 1-year FU, no significant differences were seen between RYGB and OAGB regarding readmission and minor complications. Still long-term FU including the risk of malnutrition is needed to have a complete evaluation of OAGB as a RBS for the future.
TL;DR: Continuous deep NMB and OFA were associated with fewer complications after bariatric surgery and lower healthcare resource utilization.
Abstract: Deep neuromuscular block (NMB) and opioid-free anaesthesia (OFA) improve surgical workspace and reduce post-operative opioid consumption, but its impact on perioperative outcomes is unknown. This observational study compared complications and healthcare resource utilization after bariatric surgery, with or without continuous deep NMB or OFA. We included all 9246 patients who underwent laparoscopic bariatric surgery at our institution from January 2009 to February 2017. Continuous clinical deep NMB was defined as receiving a continuous infusion of rocuronium with a dose of > 1 mg/kg IBW for each hour or sugammadex > 2 mg/kg total body weight at the time of reversal. We analysed the effect of continuous clinical deep NMB and OFA and covariates on 1 month post-operative complications using the Clavien-Dindo (CD) classification (grades II–V) and healthcare utilization (hospital length of stay [LOS], rates of reoperations within 1 week, high-dependency care unit admissions, and readmissions within 1 month). Covariates included experience of the attending anaesthesiologist, patient age, sex, body mass index, American Society of Anesthesiologists physical status score, obstructive sleep apnoea syndrome, diabetes, hypertension, surgery type, surgical team experience, and neostigmine use. OFA, continuous deep NMB, surgical and anaesthesia team experience, younger age, and surgery type were associated with fewer complications. OFA was associated with lower healthcare resource utilization. Reduced LOS was also associated with younger age, surgical team experience, and surgery type, but not continuous deep NMB. Continuous deep NMB and OFA were associated with fewer complications after bariatric surgery.
TL;DR: Sustained weight-loss induced by bariatric surgery had a significant effect on increasing male sex hormones and decreasing female sex hormones in male patients with obesity, however, sperm quality and function were not improved after surgery.
Abstract: This systematic review and meta-analysis aims to establish the effects of bariatric surgery on male sex hormones, sperm parameters, and sexual function. We searched MEDLINE, EMBASE, Web of Science, and Scopus from database inception through June 2018. Articles were eligible for inclusion if they examined the effect of bariatric surgery on male sex hormones and sperm parameters in patients with obesity. Primary outcomes of interest were sex hormones and sperm quality. Secondary outcome was sexual function (International Index of Erectile Function (IIEF) score). Pooled estimates were calculated using random effects meta-analysis. A total of 28 cohort studies with 1022 patients were identified from 3896 potentially relevant citations. Both free and calculated testosterone levels were significantly increased after bariatric surgery (mean difference (MD) − 7.47 nM, 95% CI − 8.62 to − 6.31, p < 0.001 and MD − 0.05 nM, 95% CI − 0.07 to − 0.02, p < 0.001, respectively). Consistent with the increase in testosterone, LH, FSH, and SHBG levels were also significantly increased after surgery. In contrast, free and total estradiol and prolactin levels were significantly decreased after bariatric surgery. From studies that reported the IIEF score, bariatric surgery led to a significant increase in erectile function after surgery (MD − 0.46, 95% CI − 0.89 to − 0.02, p = 0.04). However, bariatric surgery did not affect sperm quality, DHEA, androstenedione, and inhibin B levels. Sustained weight-loss induced by bariatric surgery had a significant effect on increasing male sex hormones and decreasing female sex hormones in male patients with obesity. However, sperm quality and function were not improved after surgery.
TL;DR: OAGB is a safe and effective option for management of super and super-super obese patients with tailoring of the BPL with large comparison, follow-up and randomised trials are necessary to validate these findings.
Abstract: To explore the role of one anastomosis (Mini) gastric bypass (OAGB) for the super-obese patients. Literature review was performed in March 2019 as per PRISMA guidelines. A total of 318 patients were identified. Mean age was 31.8 years. Mean body mass index (BMI) was 57.4 kg/m2. The mean operative time was 93.1 min with median length of stay of 4.5 days. The biliopancreatic limb (BPL) varied from 190 to 350 cm(median 280 cm). Early mortality was 0.31% with seven complications (including 1 revisional surgery). Leak rate was 0%. Mean %excess weight loss (EWL) at 12, 18–24 and 60 months was 67.7%, 71.6% and 90.75%, respectively. OAGB is a safe and effective option for management of super and super-super obese patients with tailoring of the BPL. Larger comparison, follow-up and randomised trials are necessary to validate these findings.
TL;DR: Although the vast majority of bariatric procedures seem to present a negligible relationship with any esophagogastric (EG) malignancy, published data remain incomplete and it was however considered of interest to update the number of EG neoplasms arisen following bariatric surgery.
Abstract: The risk of gastric and/or esophageal cancers after bariatric surgery has been previously discussed in literature. A systematic review was performed to identify articles published between June 2012 and December 2018 reporting new cases of esophageal or gastric cancer not included in previous systematic reviews. Ten gastric malignancies, 28 esophageal cancers, and 2 gastro-intestinal stromal tumors (GIST) were identified. Primary bariatric surgery was a restrictive procedure in 26 cases, a purely malabsorptive procedure in 1 subject, and a gastric bypass in 13 patients. Although the vast majority of bariatric procedures seem to present a negligible relationship with any esophagogastric (EG) malignancy, published data remain incomplete. It was however considered of interest to update the number of EG neoplasms arisen following bariatric surgery.
TL;DR: Both studies showed that OAGB is a technically easier procedure and features better glycemic control than RYGB, but has a mal-absorptive effect, however, the bile reflux and abdominal pain controversies persisted.
Abstract: The YOMEGA study (Y-study) was a randomized trial comparing one anastomosis gastric bypass (OAGB) and Roux-en-Y gastric bypass (RYGB). Here, we aim to compare the Y-study and our pioneer trial from Taiwan (T-study). Data from the Y-study and the T-study were collected and compared. The Y-study recruited 234 patients with a mean body mass index (BMI) of 43.9 and age of 43.5 years. The T-study recruited 80 patients with a similar mean BMI of 44.3 and mean age of 31.4 years. The studies had similar findings including (1) OAGB is easier and possibly safer procedure than RYGB. Both studies showed that OAGB had a shorter operation time than RYGB, but a lower surgical complication rate was only demonstrated in T-study. (2) Both procedures have similar weight loss but OAGB features better glycemic control than RYGB. Weight loss at 2 years after surgery was similar between two procedures, but OAGB reduced HbA1c to a greater degree than RYGB at 2 years in Y-study (− 2.3% vs. − 1.3%; p = 0.025). The resolution of the metabolic syndrome was 100% for both groups in the T-study. (3) OAGB carried a higher risk of malnutrition. OAGB had more malabsorptive problems with a lower hemoglobin level than RYGB at 2 years after surgery. Adverse malnutrition events occurred in nine (7.8%) OAGB patients in the Y-study. Four (3.4%) patients of OAGB received revision surgery in Y-study but none in T-study. (4) Bile reflux was noted in OAGB patients but did not influence quality of life or revision rate. Y-study found that bile in the gastric pouch was present in 16% of patients in the OAGB group versus none in the RYGB, but no inter-group difference in quality of life was detected. There was a trend for RYGB patients to experience more abdominal pain than OAGB. Both studies showed that OAGB is a technically easier procedure and features better glycemic control than RYGB, but has a mal-absorptive effect. However, the bile reflux and abdominal pain controversies persisted.
TL;DR: LSG is a “pro-reflux” surgical procedure, which should be continuously evaluated late after surgery, and patients submitted to LSG showed a significant and progressive increase in the presence of “de novo” GERD.
Abstract: Perform a prospective study based on sequential clinical, endoscopic, and histologic evaluations of the foregut late after laparoscopic sleeve gastrectomy (LSG) in obese patients. After LSG, several studies have suggested an increase in the incidence of clinical gastroesophageal reflux (GERD) while others have reported an improvement but based mainly on clinical questionnaires. Prospective study of 104 consecutive patients submitted to LSG. Several postoperative endoscopic and histologic evaluations of the esophagogastric junction (EGJ) and the gastric tube (GT) were performed and correlated with symptomatic findings. According to clinical preoperative findings, patients were divided into non-refluxers (Group I) and refluxers (Group II). Seven patients were unreachable, leaving 97 (93%) for late evaluation. Among Group I, 58.5% developed de novo GERD, while in Group II just 13.6% showed the disappearance of them. Endoscopic evaluations showed progressive deterioration of the EGJ in Group I, with the development of erosive esophagitis (EE), hiatal hernia (HH), and dilated cardia in a large proportion of them. In the GT, the presence of bile was seen in 40%, and an open immobile pylorus was detected in 82%. Short-segment Barrett’s esophagus (BE) appeared in 4%. Patients submitted to LSG showed a significant and progressive increase in the presence of “de novo” GERD. Also, an increased duodenogastric reflux was seen through an open and immobile pylorus. Therefore, based on these results, it seems like LSG is a “pro-reflux” surgical procedure, which should be continuously evaluated late after surgery.
TL;DR: Using the ordered TO for bariatric surgery, more hospital variation was captured thereby enabling individual hospitals to identify which outcomes and specific groups need improvement.
Abstract: Textbook outcome (TO) studies have previously shown that a composite measure can provide additional information on the overall quality of surgical care. However, these were binominal outcomes which do not give individual hospitals the required information on how to improve their performance. The aim of this study is to create an ordered TO consisting of multiple outcome parameters for bariatric surgery to assess the extent of hospital variation. Patients who underwent a primary bariatric procedure in the Netherlands were included for analyses. The outcomes were ordered as mortality, severe postoperative complications, readmission, mild complications and prolonged length of stay (LOS) within 30 days after primary surgery with TO defined as none of these outcomes occurring. Hospitals were identified with a significantly higher or lower observed/expected ratio than expected based on case-mix and the extent of hospital variation was expressed as the median and interquartile range (IQR). From a total of 27,360 patients on average, 88.7% reached TO (range 35.5–96.9%). Two hospitals had less than expected TO due to more prolonged LOS (57.6%) in one hospital and more mild complications in another (17.1%). Hospital variation was much smaller for TO (median OR 0.91 IQR [0.62–1.06]) than for an ordered TO (median POR 0.66 IQR [0.55–0.96]). Using the ordered TO for bariatric surgery, more hospital variation was captured thereby enabling individual hospitals to identify which outcomes and specific groups need improvement. This could attribute to the ongoing effort to improve the quality of the outcome of bariatric surgery.
TL;DR: Both RYGB and LSG lead to nutritional deficiencies despite different properties of operations and similar %EWL during follow-up, according to analysis of incidence and severity of malnutrition after bariatric surgery in patients submitted to RY GB or LSG during 12 months of follow- up.
Abstract: Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are the two most frequently performed bariatric operations. These two types of metabolic surgery alter the anatomy and function of digestive tract producing significant weight loss in morbidly obese patients but may lead to malnutrition. Analysis of incidence and severity of malnutrition after bariatric surgery in patients submitted to RYGB or LSG during 12 months of follow-up. Retrospective study of 98 patients after RYGB (n = 47) or LSG (n = 51) assessed for nutritional deficiencies during 12 months after surgery was conducted. The differences in body mass index (BMI) and blood tests including erythrocytes, haemoglobin, total protein, albumin, iron, ferritin, transferrin, vitamin B12, folic acid, calcium and phosphorus concentrations were compared between groups before the operations and at 1 and 12 months. Nutritional deficiencies were common before surgery with prevalence up to 19.6% for albumin in the LSG group. Median preoperative BMI levels and albumin concentrations were higher in the RYGB group compared to the LSG group, but there was no difference in percent excess weight loss (%EWL) at 1 and 12 months between LSG and RYGB. One month after LSG erythrocyte count, haemoglobin, iron, ferritin and transferrin levels were significantly higher than in the RYGB group. These differences subsided at 12 months. At 12 months, only the prevalence of vitamin B12 deficiency was significantly higher in the RYGB group. Both RYGB and LSG lead to nutritional deficiencies despite different properties of operations and similar %EWL during follow-up.
TL;DR: In conclusion, revision rate is not rare after SG, especially when looking at long-term follow-up, but bariatric surgeons and patients need to fully understand and deal with the need for revision after SG.
Abstract: This study aimed to make a meta-analysis regarding mid-long-term outcomes (≥ 3-year follow-up) after sleeve gastrectomy (SG), focusing on incidence, reasons, and results of revisional surgery. PubMed, EMBASE, and CENTRAL were searched and 32 studies were included. The overall revision rate was 10.4%, but for patients with ≥ 10-year follow-up, the rate was 22.6%. European studies had a higher revision rate (14.4%) than other studies. The most common reason for revision was failure in weight loss, and the most frequent revisional procedure was gastric bypass. Revisional surgery was favorable for weight reduction and comorbidity resolution. In conclusion, revision rate is not rare after SG, especially when looking at long-term follow-up. Bariatric surgeons and patients need to fully understand and deal with the need for revision after SG.
TL;DR: At similar weight loss and glycemic improvement, the greatest alteration in gut microbiota occurred after RYGB with an increase in the potentially beneficial bacterium, F. prausnitzii.
Abstract: Gut microbiota likely impact obesity and metabolic diseases. We evaluated the changes in gut microbiota after surgical versus medical weight loss in adults with diabetes and obesity. We performed 16S rRNA amplicon sequencing to identify the gut microbial composition at baseline and at 10% weight loss in adults with diabetes who were randomized to medical weight loss (MWL, n = 4), adjustable gastric banding (AGB, n = 4), or Roux-en-Y gastric bypass (RYGB, n = 4). All participants were female, 75% reported black race with mean age of 51 years. At similar weight loss amount and glycemic improvement, the RYGB group had the most number of bacterial species (10 increased, 1 decreased) that significantly changed (p < 0.05) in relative abundance. Alpha-diversity at follow-up was significantly lower in AGB group compared to MWL and RYGB (observed species for AGB vs. MWL, p = 0.0093; AGB vs. RYGB, p = 0.0093). The relative abundance of Faecalibacterium prausnitzii increased in 3 participants after RYGB, 1 after AGB, and 1 after MWL. At similar weight loss and glycemic improvement, the greatest alteration in gut microbiota occurred after RYGB with an increase in the potentially beneficial bacterium, F. prausnitzii. Gut microbial diversity tended to decrease after AGB and increase after RYGB and MWL. Future studies are needed to determine the impact and durability of gut microbial changes over time and their role in long-term metabolic improvement after bariatric surgery in adults with type 2 diabetes. NCTDK089557—
ClinicalTrials.gov
Oita University1, The Chinese University of Hong Kong2, Jinan University3, China Medical University (Taiwan)4, Austin Hospital5, Max Super Speciality Hospital6, Kuwait University7, Chulalongkorn University8, Inha University9, King Khalid University10, Hamad Medical Corporation11, Universiti Putra Malaysia12, Tan Tock Seng Hospital13
TL;DR: It was showed that bariatric/metabolic surgery is rapidly developing along with various problems in Asia-Pacific countries, including public insurance coverage, training system, national registry, and lack of awareness and comprehension.
Abstract: The Asia-Pacific Metabolic and Bariatric Surgery Society (APMBSS) held its congress in Tokyo at the end of March, 2018, and representatives from Asia-Pacific countries presented the current status of bariatric/metabolic surgery in the “National Reports” session. The data are summarized here to show the current status and problems in the Asia-Pacific region in 2017. A questionnaire including data of 2016 and 2017 and consisting of eight general questions was prepared and sent to representatives in 18 Asia-Pacific countries by e-mail before the congress. After the congress, the data were analyzed and summarized. Seventeen of 18 countries responded to the survey. The frequency of obesity (BMI ≥ 30) in the 4 Gulf countries was > 30%, much higher than that in the other countries. In total, 1640 surgeons and 869 institutions were engaging in bariatric/metabolic surgery. In many East and Southeast Asian countries, the indication for bariatric surgery was BMI ≥ 35 or ≥ 37, whereas in many Gulf countries and Australia, it was BMI ≥ 40 or ≥ 35 with obesity-related disease. Ten of the 17 countries (58.8%) but only one of the 5 Southeast Asian countries (20.0%) had public health insurance coverage for bariatric surgery. In 2017, 95,125 patients underwent bariatric/metabolic surgery, with sleeve gastrectomy accounting for 68.0%, bypass surgery for 19.5%, and others for 12.5%. Current problems included public insurance coverage, training system, national registry, and lack of awareness and comprehension. This summary showed that bariatric/metabolic surgery is rapidly developing along with various problems in Asia-Pacific countries.
TL;DR: This study is the first attempt to understand patient perspectives on poor adherence to post-bariatric surgery nutritional recommendation and offers suggestions on how to improve it.
Abstract: Adherence to post-bariatric surgery nutritional supplements can be poor and is associated with higher micronutrient deficiency rates. There is currently no available study specifically seeking patients’ perspectives on the reasons behind poor adherence and how to address it. Bariatric surgery patients living in the UK were invited to take part in an anonymous survey on SurveyMonkey®. A total of 529 patients (92.61% females, mean age 47.7 years) took part. Most of these patients had undergone either a Roux-en-Y gastric bypass (63.0%) or sleeve gastrectomy (24.0%). Most of the patients were in full-time (49.0%, n = 260/529) or part-time (15.7%, n = 83/529) employment. Approximately 54.0% (n = 287/529) of the respondents reported having trouble taking all their supplements. Males were significantly more likely to report complete compliance. The most important reported reason for poor compliance was difficulty in remembering (45.6%), followed by too many tablets (16.4%), side effects (14.3%), cost (11.5%), non-prescribing by GP (10.8%), bad taste (10.1%), and not feeling the need to take (9.4%). Patients suggested reducing the number of tablets (41.8%), patient education (25.7%), GP education (24.0%), reducing the cost (18.5%), and more information from a healthcare provider (12.5%) or a pharmacist (5.2%) to improve the compliance. This study is the first attempt to understand patient perspectives on poor adherence to post-bariatric surgery nutritional recommendation. Patients offered a number of explanations and also provided with suggestions on how to improve it.