Showing papers in "Obesity Surgery in 2020"
TL;DR: RYGB resulted in greater %EWL, improved dyslipidaemia outcomes and a lower incidence of postoperative gastro-oesophageal reflux disease (GORD), which resulted in sustained weight loss and comorbidity control at 5 years.
Abstract: Sleeve gastrectomy (SG) has overtaken Roux-En-Y gastric bypass (RYGB) as the most common bariatric procedure worldwide. However, there is little long-term data comparing the two procedures. We perform a systematic review and meta-analysis comparing 5-year outcomes of randomised controlled trials (RCTs) comparing RYGB and SG. Medline, Embase, The Cochrane Library, and NHS Evidence were searched for English language RCTs comparing RYGB with SG and assessed weight loss and/or comorbidity resolution at 5 years. Five studies were included in the final analysis. Meta-analysis demonstrates a significantly greater percentage excess weight loss in patients undergoing RYGB compared with SG (65.7% vs 57.3%, p < 0.0001). Resolution of diabetes was seen in 37.4% and 27.5% after RYGB and SG respectively. There was no significant difference between RYGB and SG in rates of resolution or improvement of diabetes. Similarly, HbA1C levels were not significantly different between the two procedures. Resolution of dyslipidaemia was more common after RYGB (68.6% vs 55.2%, p = 0.0443). Remission of gastro-oesophageal reflux occurred in 60.4% in the RYGB group in contrast to 25.0% in the SG group (p = 0.002). Both RYGB and SG result in sustained weight loss and comorbidity control at 5 years. RYGB resulted in greater %EWL, improved dyslipidaemia outcomes and a lower incidence of postoperative gastro-oesophageal reflux disease (GORD).
93 citations
TL;DR: Although there is general agreement that the OAGB-MGB is an effective and usually safe option for the management of patients with obesity or severe obesity, numerous areas of non-consensus remain in its use.
Abstract: One-anastomosis gastric bypass (OAGB-MGB) is currently the third performed primary bariatric surgical procedure worldwide. However, the procedure is hampered by numerous controversies and there is considerable variability in surgical technique, patient selection, and pre- and postoperative care among the surgeons performing this procedure. This paper reports the results of a modified Delphi consensus study organized by the International Federation for Surgery of Obesity and Metabolic Disorders (IFSO). Fifty-two internationally recognized bariatric experts from 28 countries convened for voting on 90 consensus statements over two rounds to identify those on which consensus could be reached. Inter-voter agreement of ≥ 70% was considered consensus, with voting participation ≥ 80% considered a robust vote. At least 70% consensus was achieved for 65 of the 90 questions (72.2% of the items), 61 during the first round of voting and an additional four in the second round. Where consensus was reached on a binary agree/disagree or yes/no item, there was agreement with the statement presented in 53 of 56 instances (94.6%). Where consensus was reached on a statement where options favorable versus unfavorable to OAGB-MGB were provided, including statements in which OAGB-MGB was compared to another procedure, the response option favorable to OAGB-MGB was selected in 13 of 23 instances (56.5%). Although there is general agreement that the OAGB-MGB is an effective and usually safe option for the management of patients with obesity or severe obesity, numerous areas of non-consensus remain in its use. Further empirical data are needed.
83 citations
TL;DR: The results indicate that identifying one single categorical definition of clinically significant weight regain is difficult and additional research is needed to inform the development of a standardized definition that includes all dimensions of surgery success: weight, HRQoL, and comorbidity remission.
Abstract: The prevalence and clinical significance of weight regain after bariatric surgery remains largely unclear due to the lack of a standardized definition of significant weight regain. The development of a clinically relevant definition of weight regain requires a better understanding of its clinical significance. To assess rates of weight regain 5 years after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), applying six definitions and investigating their association with clinical outcomes. Patients were followed up until 5 years after surgery and weight regain was calculated. Regression techniques were used to assess the association of weight regain with health-related quality of life (HRQoL) and the presence of comorbidities. A total of 868 patients participated in the study, with a mean age of 46.6 (± 10.4) years, of which 79% were female. The average preoperative BMI was 44.8 (± 5.9) kg/m2 and the total maximum weight loss was 32% (± 8%). Eighty-seven percent experienced any regain. Significant weight regain rates ranged from 16 to 37% depending on the definition. Three weight regain definitions were associated with deterioration in physical HRQoL (p < 0.05), while associations between definitions of weight regain and the presence of comorbidities 5 years after surgery were not significant. These results indicate that identifying one single categorical definition of clinically significant weight regain is difficult. Additional research into the clinical significance of weight regain is needed to inform the development of a standardized definition that includes all dimensions of surgery success: weight, HRQoL, and comorbidity remission.
75 citations
TL;DR: The following position statement is issued by the IFSO Endoscopy in Bariatric/Metabolic Surgery Taskforce, based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence.
Abstract: One of the roles of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) is to provide guidance on the management of patients seeking surgery for adiposity-based chronic diseases. The role of endoscopy around the time of endoscopy is an area of clinical controversy. In 2018, IFSO commissioned a task force to determine the role of endoscopy before and after surgery for the management of adiposity and adiposity-based chronic diseases. The following position statement is issued by the IFSO Endoscopy in Bariatric/Metabolic Surgery Taskforce. It has been approved by the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence. It will be reviewed regularly.
70 citations
TL;DR: In response to the COVID-19 pandemic outbreak, the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has issued these recommendations to the global healthcare providers aimed at keeping all patients and practice staff in an as safe an environment as possible.
Abstract: Coronavirus disease 2019 (COVID-19) emerged in Wuhan City and rapidly spread throughout China and around the world since December 2019 [1]. The World Health Organization (WHO) declared the COVID-19 outbreak a global pandemic on 11 March 2020 [2, 3]. Patients with metabolic disorders like cardiovascular diseases, diabetes and obesity may face a greater risk of infection of COVID-19 and it can also greatly affect the development and prognosis of pneumonia [1, 4–6]. In response to the COVID-19 pandemic outbreak, the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has issued these recommendations to our global healthcare providers aimed at keeping all our patients and practice staff in an as safe an environment as possible. General Recommendations
66 citations
TL;DR: In this paper, a systematic review of the literature and a standardization of phases of learning curves for Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (LSG) were provided.
Abstract: The most commonly performed bariatric procedures are laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (LSG). Impact of learning curves on operative outcome has been well shown, but the necessary learning curves have not been clearly defined. This study provides a systematic review of the literature and proposes a standardization of phases of learning curves for RYGB and LSG. A systematic literature search was performed using PubMed, Web of Science, and CENTRAL databases. All studies specifying a number or range of approaches to characterize the learning curve for RYGB and LSG were selected. A total of 28 publications related to learning curves for 27,770 performed bariatric surgeries were included. Parameters used to determine the learning curve were operative time, complications, conversions, length of stay, and blood loss. Learning curve range was 30–500 (RYGB) and 30–200 operations (LSG) according to different definitions and respective phases of learning curves. Learning phases described the number of procedures necessary to achieve predefined skill levels, such as competency, proficiency, and mastery. Definitions of learning curves for bariatric surgery are heterogeneous. Introduction of the three skill phases competency, proficiency, and mastery is proposed to provide a standardized definition using multiple outcome variables to enable better comparison in the future. These levels are reached after 30–70, 70–150, and up to 500 RYGB, and after 30–50, 60–100, and 100–200 LSG. Training curricula, previous laparoscopic experience, and high procedure volume are hallmarks for successful outcomes during the learning curve.
54 citations
TL;DR: The authors' meta-analysis indicated that bariatric surgery for severe obesity was associated with decreased cancer risk, both for cancer incidence and mortality, and further studies estimating the functional effect and side effects may eventually provide a better, comprehensive understanding.
Abstract: Weight loss after bariatric surgery yields important health benefits. A multitude of observational studies have investigated the association of bariatric surgery for severe obesity with the risk of cancer. However, the results were debatable. The aim of the present study was to estimate the effect of bariatric surgery on overall cancer risk. A systematic literature search was performed to identify studies evaluating the association of bariatric surgery for severe obesity with the risk of cancer. Meta-analysis was performed to calculate combined prevalence. Twenty-one cohort studies with 304,516 patients with obesity having under gone bariatric surgery and 8,492,408 patients with obesity as controls were included. Meta-analysis found decreased cancer risk to be associated with bariatric surgery (OR = 0.56, 95% CI = 0.48–0.66), both for the incidence of cancer (OR = 0.56, 95% CI = 0.46–0.68) and mortality of cancer (OR = 0.56, 95% CI = 0.41–0.75). In subgroup analysis, bariatric surgery was significantly associated with decreased breast cancer risk and endometrial cancer risk, but not associated with other cancer risk. Our meta-analysis indicated that bariatric surgery for severe obesity was associated with decreased cancer risk, both for cancer incidence and mortality. Moreover, further studies estimating the functional effect and side effects may eventually provide a better, comprehensive understanding.
54 citations
TL;DR: Biliary reflux although rare can complicate OAGB and RYGB is a safe and feasible technique of revision in this case, and a shorter length of the afferent limb during the initial operation facilitates the revision.
Abstract: Biliary reflux resistant to medical treatment has an incidence of 0.6–10% after one anastomosis gastric bypass (OAGB) and may be a reason for revisional surgery. The aim of this study is to report the results of a single-institution series of patients who underwent conversion from OAGB to Roux-en-Y gastric bypass (RYGB) for biliary reflux. Data of OAGB patients converted to RYGB between May 2010 and December 2017 were prospectively collected and retrospectively analyzed. The afferent limb was sectioned proximally to the gastrojejunal anastomosis. A jejuno-jejunal latero-lateral anastomosis was performed between the biliary and alimentary limb. The final RYGB had an alimentary limb of 100 cm and a biliary limb of 150 cm. During the study period, 2780 patients underwent OAGB. A total of 32 patients (1.2%) underwent conversion from OAGB to RYGB for biliary reflux, at a mean of 30.3 months from OAGB. Mean weight before RYGB was 70.6 kg, and mean body mass index BMI was 26 kg/m2. Four patients experienced postoperative complications (12.5%). Patients’ mean weight was 74.3 kg at 24 months follow-up, with BMI of 27.2 kg/m2. Conversion to RYGB relieved symptoms of biliary reflux in all patients but 2 (93.8%). Biliary reflux although rare can complicate OAGB. RYGB is a safe and feasible technique of revision in this case. A shorter length of the afferent limb during the initial operation facilitates the revision.
52 citations
TL;DR: This work focuses on the endogenous imbalance of RAAS in obesity, which appears as the main risk factor for severe forms of COVID-19 and investigates the role of angiotensin-converting enzyme (ACE) 2 in this imbalance.
Abstract: The COVID-19 pandemic is the major health crisis of our time. It bears the potential to create devastating social, economic, and political consequences in all the countries it touches. At the same time, it represents a great challenge for the entire scientific community. Indeed, the latter is currently making extraordinary efforts to increase knowledge on the severe acute respiratory syndrome coronavirus 2 (SARSCoV 2), and so helps in containing the pandemic and hopefully in eradicating it. The renin-angiotensin-aldosterone system (RAAS) has recently been put on the forefront as the angiotensin-converting enzyme (ACE) 2 is targeted by SARS-CoV 2. In parallel, obesity appears as the main risk factor for severe forms of COVID-19. The RAAS and obesity are closely related, leading to the aggravation of the disease. Here, we focus on the endogenous imbalance of RAAS in obesity. In the beginning of the pandemic, the paradox of hypertension as most common risk factor for ICU admission, intubation, and COVID-19-related death has not driven major attention [1]. Then, it has become clear that type 2 diabetes (DT2) also withstands as a risk factor. Scientist further speculated that ACE inhibitors and angiotensin II type 1 receptor (ATR1) antagonists, which are widely used in DT2 patients, could upregulate ACE 2 and consequently might account for the high prevalence of hypertension and diabetes among patients with severe disease course. However, this causative effect has not been confirmed so far [2, 3]. Shreds of evidence show that RAAS is involved in energy metabolism, food intake, inflammatory process, oxidative stress, and blood pressure control. A classic view opposes the pro-inflammatory and hypertensive angiotensin (ANG) II and ATR1 axis to the anti-inflammatory and vasodilator
51 citations
TL;DR: Race and socioeconomic factors should be considered during psychosocial evaluations to support patients at risk of surgical attrition and poorer weight loss outcomes, and qualitative work may help with understanding racial disparities in bariatric surgery.
Abstract: The purpose of this study was to examine the associations among race and socioeconomic factors (receiving social security disability, insurance type, and income) with undergoing bariatric surgery and weight loss outcomes in a racially diverse, urban cohort of bariatric surgery candidates (N = 314). Patients with private insurance and who identified as Caucasian were more likely to undergo bariatric surgery. Income significantly predicted percentage of excess weight loss 1 year after surgery, although this was no longer significant when accounting for race. Race and socioeconomic factors should be considered during psychosocial evaluations to support patients at risk of surgical attrition and poorer weight loss outcomes. Future research should explore policy solutions to improve access, while qualitative work may help with understanding racial disparities in bariatric surgery.
46 citations
TL;DR: The SASI bypass is an effective bariatric and metabolic surgery that achieved satisfactory weight loss and improvement in medical comorbidities, including T2DM, hypertension, sleep apnea, and GERD, with a low complication rate.
Abstract: Single anastomosis sleeve ileal (SASI) bypass is a newly introduced bariatric and metabolic procedure. The present multicenter study aimed to evaluate the efficacy of the SASI bypass in the treatment of patients with morbid obesity and the metabolic syndrome. This is a retrospective, seven-country, multicenter study on patients with morbid obesity who underwent the SASI bypass. Data regarding patients’ demographics, body mass index (BMI), percentage of total weight loss (%TWL), percentage of excess weight loss (%EWL), and improvement in comorbidities at 12 months postoperatively and postoperative complications were collected. Among 605 patients who underwent the SASI, 54 were excluded and 551 (390; 70.8% female) were included. At 12 months after the SASI, a significant decrease in the BMI was observed (43.2 ± 12.5 to 31.2 ± 9.7 kg/m2; p < 0.0001). The %TWL was 27.4 ± 13.4 and the %EWL was 63.9 ± 29.5. Among the 279 patients with type 2 diabetes mellitus (T2DM), complete remission was recorded in 234 (83.9%) patients and partial improvement in 43 (15.4%) patients. Eighty-six (36.1%) patients with hypertension, 104 (65%) patients with hyperlipidemia, 37 (57.8%) patients with sleep apnea, and 70 (92.1%) patients with GERD achieved remission. Fifty-six (10.1%) complications and 2 (0.3%) mortalities were recorded. Most complications were minor. All patients had 12 months follow-up. The SASI bypass is an effective bariatric and metabolic surgery that achieved satisfactory weight loss and improvement in medical comorbidities, including T2DM, hypertension, sleep apnea, and GERD, with a low complication rate.
TL;DR: The critical role of adipocyte hypertrophy in the development of metabolic disturbances is summarized and future studies are required to establish a standard criterion of size measurement to better clarify the impact of adipocyteshypertrophy on changes in metabolic homeostasis.
Abstract: Emerging evidence highlights that dysfunction of adipose tissue contributes to impaired insulin sensitivity and systemic metabolic deterioration in obese state. Of note, adipocyte hypertrophy serves as a critical event which associates closely with adipose dysfunction. An increase in cell size exacerbates hypoxia and inflammation as well as excessive collagen deposition, finally leading to metabolic dysregulation. Specific mechanisms of adipocyte hypertrophy include dysregulated differentiation and maturation of preadipocytes, enlargement of lipid droplets, and abnormal adipocyte osmolarity sensors. Also, weight loss therapies exert profound influence on adipocyte size. Here, we summarize the critical role of adipocyte hypertrophy in the development of metabolic disturbances. Future studies are required to establish a standard criterion of size measurement to better clarify the impact of adipocyte hypertrophy on changes in metabolic homeostasis.
TL;DR: One year after surgery, persistent or de novo GERD were substantially more frequent in patients treated with LSG compared with LRYGB, and LSG was the strongest predictor for GERD in the authors' trial.
Abstract: To evaluate the impact of laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) on gastroesophageal reflux disease (GERD) in patients with obesity. Patients with class II or III obesity were treated with LSG or LRYGB. Procedure choice was based on patients and surgeon preferences. GERD symptoms, endoscopy, barium swallow X-ray, esophageal manometry, and 24-h pH monitoring were obtained before and 1 year after surgery. Seventy-five patients underwent surgery (83% female, 39.3 ± 12.1 years, BMI of 41.5 ± 5.1 kg/m2): 35 (46.7%) had LSG and 40 (53.3%) LRYGB. LSG patients had lower BMI (40.3 ± 4.0 kg/m2 vs. 42.7 ± 5.7 kg/m2; p = 0.041) and trend toward lower prevalence of GERD (20% vs. 40%; p = 0.061). One year after surgeries, GERD was more frequent in LSG patients (74% vs. 25%; p < 0.001) and all LSG patients with preoperative GERD continue to have GERD postoperatively. De novo GERD occurred in 19 of 28 (67.9%) of LSG patients and 4 of 24 (16.7%) patients treated with LRYGB (OR 10.6, 95%CI 2.78–40.1). Independent predictors for post-operative GERD were as follows: LSG (OR 12.3, 95%CI 2.9–52.5), preoperative esophagitis (OR 8.5, 95% CI 1.6–44.8), and age (OR 2.0, 95%CI 1.1–3.4). One year after surgery, persistent or de novo GERD were substantially more frequent in patients treated with LSG compared with LRYGB. LSG was the strongest predictor for GERD in our trial. Preoperative counseling and choice of bariatric surgical options must include a detailed assessment and discussion of GERD-related surgical outcomes.
TL;DR: OAGB performed with a BPL of 150 cm delivers weight loss outcomes similar to that seen with aBPL of 200 cm, and there was no significant difference in albumin and haemoglobin levels in the two groups at 18-month follow-up.
Abstract: It has been suggested that shortening the biliopancreatic limb (BPL) length with one anastomosis gastric bypass (OAGB) to 150 cm would reduce the revision rates for malnutrition. But, it remains unclear if this would not compromise the efficacy of this procedure. We examined our prospectively maintained database to compare the outcomes of patients who had their OAGB performed with a 150-cm BPL with those performed with a 200-cm BPL. Medium-term weight loss data at 18–24 months was available for 343/398 (86.1% follow-up) patients. Of these, 225 had undergone OAGB-200 and 118 had undergone OAGB-150. The mean preoperative weight and body mass index were 141.6 ± 32.8 kg and 49.76 ± 8.6 kg/m2, respectively, in the OAGB-200 group compared with 133.7 ± 24.5 kg and 47.83 ± 7.2 kg/m2, respectively, in the OAGB-150 group. There was no significant difference in albumin and haemoglobin levels in the two groups at 18-month follow-up. The mean excess weight loss was 75.0% ± 20.1 in the OAGB-200 group and 74.0% ± 22.0 in the OAGB-150 group (p = 0.6714). A total of 89.7% (n = 202) patients achieved an excess weight loss (EWL) of ≥ 50.0% in the OAGB-200 group compared with 85.5% (n = 103) in the OAGB-150 group (p value = 0.4754). The mean total weight loss was 36.1% ± 9.2 in the OAGB-200 group compared with 34.0% ± 9.8 in the OAGB-150 group (p value = 0.0598). OAGB performed with a BPL of 150 cm delivers weight loss outcomes similar to that seen with a BPL of 200 cm.
TL;DR: This meta-analysis showed that LRYGB was more effective than LSG in comorbidities’ resolution or improvement in short term and for weight loss, LryGB had better long-term effects than LSg.
Abstract: To systematically and comprehensively evaluate the differences between laparoscopic Roux-en-Y gastric bypass (LRYGB) versus sleeve gastrectomy (LSG) in obese patients. A systematic literature search was performed in PubMed, EMBASE, Web of Science, and the Cochrane Library from inception to December 2018. The meta-analysis was performed by the RevMan 5.3 software. Twenty-three articles with 7443 patients were included. In short term ( 0.05). LRYGB achieved a higher EWL% than LSG (after 3 years, WMD 5.48, 0.13–10.84. P < 0.05; after 5 years, WMD 4.55, 1.04–8.05, P < 0.05) in long term, but no significant differences were found during 0.25- to 2.0-year follow-up. The rate of early and late complications was much higher in LRYGB than in LSG (early complications, OR = 2.11, 95% CI = 1.53–2.91, P < 0.001; late complications, OR = 2.60, 95% CI = 1.93–3.49, P < 0.001). This meta-analysis showed that LRYGB was more effective than LSG in comorbidities’ resolution or improvement in short term. For weight loss, LRYGB had better long-term effects than LSG. In addition, no differences were observed in the quality of life after LRYGB or LSG. LRYGB was associated with more complications than LSG.
TL;DR: A global survey on the behavioral modification towards food consumption during the third week of confinement shows that a considerable part of the population finds comfort and consolation through food consumption, which is striking as they were obtained only 3 weeks after the beginning of mass quarantine.
Abstract: The world is currently facing the COVID-19 pandemic and countries are one-by-one increasing restrictive measures on their populations. To avoid rapid transmission of the virus, governmental authorities have had to impose nationwide lockdowns. Humans were asked to be patient and stay inside their home, imposing social distancing and limiting drastically any human contact. France was not an exception, and such constrain inflicted inhabitants to change their habits, without notice, which eventually altered their perception of health risks. It would not take long to foresee the consequences of prolonged physical inactivity, social isolation, behavioral addiction, impatience, and so on [1]. While as a bariatric multidisciplinary team, we could not pursue our surgical activity in the matter, we began to be aware of the fallouts, through our teleconsultation service. To illustrate the common awareness we shared, we conducted a global survey on the behavioral modification towards food consumption during the third week of confinement. An automated questionnaire including five simple and straight-forward questions was diffused through social media in France. The population of the study was unspecific. A thousand ninety-two individuals replied to the questionnaires in no more than 7 days. Results are available in Fig. 1. More than a quarter of the respondents have currently no physical activity, corresponding to another quarter feeling that they lost control of their usual alimentation habits. Additionally, stress, feeling of emptiness, and boredom are managed with food consumption in 37.4, 36.7, and 43% of individuals, respectively. Furthermore, and more importantly, the latter three emotional eating habits show a low though significant positive correlation with lower physical activity (lowest Spearman’s Rho = 0.10, p value < 0.001) and a high positive correlation with loss of control of usual alimentation (lowest Spearman’s Rho = 0.32, p value < 0.001). Although such survey does not have the same merits of traditional scientific comparative studies, the results are striking as they were obtained only 3 weeks after the beginning of mass quarantine. From the viewpoint of the psychiatrist, it is clear that any addictions, from tobacco consumption to online shopping, would dramatically increase during such period. Quarantine and isolation lead to impatience and risk-seeking behavior that in turn have been recently found to increase the likelihood to become obese [2]. In line with those intuitions, our poll shows that a considerable part of the population finds comfort and consolation through food consumption. Doing so, we can anticipate that unhealthy dietary might settle, leading to substantial weight gain and worsening of eating disorders such as bulimia or bing-eating. Similarly, following a prolonged shelter-in-place, doctors might encounter an increase in the incidence of obesity-related comorbidities. Thus, a group of individuals require our attention now. If not, patient care might be more complex as eating disorders often come along with depression, anxiety, or even psychotic decompensation in the vulnerable ones. To provide sufficient health caregivers, authorities have logically mandated hospitals to cancel any surgical * Antonio Iannelli iannelli.a@chu-nice.fr
TL;DR: Postoperative bile reflux in the gastric pouch after OAGB is a common finding in scintigraphy and endoscopy and the long-term effects of bile exposure will be analyzed in future reports after a longer follow-up.
Abstract: Data on postoperative bile reflux after one anastomosis gastric bypass (OAGB) is lacking. Bile reflux scintigraphy (BRS) has been shown to be a reliable non-invasive tool to assess bile reflux after OAGB. We set out to study bile reflux after OAGB with BRS and endoscopy in a prospective series (RYSA Trial). Forty patients (29 women) underwent OAGB between November 2016 and December 2018. Symptoms were reported and upper gastrointestinal endoscopy (UGE) was done preoperatively. Six months after OAGB, bile reflux was assessed in UGE findings and as tracer activity found in gastric tube and esophagus in BRS (follow-up rate 95%). Twenty-six patients (68.4%) had no bile reflux in BRS. Twelve patients (31.6%) had bile reflux in the gastric pouch in BRS and one of them (2.6%) had bile reflux also in the esophagus 6 months postoperatively. Mean bile reflux activity in the gastric pouch was 5.2% (1–21%) of total activity. De novo findings suggestive of bile reflux (esophagitis, stomal ulcer, foveolar inflammation of gastric pouch) were found for 15 patients (39.5%) in postoperative UGE. BRS and UGE findings were significantly associated (P = 0.022). Eight patients experienced de novo reflux symptoms at 6 months, that were significantly associated with BRS and de novo UGE findings postoperatively (P = 0.033 and 0.0005, respectively). Postoperative bile reflux in the gastric pouch after OAGB is a common finding in scintigraphy and endoscopy. The long-term effects of bile exposure will be analyzed in future reports after a longer follow-up. Clinical Trials Identifier NCT02882685
TL;DR: Patients with previous bariatric surgery or patients planned for RYGB are at high risk to develop postoperative symptomatic gallbladder disease and there was a significant difference between the type of the bariatric procedure and the incidence of symptomatic cholecystectomy after the operation.
Abstract: Bariatric surgery predisposes patients to cholelithiasis and therefore the need of a subsequent cholecystectomy; however, the incidence of cholecystectomy after bariatric surgery is debated. Medical records of 601patients hospitalized for bariatric surgery between January 2010 and July 2018 were reviewed. Our aim was to evaluate the incidence of cholecystectomy following different types of common bariatric procedures. All patients who developed cholelithiasis and a subsequent cholecystectomy were included. Cholelithiasis was diagnosed by clinical criteria and characteristic ultrasound findings. We retrospectively evaluated 580 patients with an average follow-up of 12 months (range 6–24 months). Twenty-one patients were excluded because of missing data. Mean age was 48 ± 19 years (78% females). Twenty-nine patients (5%) underwent laparoscopic cholecystectomy (LC) before the bariatric surgery, and 58 patients (10%) performed concomitant LC with the bariatric procedure due to symptomatic gallstone disease (including stones, sludge, and polyps). There were 203 laparoscopic sleeve gastrectomy (SG) (35%), 175 laparoscopic gastric band (LAGB) (30%), 55 Roux-en-Y gastric bypass (RYGB) (9.5%), and 147 (25%) mini gastric bypass (MGB) procedures during the study period. At the follow-up period, 36 patients (6.2%) developed symptomatic cholelithiasis, while the most common clinical presentation was biliary colic. There was a significant difference between the type of the bariatric procedure and the incidence of symptomatic cholelithiasis after the operation. The incidence of symptomatic gallstone formation in patients who underwent RYGB was 14.5%. This was significantly higher comparing to 4.4% following SG, 4.1% following LAGB, and 7.5% following MGB (p = 0.04). We did not find any predictive risk factors including smoking; BMI at surgery; change in BMI; comorbidities such as diabetes, hyperlipidemia, hypertension, and COPD for gallstone formation; or a subsequent cholecystectomy. Interestingly we found that previous bariatric surgery was a risk factor for gallstone formation and cholecystectomy, 13/82 patients (15.8%) compared to 23/492 patients (4.6%) among those without previous bariatric operation (p < 0.001)]. Our data demonstrate that patients with previous bariatric surgery or patients planned for RYGB are at high risk to develop postoperative symptomatic gallbladder disease. Concomitant cholecystectomy during the bariatric procedure or alternatively UDCA treatment for at least for 6 months to avoid the high incidence of postoperative symptomatic gallstones should be considered in those asymptomatic patients.
TL;DR: RYGB is an effective therapy for patients with BE and reflux after SG and its outcomes in the current study were BE remission in the majority of cases as well as a decrease in reflux activity.
Abstract: Laparoscopic sleeve gastrectomy (SG) is the most frequently performed bariatric procedure today. While an increasing number of long-term studies report the occurrence of Barrett’s esophagus (BE) after SG, its treatment has not been studied, yet. The aim of this study was to evaluate Roux-en-Y gastric bypass (RYGB) as treatment for BE and reflux after SG. University hospital setting, Austria This multi-center study includes all patients (n = 10) that were converted to RYGB due to BE after SG in Austria. The mean interval between SG and RYGB was 42.7 months. The follow-up after RYGB in this study was 33.4 months. Gastroscopy, 24 h pH-metry, and manometry were performed and patients were asked to complete the BAROS and GIQLI questionnaires. Weight and BMI at the time of SG was 120.8 kg and 45.1 kg/m2. Eight patients (80.0%) went into remission of BE after the conversion to RYGB. Two patients had RYGB combined with hiatoplasty. The mean acid exposure time in 24 h decreased from 36.8 to 3.8% and the mean DeMeester score from 110.0 to 16.3. Patients scored 5.1 on average in the BAROS after conversion from SG to RYGB which denotes a very good outcome. RYGB is an effective therapy for patients with BE and reflux after SG. Its outcomes in the current study were BE remission in the majority of cases as well as a decrease in reflux activity. Further studies with larger cohorts are necessary to confirm these findings.
TL;DR: In patients with initial BMI > 55 kg/m2, DS obtained better BMI control at 2 years and better diabetes remission, but more long-term complications and supplementation needs, while SADI-S showed similar weight loss and comorbidity remission rates at 1 years.
Abstract: To study weight loss, comorbidity remission, complications, and nutritional deficits after duodenal switch (DS) and single-anastomosis DS with sleeve gastrectomy (SADI-S). Retrospective review of patients submitted to DS or SADI-S for morbid obesity in a single university hospital. Four hundred forty patients underwent DS (n = 259) or SADI-S (n = 181). Mean preoperative body mass index (BMI) was 50.8 ± 6.4Kg/m2. Mean follow-up was 56.1 ± 37.2 months for DS and 27.2 ± 18.9 months for SADI-S. Global mean excess weight loss was 77.4% at 2 years similar for SADI-S and DS, and 72.1% at 10 years after DS. Although early complications were similar in SADI-S and DS (13.3% vs. 18.9%, p = n.s.), long-term complications and vitamin and micronutrient deficiencies were superior after DS. Rate of comorbidities remission was 85.2% for diabetes, 63.9% for hypertension, 77.6% for dyslipidemia, and 82.1% for sleep apnea, with no differences between both techniques. In patients with initial BMI > 55 kg/m2 (n = 91), DS achieved higher percentage of BMI 55 kg/m2, DS obtained better BMI control at 2 years and better diabetes remission, but more long-term complications and supplementation needs.
TL;DR: It is suggested that One Anastomosis Gastric Bypass is superior to RYGB as a remedy for insufficient weight loss and weight regain after failed restrictive surgery with more weight Loss and a lower early complication rate.
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TL;DR: OAGB performed with a 150-cm BPL is an effective bariatric procedure, associated with good long-term outcomes in relation to weight loss, quality of life (QoL), resolution of comorbidities, and a very low rate of protein-calorie malnutrition.
Abstract: One anastomosis gastric bypass (OAGB) is now recognized as a mainstream bariatric procedure, nonetheless concerns about the risk of nutritional deficiencies and biliary reflux persist, and the ideal length of the biliopancreatic limb (BPL) is debated Data of patients who underwent OAGB between May 2010 and December 2010 were collected prospectively and analyzed retrospectively At an 8-year follow-up, a complete evaluation included clinical examination, blood tests, upper gastrointestinal endoscopy, and quality of life (QoL) assessed through the BAROS score Overall, 115 patients underwent OAGB with a BPL of 150 cm Thirty-six (31%) were lost at the 8-year follow-up Mean preoperative weight was 117 ± 208 kg and mean BMI 432 ± 58 kg/m2 At 8 years, weight was 765 ± 173 kg, BMI 283 ± 58, %TWL 348 ± 107, and %EWL 848 ± 271 No patients were readmitted for nutritional complications or underwent revisional surgery for malnutrition; 6 patients were converted to Roux-en-Y gastric bypass for intractable reflux High rates of vitamin D and A deficiencies and secondary hyperparathyroidism were found at 8 years The BAROS score was > 3 at 8 years for 93% of patients Upper gastrointestinal endoscopy was available for 46 patients and found esophagitis in 65% of cases but no cases of Barrett’s esophagus OAGB performed with a 150-cm BPL is an effective bariatric procedure, associated with good long-term outcomes in relation to weight loss, QoL, resolution of comorbidities, and a very low rate of protein-calorie malnutrition Fat-soluble vitamin deficiencies represent the main long-term concern Endoscopic findings at 8 years are reassuring
TL;DR: The current evidence base suggests that despite being effective in reducing energy intake, bariatric surgery can result in unbalanced diets, inadequate micronutrient and protein intakes, and excessive intakes of fats.
Abstract: Bariatric surgery is currently the most effective treatment for morbid obesity. These procedures change the gastrointestinal system with the aim of reducing dietary intake. Improving diet quality is essential in maintaining nutritional health and achieving long-term benefits from the surgery. The aim of this systematic review was to examine the relationship between bariatric surgery and diet quality at least 1 year after surgery. A systematic search of five databases was conducted. Studies were included that reported diet quality, eating pattern, or quality of eating in adult patients who had undergone laparoscopic-adjusted gastric banding (LAGB), Roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (SG) procedures. Data was extracted to determine the relationship between having had bariatric surgery and subsequent diet quality. A total of 34 study articles (described in 36 articles) met the inclusion criteria. The majority of studies were observational in nature and showed a reduction in energy intake following surgery, as well as inadequate intakes of micronutrients and protein, and an excessive intake of fats. There was evidence of nutrient imbalances, suboptimal compliance with multivitamin and mineral supplementation, and limited follow-up of patients. The current evidence base suggests that despite being effective in reducing energy intake, bariatric surgery can result in unbalanced diets, inadequate micronutrient and protein intakes, and excessive intakes of fats. In combination with suboptimal adherence to multivitamin and mineral supplementation, this may contribute to nutritional deficiencies and weight regain. There is a need for high-quality nutrition studies, to identify optimal dietary compositions following bariatric surgery.
TL;DR: ESG is a safe and effective procedure for primary obesity therapy with promising short- and mid-term results.
Abstract: Endoscopic sleeve gastroplasty (ESG) has emerged as a promising technique in endoscopic bariatric and metabolic therapies (EBMTs). We aimed to perform a systematic review and meta-analysis to provide an update on its efficacy and safety. This is a systematic review and meta-analysis was performed following the PRISMA guidelines. MEDLINE, Cochrane, EMBASE, and LILACS were searched to identify the studies related to ESG. Eleven studies with a total of 2170 patients were included. The average BMI pre-ESG was 35.78 kg/m2. Pooled mean %TWL observed at 6, 12, and 18 months was 15.3%, 16.1%, and 16.8% respectively. Pooled mean %EWL at 6, 12, and 18 months was 55.8%, 60%, and 73% respectively. No procedure-related mortality was reported. ESG is a safe and effective procedure for primary obesity therapy with promising short- and mid-term results.
TL;DR: D-SLEEVE is an effective restrictive procedure, which recreates a functional LES pressure able to control and/or prevent mild GERD at 1-year follow-up.
Abstract: A worrying increase of gastroesophageal reflux disease (GERD) and Barrett esophagus has been reported after sleeve gastrectomy (SG). Recent reports on combined fundoplication and SG seem to accomplish initial favorable results. However, no study included manometry or pH monitoring to evaluate the impact of fundoplication in SG on esophageal physiology. In this study, 32 consecutive bariatric patients with GERD and/or esophagitis had high-resolution impedance manometry (HRiM) and combined 24-h pH and multichannel intraluminal impedance (MII-pH) before and after laparoscopic sleeve gastrectomy associated to anterior fundoplication (D-SLEEVE). The following parameters were calculated at HRiM: lower esophageal sphincter pressure and relaxation, peristalsis, and mean total bolus transit time. The acid and non-acid GER episodes were assessed by MII-pH, symptom index association (SI), and symptom-association probability (SAP) were also analyzed. At a median follow-up of 14 months, HRiM showed an increased LES function, and MII-pH showed an excellent control of both acid exposure of the esophagus and number of reflux events. Bariatric outcomes (BMI and EWL%) were also comparable to regular SG (p = NS). D-SLEEVE is an effective restrictive procedure, which recreates a functional LES pressure able to control and/or prevent mild GERD at 1-year follow-up.
TL;DR: COVID-19 can complicate the postoperative course of patients after bariatric surgery and correct diagnosis and management in the postoperatively setting would be challenging.
Abstract: There is no data on patients with severe obesity who developed coronavirus disease 2019 (COVID-19) after bariatric surgery. Four gastric bypass operations, performed in a 2-week period between Feb 24 and March 4, 2020, in Tehran, Iran, were complicated with COVID-19. The mean age and body mass index were 46 ± 12 years and 49 ± 3 kg/m2. Patients developed their symptoms (fever, cough, dyspnea, and fatigue) 1, 2, 4, and 14 days after surgery. One patient had unnoticed anosmia 2 days before surgery. Three patients were readmitted in hospital. All 4 patients were treated with hydroxychloroquine. In two patients who required admission in intensive care unit, other off-label therapies including antiretroviral and immunosuppressive agents were also administered. All patients survived. In conclusion, COVID-19 can complicate the postoperative course of patients after bariatric surgery. Correct diagnosis and management in the postoperative setting would be challenging. Timing of infection after surgery in our series would raise the possibility of hospital transmission of COVID-19: from asymptomatic patients at the time of bariatric surgery to the healthcare workers versus acquiring the COVID-19 infection by non-infected patients in the perioperative period.
TL;DR: The meta-analysis suggested that obese patients undergoing GB had lower levels of serum calcium and 25-hydroxyvitamin D as well as higher Levels of serum phosphorus and PTH.
Abstract: Gastric bypass (GB) and sleeve gastrectomy (SG) are two common types of bariatric surgery that carry many potential complications. Among these complications, bone metabolism-related diseases have attracted substantial attention; however, no meta-analysis of them has been performed to date. We searched PubMed, Web of Science, The Cochrane Library, and Embase to identify relevant studies published before January 2019. The following indicators were evaluated: serum parathyroid hormone (PTH), calcium, phosphorus and 25-hydroxyvitamin D levels, body mass index (BMI), and bone mineral density (BMD). Thirteen studies met our inclusion criteria. Overall results showed that patients undergoing GB had lower levels of 25-hydroxyvitamin D (MD = − 1.85, 95% CI (− 3.32, − 0.39) P = 0.01) and calcium (MD = − 0.15, 95% CI (− 0.24, − 0.07) P = 0.0006) as well as higher levels of PTH (MD = 3.58, 95% CI (0.61, 7.09) P = 0.02) and phosphorus (MD = 0.22, 95% CI (0.10, 0.35) P = 0.0005). The results of BMI and BMD were comparable in each group. Our meta-analysis suggested that obese patients undergoing GB had lower levels of serum calcium and 25-hydroxyvitamin D as well as higher levels of serum phosphorus and PTH. To prevent postoperative bone metabolism-related diseases, appropriate postoperative interventions should be undertaken for particular surgical procedures.
TL;DR: ESG prevented a compensatory rise in ghrelin and promoted beneficial changes in the insulin secretory pattern with weight loss and induced gut hormone changes differently as compared to LSG.
Abstract: ESG reduces gastric lumen similar to LSG and induces significant weight loss. However, the metabolic and physiological alteration after ESG is not fully understood. We aim to study the gastrointestinal hormone changes after ESG and compared it with LSG. We conducted a prospective pilot study comparing ESG and LSG at two centers in Spain. We administered a standard test meal after an overnight fast, and collected blood samples before and after meal. We measured the levels of ghrelin, GLP-1, peptide-YY, insulin, leptin, and adiponectin. We evaluated the hormone profile and weight changes (%TBWL) at baseline and at 6 months after the procedure. Twenty-four patients were recruited (ESG-12, LSG-12). The baseline age, sex, BMI, and fasting hormone levels were similar between the groups. At 6-month post-ESG, there was a significant decline in the leptin levels. We found a trend towards a decrease in insulin levels and improvement in insulin secretory pattern. We did not observe any change in fasting ghrelin levels, GLP-1, and PYY. At 6 months, LSG induced a significant reduction in the ghrelin, and leptin levels, and increase in peptide-YY, and adiponectin levels, respectively. A trend towards an increase in GLP-1 level was noted. However, no change in insulin was observed. LSG achieved greater %TBWL (24.4 vs. 13.3, p < 0.001) and significantly change in ghrelin, PYY, and adiponectin levels at 6 months compared to ESG. ESG induced gut hormone changes differently as compared to LSG. ESG prevented a compensatory rise in ghrelin and promoted beneficial changes in the insulin secretory pattern with weight loss.
TL;DR: Among this cohort of morbid obese bariatric patients, the clinical effects of heterozygous mutations in POMC and PCSK1 do not interfere with the effectiveness of most commonly performed bariatric procedures within the first 2 years of follow-up.
Abstract: Mutations in the leptin-melanocortin pathway genes are known to cause monogenic obesity. The prevalence of these gene mutations and their effect on weight loss response after bariatric surgery are still largely unknown. To determine the prevalence of genetic obesity in a large bariatric cohort and evaluate their response to bariatric surgery. Mutation analysis of 52 obesity-associated genes. Patient inclusion criteria were a BMI > 50 kg/m2, an indication for revisional surgery or an early onset of obesity (< 10 years of age). A total of 1014 patients were included, of whom 30 (3%) were diagnosed with genetic obesity, caused by pathogenic heterozygous mutations in either MC4R, POMC, PCSK1, SIM1, or PTEN. The percentage total body weight loss (%TBWL) after Roux-en-Y gastric bypass (RYGB) surgery was not significantly different for patients with a mutation in MC4R, POMC, and PCSK1 compared with patients lacking a molecular diagnosis. Of the confirmed genetic obesity cases, only patients with MC4R mutations receiving a sleeve gastrectomy (SG) showed significantly lower %TBWL compared with patients lacking a molecular diagnosis, during 2 years of follow-up. In this cohort of morbid obese bariatric patients, an estimated prevalence of monogenic obesity of 3% is reported. Among these patients, the clinical effects of heterozygous mutations in POMC and PCSK1 do not interfere with the effectiveness of most commonly performed bariatric procedures within the first 2 years of follow-up. Patients with MC4R mutations achieved superior weight loss after primary RYGB compared with SG.
TL;DR: EGJ disruption as indicated by increased (more obtuse) esophagogastric insertion angle and small gastric capacity were associated with the risk of GERD after LSG, and LSG has multiple effects on the EGJ and stomach that facilitate reflux.
Abstract: The incidence of de novo gastroesophageal reflux disease (GERD) after LSG is substantial. However, an objective correlation with the structural gastric and EGJ changes has not been demonstrated yet. We aimed to prospectively evaluate the effects of laparoscopic sleeve gastrectomy (LSG) on the structure and function of the esophagogastric junction (EGJ) and stomach. Investigations were performed before and after > 50% reduction in excess body weight (6–12 months after LSG). Subjects with GERD at baseline were excluded. Magnetic Resonance Imaging (MRI), high-resolution manometry (HRM), and ambulatory pH-impedance measurements were used to assess the structure and function of the EGJ and stomach before and after LSG. From 35 patients screened, 23 (66%) completed the study (age 36 ± 10 years, BMI 42 ± 5 kg/m2). Mean excess weight loss was 59 ± 18% after 7.1 ± 1.7-month follow-up. Esophageal acid exposure (2.4 (1.5–3.2) to 5.1 (2.8–7.3); p = 0.040 (normal 80% reduction in gastric capacity (TGV) had the highest prevalence of symptomatic GERD. LSG has multiple effects on the EGJ and stomach that facilitate reflux. In particular, EGJ disruption as indicated by increased (more obtuse) esophagogastric insertion angle and small gastric capacity were associated with the risk of GERD after LSG.
: NCT01980420