Bariatric Surgery and Endoluminal Procedures: IFSO Worldwide Survey 2014

Association of Bariatric Surgery With Risk of Fracture in Patients With Severe Obesity

IMPORTANCE

Given the complex relationship between body mass index, body composition, and bone density and the correlative nature of the studies that have established the prevailing notion that higher body mass indices may be protective against osteopenia and osteoporosis and, therefore, fracture, the absolute risk of fracture in patients with severe obesity who undergo either Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) compared with those who do not undergo bariatric surgery is unknown.

OBJECTIVE

To assess the rates of fractures associated with obesity and compare rates between those who do not undergo bariatric surgery, those who undergo RYGB, and those who undergo SG.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective multicenter cohort study of Medicare Standard Analytic Files derived from Medicare parts A and B records from January 2004 to December 2014, patients classified as eligible for bariatric surgery using the US Centers of Medicare & Medicaid criteria who either did not undergo bariatric surgery or underwent RYGB or SG were exactly matched in a 1:1 fashion based on their age, sex, Elixhauser Comorbidity Index, hypertension, smoking status, nonalcoholic fatty liver disease, hyperlipidemia, type 2 diabetes, osteoporosis, osteoarthritis, and obstructive sleep apnea status. Data were analyzed from November to December 2019.

EXPOSURES

RYGB or SG.

MAIN OUTCOMES AND MEASURES

The primary outcome measured in this study was the odds of fracture overall based on exposure to bariatric surgery. Secondary outcomes included the odds of type of fracture (humerus, radius or ulna, pelvis, hip, vertebrae, and total fractures) based on exposure to bariatric surgery.

RESULTS

A total of 49 113 patients were included and were equally made up of 16 371 bariatric surgery-eligible patients who did not undergo weight loss surgery, 16 371 patients who had undergone RYGB, and 16 371 patients who had undergone SG. Each group consisted of an equal number of 4109 men (25.1%) and 12 262 women (74.9%) and had an equal distribution of ages, with 11 780 patients (72.0%) 64 years or younger, 4230 (25.8%) aged 65 to 69 years, 346 (2.1%) aged 70 to 74 years, and 15 (0.1%) aged 75 to 79 years. Patients undergoing RYGB were found to have no significant difference in odds of fractures compared with bariatric surgery-eligible patients who did not undergo surgery. Patients undergoing undergone SG were found to have decreased odds of fractures of the humerus (odds ratio [OR], 0.57; 95% CI, 0.45-0.73), radius or ulna (OR, 0.38; 95% CI, 0.25-0.58), hip (OR, 0.49; 95% CI, 0.33-0.74), pelvis (OR, 0.34; 95% CI, 0.18-0.64), vertebrae (OR, 0.60; 95% CI, 0.48-0.74), or fractures in general (OR, 0.53; 95% CI, 0.46-0.62). Compared with patients undergoing SG, patients undergoing RYGB had a significantly greater risk of total fractures (OR, 1.79; 95% CI, 1.55-2.06) and humeral fractures (OR, 1.60; 95% CI, 1.24-2.07).

CONCLUSIONS AND RELEVANCE

In this cohort study, bariatric surgery was associated with a reduced risk of fracture in bariatric surgery-eligible patients. Sleeve gastrectomy might be the best option for weight loss in patients in which fractures could be a concern, as RYGB may be associated with an increased fracture risk compared with SG.

The Skeletal Consequences of Bariatric Surgery

PURPOSE OF REVIEW

This review outlines the recent findings regarding the impact of bariatric surgery on bone. It explores potential mechanisms for skeletal changes following bariatric surgery and strategies for management.

RECENT FINDINGS

Bone loss following bariatric surgery is multifactorial. Probable mechanisms include skeletal unloading, abnormalities in calciotropic hormones, and changes in gut hormones. Skeletal changes that occur after bariatric surgery are specific to procedure type and persist for several years post-operatively. Studies suggest that while bone loss begins early, fracture risk may be increased later in the post-operative course, particularly after Roux-en-Y gastric bypass (RYGB). Further research is needed to assess the extent to which skeletal changes following bariatric surgery result in fragility. Current management should be geared toward prevention of bone loss, correction of nutritional deficiencies, and incorporation of weight bearing exercise. Pharmacologic treatment should be considered for high-risk patients.

Diabetes Remission Rate after Sleeve Gastrectomy or Roux-en-Y Gastric Bypass; Utilizing Individualized Metabolic Surgery Score for Korean Patients

Purpose

The purpose of this study is to evaluate the usefulness of individualized metabolic surgery score for Korean patients in determining bariatric surgical procedures.

Materials and Methods

A total of 135 patients with type 2 diabetes mellitus who underwent sleeve gastrectomy (n=19) or Roux-en-Y gastric bypass (n=116) at our institute with a 1-year follow up were analyzed for the predictive power of diabetes remission using the individualized metabolic surgery scoring system.

Results

At the postoperative follow-up of 1 year, the remission of type 2 diabetes mellitus (HbA_1C<6.5%, off medications) was achieved in 88 (65.2%) patients. The remission rates showed no significant differences between patients who underwent sleeve gastrectomy and Roux-en-Y gastric bypass (63.2% versus 65.5%; P=0.84), regardless of the severity of type 2 diabetes mellitus. Although there was no statistically significant difference in the remission rate according to the bariatric surgery procedures (P>0.99 in mild, P=0.11 in moderate, P>0.99 in severe IMS score), remission rates were higher in moderate severity patients who underwent Roux-en-Y gastric bypass than in those who underwent sleeve gastrectomy (69.7% versus 37.5%).

Conclusion

The remission rates after bariatric surgery procedures were similar to that of the previously reported study. Despite the limitations of our data, the individualized metabolic surgery score can be used as a complement to other scoring systems in Korean patients.

Comparison of New Era's Education Platforms, YouTube® and WebSurg®, in Sleeve Gastrectomy

INTRODUCTION

The Internet is a widely used resource for obtaining medical information. However, the quality of information on online platforms is still debated. Our goal in this quality-controlled WebSurg® and YouTube®-based study was to compare these two online video platforms in terms of the accuracy and quality of information about sleeve gastrectomy videos.

METHODS

Most viewed (popular) videos returned by YouTube® search engine in response to the keyword "sleeve gastrectomy" were included in the study. The educational accuracy and quality of the videos were evaluated according to known scoring systems. A novel scoring system measured technical quality. The ten most viewed (popular) videos in WebSurg® in response to the keyword "sleeve gastrectomy" were compared with ten YouTube® videos with the highest educational/technical scores.

RESULTS

Scoring systems measuring the educational accuracy and quality of WebSurg® videos were significantly higher than ten YouTube® videos which have the most top technical scores (p < 0.05), and no significant difference was found in the assessment of ten YouTube® videos that have the highest technical ratings compared with WebSurg® videos (p 0.481).

CONCLUSIONS

WebSurg® videos, which were passed through a reviewing process and were mostly prepared by academicians, remained below the expected quality. The main limitation of WebSurg® and YouTube® is the lack of information on preoperative and postoperative processes.

A Systematic Review and Meta-Analysis of the Effect of Roux-en-Y Gastric Bypass on Barrett's Esophagus

BACKGROUND

Obesity is associated with a twofold risk of gastroesophageal reflux disease (GERD) and thrice the risk of Barrett's esophagus (BE). Roux-en-Y gastric bypass (RYGB) leads to weight loss and improvement of GERD in population with obesity, but its effect on BE is less clear.

METHODS

Bibliographic databases were searched systematically for relevant articles till January 31, 2019. Studies evaluating the effect of RYGB on BE with preoperative and postoperative endoscopy and biopsy were included. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) tool. Meta-analysis was conducted using Mantel-Haenszel, random effects model and presented as risk difference (RD) or odds ratio (OR) with 95% confidence intervals.

RESULTS

Eight studies with 10,779 patients undergoing RYGB reported on 117 patients with BE with follow-up of > 1 year. Significant regression of BE after RYGB was observed (RD - 0.56.95% c.i. - 0.69 to - 0.43; P < 0.001). Subgroup analysis showed regression of both short-segment BE [ssBE] (RD - 0.51.95% c.i. - 0.68 to - 0.33; P < 0.001) and long-segment BE [lsBE] (RD - 0.46.95% c.i. - 0.71 to - 0.21; P < 0.001). RYGB also caused improvement in GERD in patients of BE (RD - 0.93, 95% c.i. - 1.04 to - 0.81; P < 0.001). RYGB was strongly associated with regression of BE compared with progression (OR 31.2.95% c.i. 11.37 to 85.63; P < 0.001).

CONCLUSIONS

RYGB leads to significant improvement of BE at > 1 year after surgery in terms of regression and resolution of the associated GERD. Both ssBE and lsBE improve after RYGB significantly.

Obesity Phenotypes, Diabetes, and Cardiovascular Diseases

This review addresses the interplay between obesity, type 2 diabetes mellitus, and cardiovascular diseases. It is proposed that obesity, generally defined by an excess of body fat causing prejudice to health, can no longer be evaluated solely by the body mass index (expressed in kg/m²) because it represents a heterogeneous entity. For instance, several cardiometabolic imaging studies have shown that some individuals who have a normal weight or who are overweight are at high risk if they have an excess of visceral adipose tissue-a condition often accompanied by accumulation of fat in normally lean tissues (ectopic fat deposition in liver, heart, skeletal muscle, etc). On the other hand, individuals who are overweight or obese can nevertheless be at much lower risk than expected when faced with excess energy intake if they have the ability to expand their subcutaneous adipose tissue mass, particularly in the gluteal-femoral area. Hence, excessive amounts of visceral adipose tissue and of ectopic fat largely define the cardiovascular disease risk of overweight and moderate obesity. There is also a rapidly expanding subgroup of patients characterized by a high accumulation of body fat (severe obesity). Severe obesity is characterized by specific additional cardiovascular health issues that should receive attention. Because of the difficulties of normalizing body fat content in patients with severe obesity, more aggressive treatments have been studied in this subgroup of individuals such as obesity surgery, also referred to as metabolic surgery. On the basis of the above, we propose that we should refer to obesities rather than obesity.

Randomized Controlled Trial of One Anastomosis Gastric Bypass Versus Roux-En-Y Gastric Bypass for Obesity: Comparison of the YOMEGA and Taiwan Studies

BACKGROUND

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).

METHODS

Data from the Y-study and the T-study were collected and compared.

RESULTS

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.

CONCLUSIONS

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.

Sleeve gastrectomy as a rescue of failed gastric banding: comparison of 1- and 2-step approaches

BACKGROUND

Series comparing gastric banding (GB) removal and sleeve gastrectomy (SG) when procedures are performed as a 1- or a 2-step approach are contradictory in their outcomes. No series comparing these approaches with midterm weight loss is available.

OBJECTIVES

Compare the outcomes and weight loss of SG performed as 1- and 2-step approaches as a revisional procedure for GB failure.

SETTING

University Hospital, France, public practice.

METHODS

Between February 2006 and January 2017, all patients undergoing SG with a previous history of implementation of GB (n = 358) were included in this 2-center, retrospective, observational study. Revisional surgery was proposed in patients with insufficient excess weight loss (excess weight loss ≤50%) or weight regain after GB. A 1-step (1-step group, n = 270) or 2-step (2-step group, n = 88) approach was decided depending on patient's choice and/or surgeon's preference. The primary efficacy endpoint was the comparison of weight loss in the 1- and 2-step groups at the 2-year follow-up. The secondary efficacy endpoints were short-term outcomes (overall mortality and morbidity at postoperative day 30, specific morbidity, reoperation, length of hospital stay, and readmission).

RESULTS

In the 1-step group, the mean preoperative body mass index before SG was 40.5 kg/m² (27.0-69.0), while in the 2-step group, the mean preoperative body mass index was 43.5 kg/m² (31.5-61.7). Mean operating time was 109 minutes (50-240) in the 1-step group and 78.7 minutes (40-175) in the 2-step group (P = .22). In the 1-step group, 6 conversions to laparotomy occurred, while in the 2-step group, 2 conversions to laparotomy occurred (P = .75). One death (.2%, in the 2-step group) and 39 complications (30 in the 1-step group [11.1%] and 9 in the 2-step group [10.2%]) also occurred. The mean length of hospital stay was 6.2 days in the 1-step group and 4.1 days in the 2-step group. At 2-year follow-up, mean body mass index was 32.4 kg/m² in the 1-step group and 33.2 kg/m² in the 2-step group (P = .15), representing excess weight losses of 61.9 and 50.1 (P = .05), respectively. The rates of revisional surgery were .7% and 2.2%, respectively.

CONCLUSIONS

SG after previous GB is efficient with similar outcomes depending on the 1- or 2-step approach. The 1-step approach seems to have increased weight loss compared with the 2-step approach.

Clinical Outcomes of Sleeve Gastrectomy Versus Roux-En-Y Gastric Bypass After Failed Adjustable Gastric Banding

BACKGROUND

Over recent decades, laparoscopic adjustable gastric banding (LAGB) has been among the most common bariatric surgeries. Nowadays, many patients require revision surgery due to insufficient weight loss and band-related complications. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the two most common revision surgeries for failed LAGB, but the conclusions about their efficacy and safety have been inconsistent. This meta-analysis aimed to review the clinical outcomes of SG and RYGB after failed LAGB.

METHODS

In accordance with the PRISMA guidelines, the PubMed, Embase, Scopus, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were systematically searched for articles that had studied the efficacy and safety of SG and RYGB. The most appropriate effects model was chosen based on the heterogeneity of the articles included in this meta-analysis. Statistical analysis was conducted using Stata 14.0.

RESULTS

Of 586 articles that were retrieved, 16 articles which examined 2141 SG and 2990 RYGB patients met the inclusion criteria. The patients in RYGB groups showed increased percent excess weight loss (%EWL) at 12 and 24 months after revision surgery but no statistically significant change was found about %EWL after 3, 6, or 36 months. In addition, RYGB was associated with a higher rate of complications, interventions, and readmission in addition to being of more operative time.

CONCLUSIONS

This review suggested that RYGB was more effective at demonstrating weight loss after 12 and 24 months, but comparisons of the long-term efficacy of RYGB with that of SG remain inconclusive. In addition, RYGB was accompanied by a greater number of post-operative complications, interventions, and readmissions. Thus, surgeons should consider the overall status of the patients and their comorbidities as crucial factors when selecting a form of revision surgery. Additional high-quality randomized controlled studies are required to further compare the efficacy and safety of these treatments with longer follow-up times.

Reduced-Port Sleeve Gastrectomy for Morbidly Obese Japanese Patients: a Retrospective Case-Matched Study

BACKGROUND

Reduced-port laparoscopic surgery remains controversial due to technical challenges that can lead to suboptimal outcomes, and data pertaining to operative and clinical outcomes of reduced-port sleeve gastrectomy (RPSG) vs. conventional laparoscopic sleeve gastrectomy (CLSG) are lacking.

AIMS

This retrospective case-matched study aimed to compare midterm (2-year) outcomes of RPSG and of CLSG.

METHODS

Patients included in the study had undergone laparoscopic bariatric surgery at our center between 2010 and 2017. Thirty-one consecutive female patients who underwent RPSG were compared to a sex-, age-, body mass index-matched group of 31 patients who underwent CLSG. Outcomes were evaluated and compared between groups.

RESULTS

Estimated blood loss volume, incidences of intraoperative and postoperative complications, and length of postoperative hospital stay did not differ significantly between the 2 groups. Operation time was significantly greater in the RPSG group than in the CLSG group (148.7 ± 22.6 vs. 120.2 ± 25.9 min, respectively; p < 0.001). Excess weight loss at 1 year was 105.9% and 109.7%, respectively (p = 0.94) and at 2 years was 101.1% and 105.3%, respectively (p = 0.64). One RPSG patient required placement of additional trocars because of bleeding from short gastric vessels, but conversion to open surgery was not required.

CONCLUSIONS

RPSG is feasible in carefully selected bariatric patients and results in midterm outcomes comparable to those observed after CLSG. Good cosmesis is a potential benefit of RPSG.

Midterm Outcomes of Gastric Pouch Resizing for Weight Regain After Roux-en-Y Gastric Bypass

PURPOSE

Resizing of the gastric pouch, with eventually resizing of the gastrojejunal anastomosis, has been proposed as revisional procedure to treat weight regain after Roux-en-Y gastric bypass (RYGB), in patients with large gastric pouch and/or large gastrojejunal (GJ) anastomosis. The aim of this study is to determine the midterm results and the safety of laparoscopic resizing of the gastric pouch after RYGB in cases where gastric pouch is > 200 ml and/or GJ anastomosis > 20 mm.

MATERIALS AND METHODS

All patients who underwent gastric pouch resizing between January 2009 and December 2016 were retrospectively reviewed from a prospective database. The gastric pouch was resized to a volume of 30-40 ml.

RESULTS

A total of 48 patients had gastric pouch resizing after RYGB. The mean initial BMI was 42.9 ± 4.8 kg/m². Perioperative morbidity was 8.3% in this series. Mean follow-up was 5.4 years. The mean BMI was 30.0 ± 7.3 kg/m² at 1 year, 30.0 ± 6.0 kg/m² at 3 years, and 30.9 ± 5.7 kg/m² at 5 years. Mean %EBMIL at 1-, 3-, and 5-year follow-up was 51.9%, 55.1%, and 39%, respectively, in 48% follow-up rate. The obesity-related comorbidities disappeared in 67.3% of cases at maximum follow-up.

CONCLUSIONS

In carefully selected patients with gastric pouch size > 200 ml and/or GJ anastomosis > 20 mm, and after extensive preoperative evaluation, gastric pouch resizing is a potentially effective option to treat weight regain due to anatomical factors after RYGB, with complication rate of 8%.

Food Tolerance After Laparoscopic Sleeve Gastrectomy with Total Antral Resection

BACKGROUND

Among the controversial points in laparoscopic sleeve gastrectomy (LSG) is how much of the antrum to be resected. This study aimed to evaluate food tolerance after preservation or resection of the antrum during LSG.

METHODS

Prospective randomized study included 50 patients scheduled for LSG. Participants were randomly allocated into one of two groups. In antral resection (AR-LSG) group (n = 25), resection started 2 cm from the pylorus. In antral sparing (AS-LSG) group (n = 25), it started 6 cm from the pylorus. Percentage of excess weight loss (%EWL) and percentage of excess BMI loss (%EBL) were evaluated after 3 and 6 months. Quality of life (QOL) was evaluated by using the Bariatric Analysis and Reporting Outcome System (BAROS). Food tolerance was assessed using the Quality of Alimentation questionnaire. Primary outcome measure was food tolerance and %EWL.

RESULTS

Food tolerance was significantly better in the antral sparing group compared to the antral resection group after 3 and 6 months. The two groups were comparable in %EWL and BMI change after 3 and 6 months. Six months after surgery, the majority of patients had a very good quality of life, with no significant difference between the two groups (p = 0.877). There was no significant difference between the two groups in operative time, intraoperative blood loss, and hospital stay.

CONCLUSIONS

Preservation of the pyloric antrum during LSG is associated with significantly better food tolerance and comparable effect of weight loss up to 6 months postoperatively when compared with total antral resection.

Bone Metabolism in Adolescents and Adults Undergoing Roux-En-Y Gastric Bypass: a Comparative Study

OBJECTIVE

To compare the bone metabolism of adolescents and adults with obesity before undergoing a Roux-en-Y gastric bypass (RYGB) and 6 and 12 months after the surgery.

MATERIALS AND METHODS

Adolescents (G1) and adults (G2) with obesity assessed before (T0), six (T1), and 12 months after (T2) RYGB. Sun exposure, serum concentrations of 25(OH)D, calcium, phosphorous, magnesium, zinc, alkaline phosphatase, parathyroid hormone (PTH), and bone mineral density (BMD) were evaluated.

RESULTS

Sixty adolescents and 60 adults were assessed. At T0, there was no significant difference between the groups' serum 25(OH)D levels (G1 21.87 + 7.52 ng/mL, G2 21.73 + 7.60 ng/mL, p = 0.94) or sun exposure (G1 17 ± 2.0 min/day, G2 13.2 ± 5.2 min/day, p = 0.85). G1 had high levels of inadequacy of calcium (66.7%), phosphorous (80.0%), and zinc (18.3%) at T0 and had a significant fall in their 25(OH)D (p < 0.01) and magnesium (p < 0.01) levels from T1 to T2. G2 saw a significant lowering of their serum zinc levels from T0 to T1 and T2 (T1 p < 0.01; T2 p < 0.01). In both groups, there was a significant rise in PTH from T1 to T2 (G1 p = 0.04, G2 p = 0.02) and from T0 to T2 (G1 and G2 p < 0.01). In G2, 40.4% of individuals with osteopenia and osteoporosis presented inadequacy of 25(OH)D.

CONCLUSION

RYGB was found to worsen the inadequacy of micronutrients related to bone metabolism and was associated with secondary hyperparathyroidism and low BMD values, especially among the adolescents. The irreversible damaging effects of obesity on bone metabolism can occur in adolescence.

Standardization of Bariatric Metabolic Procedures: World Consensus Meeting Statement

BACKGROUND

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.

METHODS

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.

RESULTS

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 (88.0%) 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.

CONCLUSIONS

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.

Effect of Roux-en-Y gastric bypass on the bioavailability of metoprolol from immediate and controlled release tablets: a single oral dose study before and after surgery

Objective

Roux-en-Y gastric bypass (RYGB) surgery induces major changes in the gastrointestinal tract that may alter the pharmacokinetics of orally administered drugs. Results from pharmacokinetic studies are sparse. This study aimed to investigate the effect of RYGB on the bioavailability of metoprolol from immediate release (IR) and controlled release (CR) tablets in female patient volunteers before and after surgery.

Methods

An explorative, two-phase, single oral dose pharmacokinetic study of metoprolol in female patients undergoing RYGB was carried out. The dose was administered twice in each patient, 1 month before and 6 months after surgery. After intake of either 100 mg of metoprolol IR or CR tablet serum concentration-time profiles of metoprolol were determined. The endpoint was the ratio of AUC_after/AUC_before of metoprolol.

Results

Twelve patients were included in the study (metoprolol IR: 7; metoprolol CR: 5). After intake of a metoprolol IR tablet major intraindividual and interindividual differences for area under the serum concentration versus time curve (AUC) of metoprolol before and after surgery were observed (range ratio AUC_{0-10 hours after}/AUC_{0-10 hours before}: 0.74-1.98). For metoprolol CR tablets a significant reduction in bioavailability of metoprolol was observed after surgery (range ratio AUC_{0-24 hours after}/AUC_{0-24 hours before}: 0.43-0.77).

Conclusion

RYGB may influence the bioavailability of metoprolol from an IR tablet. The magnitude of changes in bioavailability after RYGB requires close monitoring of patients using metoprolol IR tablets and dose adjustment if deemed necessary. RYGB clearly reduces the bioavailability of metoprolol from a CR tablet. After RYGB clinicians may consider to increase the dose according to clinical response.

Five-Year Outcomes with Stand-alone Primary Sleeve Gastrectomy

PURPOSE

Sleeve gastrectomy is now the commonest bariatric procedure worldwide, making it important to determine 5-year weight loss and micronutrient deficiency outcomes following primary, stand-alone sleeve gastrectomy (SG) with adequate follow-up. The purpose of this study was to evaluate weight loss, co-morbidity resolution, and haematological outcomes at 5 years with primary, stand-alone SG in our unit.

MATERIALS AND METHODS

Baseline data were obtained from our prospectively maintained database and patients were invited for a 5-year follow-up. For those who could not attend, further information was obtained by telephoning them and contacting their general practitioners.

RESULTS

A total of 92 patients (66 females) underwent primary SG at our centre in 2011. The median age was 46.0 years. The median weight and the body mass index (BMI) were 133.0 kg and 47.0 kg/m² respectively. After 5 years, 7 (7.6%) patients had died due to unrelated causes and 11 (12.0%) had been converted to Roux-en-Y gastric bypass (RYGB). Of the remaining 74, we were able to obtain follow-up data on 64 (86.5%). Despite all efforts, 10 (13.5%) patients were lost to follow-up. The median total weight loss was 21.9% and median excess weight loss (EWL) was 48.0%. Patients developed a range of micronutrient deficiencies over the follow-up period.

CONCLUSION

This study shows acceptable results with SG at 5 years in our unit, but a large number of patients experienced GORD and some patients needed additional micronutrient supplementation over and above our unit recommendation of a single multivitamin/mineral A-Z tablet daily.

Educational Video Addition to the Bariatric Surgery Informed Consent Process: a Randomized Controlled Trial

OBJECTIVE

Bariatric surgery is not a risk-free procedure and requires lifelong patient compliance in the postoperative period. Although the risks involved in bariatric surgery and the importance of lifelong follow-ups in the postoperative period are explained to patients in detail through verbal and written informed consent, the strong desire for weight loss can sometimes cause patients and their families to be ignorant of the mentioned issues preoperatively. The objective of this study is to evaluate the effectiveness of preoperative informational videos at improving the comprehension of informed consent content in bariatric surgery candidates.

MATERIALS AND METHODS

A total of 74 bariatric surgery candidates were randomized into two groups. The first group was given a usual verbal-written informed consent. The second group got an additional informing video presentation informed consent, in addition to the usual verbal-written informed consent. Then, both groups got a questionnaire evaluating their knowledge of bariatric surgery informed consent. The correct response scores and their relationship with patient demographics were analyzed.

RESULTS

Both groups had similar demographic features. Video-presented group had higher scores in questionnaire (11.3 ± 2.3 versus 9.4 ± 1.7, p = 0.001). Subgroup analysis showed that health care workers (12.5 ± 1.9 versus 10.3 ± 2.2, p = 0.005) and university graduates (11.6 ± 2.4 versus 10.1 ± 2.1, p = 0.03) got better results in the questionnaire. In multivariate analysis, video-assisted informing was found to be the only independent variable for high questionnaire scores (p = 0.0001).

CONCLUSIONS

This study showed that video-assisted informed consent improves patients' comprehension prior to bariatric surgery. We recommend routine preoperative video-assisted informing for bariatric surgery candidates in addition to usual verbal-written informed consent.

Bariatric Surgery Offer in Brazil: a Macroeconomic Analysis of the Health system's Inequalities

BACKGROUND

Brazil currently holds the second place in the worldwide ranking of the largest number of bariatric surgical procedures performed. The offer of bariatric surgery in the public health system is not sufficient for its demand; it remains to be determined whether the recent economic downturn affected this offer.

OBJECTIVE

To analyze the proportion of bariatric surgeries performed by the public system in Brazil and assess the influence of macroeconomic variables over time.

METHODS

This is a nationwide analysis which correlated the estimated number of bariatric surgeries in Brazil in both public and private health-providing systems from 2003 through 2017 with the main macroeconomic variables of Brazil during the evaluated period (gross domestic product [GDP], inflation rate, and unemployment rate), and both overall and public healthcare expenditures.

RESULTS

The proportion of surgeries performed in the public system varied from 7.1% in 2014 to 10.4% in 2004. There was a significant positive correlation between the public proportion of surgeries with the unemployment rate (R = 0.55666; P = 0.03868). There were significant negative correlations between the proportion of public surgeries with the public health expenditure per capita (R = - 0.88811; P = 0.00011) and with the public percentage of healthcare expenditure per capita (R = - 0.67133; P = 0.01683).

CONCLUSION

There were direct correlations between the number of public bariatric procedures and the unemployment rate, as well as with the public healthcare expenditure per capita. Despite the increase in the number of public procedures, its proportion reveals an insufficiency of the current offer of bariatric surgery provided by the public system.

Bariatric Surgery Significantly Improves the Quality of Sexual Life and Self-esteem in Morbidly Obese Women

BACKGROUND

The impact of bariatric surgery (BS) on the sexual functioning of patients is poorly studied. Our aim was to analyze the sexual function, depressive symptoms, and self-esteem of morbidly obese women (MOW) undergoing BS.

PATIENTS AND METHODS

Quality of sexual life was prospectively evaluated in 43 consecutive MOW (18-50 years) who underwent BS. Female sexual function index (FSFI), Beck depression inventory (BDI), and Rosenberg self-esteem scale (RSES) questionnaires were administered to evaluate sexual satisfaction, depressive symptoms, and self-esteem, respectively. A control group of 36 healthy, non-obese, female patients (HW) was recruited for comparison. Results of questionnaires were compared between three periods (before BS and at 3- and 6-month follow-up) and between MOW and HW.

RESULTS

Before BS, the FSFI score was significantly lower in MOW compared to HW (17 ± 12 vs 27 ± 8, p = 0.0001) while at 3- and 6-month post-BS, a significant amelioration (p = 0.01) occurred. In particular, after BS, all components of the FSFI score (sexual desire, excitement, lubrification, orgasm, satisfaction, and pain) were ameliorated. The pre-BS BDI score was higher in MOW than in HW (8 ± 6 vs 5 ± 5, p = 0.004) while at postoperative months 3 and 6, a significant amelioration was found (p = 0.025 and 0.005, respectively). Before BS, no significant differences occurred in the RSES score between MOW and HW (30 ± 7 vs 32 ± 6, p = 0.014), whereas the MOW RSES scores at 6-month post-BS were improved when compared with the HW RSES scores.

CONCLUSIONS

BS results in a significant improvement in the quality of sexual life, depressive symptoms, and self-esteem in MOW.

Weight Regain After Bariatric Surgery-A Multicentre Study of 9617 Patients from Indian Bariatric Surgery Outcome Reporting Group

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Bone Health in Patients with Type 2 Diabetes Treated by Roux-En-Y Gastric Bypass and the Role of Diabetes Remission

BACKGROUND

Roux-en-Y gastric bypass (RYGB) has been associated with negative effects on bone. Whether this association is affected by pre-surgical type 2 diabetes (T2D) and surgically induced diabetes remission is unknown.

METHODS

In this cross-sectional, matched cohort study 6 years after RYGB, we investigated bone health in 96 individuals with body mass index (BMI) > 35 kg/m² and T2D (stratified on current diabetes status) treated by RYGB 6 years earlier compared with 49 non-operated individuals with T2D matched with respect to sex, age, and current BMI. Main outcome measures were areal and volumetric bone mineral density (aBMD and vBMD), bone turnover, and odds ratio of osteoporosis/osteopenia.

RESULTS

The RYGB group had lower hip (0.916 vs 1.010 g/cm², p < 0.001), forearm (0.497 g/cm² vs 0.554 g/cm², p < 0.001) aBMD, (269.63 mg/cm³ vs 306.07 mg/cm³, p < 0.001) tibial, and radial (238.57 mg/cm³ vs 278.14 mg/cm³, p < 0.0001) vBMD than the control group. Relative to the control group, c-terminal cross-linked telopeptide, procollagen type I amino-terminal propeptide, and osteocalcin were 75%, 41%, and 72% higher in the RYGB group, respectively (all p < 0.001). Odds ratio for osteopenia/osteoporosis in operated individuals was 2.21 (95% CI 1.06; 4.79, p = 0.05). Overall, stratified analysis on current diabetes status did not alter these outcomes.

CONCLUSIONS

Individuals with T2D treated by RYGB, compared to individuals with T2D of similar age and body composition not treated by RYGB, have lower BMD, lower bone strength, and increased levels of several bone turnover markers. Bone health was not associated with current diabetes status in the RYGB group.

Closure versus non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass: a systematic review and meta-analysis

BACKGROUND

The comparative evidence regarding the outcomes of closure versus non-closure of mesenteric defects in laparoscopic Roux-en-Y gastric bypass (LRYGB) is poorly understood. We aimed to compare the outcomes of closure versus non-closure of mesenteric defects in LRYGB for morbid obesity.

METHODS

We conducted a search of electronic information sources to identify all comparative studies investigating the outcomes of closure versus non-closure of mesenteric defects in patients undergoing LRYGB for morbid obesity. We used the Cochrane risk of bias tool and the ROBINS-I tool to assess the risk of bias of RCTs and observational studies, respectively. Random or fixed effects modelling was applied as appropriate.

RESULTS

We included 10,031 patients from six observational studies and 2609 patients from two RCTs. Analysis of observational studies showed closure defects resulted in lower risks of internal hernia (OR 0.28, 95% CI 0.15, 0.54) and reoperation for small bowel obstruction (SBO) (OR 0.30, 95% CI 0.10, 0.83); no difference was found between the two groups in terms of SBO not related to internal hernia (OR 1.19, 95% CI 0.47, 2.99), early SBO (OR 0.74, 95% CI 0.04, 14.38), anastomotic leak (OR 0.84, 95% CI 0.45, 1.57), bleeding (OR 1.08, 95% CI 0.62, 1.89), and anastomotic ulcer (OR 2.08, 95% CI 0.62, 6.94). Analysis of RCTs showed closure of defects resulted in lower risks of internal hernia (OR 0.29, 95% CI 0.19,0.45) and reoperation for SBO (OR 0.51, 95% CI 0.38, 0.69) but higher risks of SBO not related to internal hernia (OR 1.90, 95% CI 1.09, 3.34) and early SBO (OR 2.63, 95% CI 1.16, 5.96); no difference was found between the two groups in terms of anastomotic leak (OR 1.95, 95% CI 0.80, 4.72), bleeding (OR 0.67, 95% CI 0.38, 1.17), and anastomotic ulcer (OR 2.08, 95% CI 0.62, 6.94).

CONCLUSIONS

Our results suggest that closure of mesenteric defects in LRYGB may be associated with lower risks of internal herniation and reoperation for SBO compared with non-closure of the defects (moderate certainty). The available evidence is inconclusive regarding the risks of SBO not related to internal hernia and early SBO (low certainty). More RCTs are needed to improve the robustness of the available evidence.

Multidisciplinary Management of Leaks After One-Anastomosis Gastric Bypass in a Single-Center Series of 2780 Consecutive Patients

PURPOSE

Few data exist in the literature concerning leaks after one-anastomosis gastric bypass (OAGB). Our aim was to describe the incidence, presentation, and management of leaks after OAGB.

SETTING

A private clinic in France.

METHODS

Between May 2010 and December 2017, 2780 consecutive patients underwent OAGB. A retrospective chart review was performed on the 46 patients (1.7%) who experienced postoperative leaks.

RESULTS

Leaks arose from the anastomosis in 6 cases (13%) and from the gastric pouch in 27 cases (59%), while the remaining 13 patients (28%) had leaks from an undetermined origin. Management followed a standardized algorithm taking into consideration the clinical situation and findings on an oral contrast computed tomography (CT) scan. All patients were treated by fasting, total parenteral nutrition, and antimicrobial therapy. Nine patients (20%) could be managed by medical treatment only, 13 patients (28%) underwent laparoscopic management (washout and drainage plus T-tube placement in 5 cases or conversion to Roux-en-Y gastric bypass (RYGB) in one case). The remaining 23 patients (50%) were managed by percutaneous drainage and/or endoscopy. No mortality was observed; the major morbidity rate was 20%. The median length of a hospital stay was 17 days (5-80).

CONCLUSION

Management of leaks after OAGB depends on clinical conditions and presence, size, and location of an abscess and/or a fistula. If endoscopy and interventional radiology are available, reoperation can be avoided in most patients. In most leaks at the gastrojejunal anastomosis, inserting a T-tube in the leak orifice avoids the necessity for conversion to RYGB.

Feasibility and safety of robot-assisted bariatric conversions and revisions

BACKGROUND

Conversions and revisions after bariatric procedures are inevitable and associated with longer operative time and higher complication rates. Because robot-assisted procedures allow better dissection, robotic conversions and revisions may be more beneficial to the patients than laparoscopic ones.

OBJECTIVES

This study aimed to compare the feasibility and safety of robot-assisted conversions and revisions to laparoscopic procedures.

SETTING

Academic Hospital, United States.

METHODS

A retrospective chart review was performed on 94 consecutive patients who underwent a bariatric conversion or revision (revision of gastrojejunostomy, conversions of vertical sleeve gastrectomy to Roux-en-Y gastric bypass, adjustable gastric banding to sleeve gastrectomy, Roux-en-Y gastric bypass to sleeve gastrectomy, adjustable gastric banding to Roux-en-Y gastric bypass, Roux-en-Y gastric bypass to duodenal switch, and adjustable gastric banding to duodenal switch) between January 1, 2017, and February 28, 2019. Of these, 30 underwent a robot-assisted conversion or revision.

RESULTS

Patients who underwent a robot-assisted approach were more likely to be older (45.4-versus 38.8-yr old) and lighter (44.6 versus 50.3 kg/m²) than patients who underwent a laparoscopic approach. The mean operative time was longer in the robot-assisted group (155.5 min) than in the laparoscopic group (113.3 min). No difference was observed between the 2 groups in the mean length of hospital stay, 30-day readmission rate, or 30-day reoperation rate. Results were similar when the baseline difference in age and body mass index were accounted for.

CONCLUSIONS

Robot-assisted conversions and revisions were as feasible and safe as laparoscopic procedures. However, operative time was longer in robot-assisted conversions.

Long Non-Coding RNA (lncRNA) SNHG5 Participates in Vertical Sleeve Gastrectomy for Type II Diabetes Mellitus by Regulating TGR5

BACKGROUND Due to its remarkable effect in controlling glycometabolism, relatively simple operation, and low risk of complications, sleeve gastrectomy (SG) has become the preferred surgical treatment for type II diabetes mellitus. Increased blood glucose in the body can cause damage to functional cells. MATERIAL AND METHODS Long non-coding RNA SNHG5 expression and TGR5 in serum were analyzed by real-time PCR. A diabetic cell model was established by culturing normal human intestinal epithelial cells NCM460 and DLD-1 with high-glucose and high-fat medium. CCK-8 assay, TUNEL assay, and flow cytometry were used to assess cell growth and apoptosis, respectively. The secretion of lactate dehydrogenase (LDH) was detected using the LDH Cytotoxicity Kit. lncRNA SNHG5 was downregulated by siRNA. The changes in expression of SNHG5, TGR5, Akt, p65, and Bcl-2 were analyzed by real-time PCR assay or Western blot. RESULTS In 40 type II diabetes patients who underwent sleeve gastrectomy, the expression of SNHG5 decreased and the expression of TGR5 increased compared with that before the operation. After high-glucose and high-fat culture, cell growth was inhibited and cell apoptosis increased significantly. The expression of SNHG5 was increased and TGR5 was decreased with high-glucose and high-fat culture. However, high glucose and high fat showed an opposite trend for cell growth, apoptosis, and LDH release under inhibition of SNHG5. The expression levels of TGR5 and Akt, p65, and Bcl-2 were also returned to normal by SNHG5 inhibition. CONCLUSIONS By downregulating expression of the SNHG5 gene and then altering expression of the TGR5 gene, the damage to colorectal cells induced by high glucose was alleviated. This may be one of the mechanisms underlying the effect of sleeve gastric surgery in treatment of diabetes mellitus.

Cholelithiasis After Sleeve Gastrectomy and Effectiveness of Ursodeoxycholic Acid Treatment

Aim: Few adverse effects may occur after bariatric surgery, one being the formation of gallstones. The aim of this study is to determine the incidence of cholelithiasis after laparoscopic sleeve gastrectomy (LSG) and whether ursodeoxycholic acid (UDCA) treatment reduces gallstone formation. Materials and Methods: Gall bladders of all patients planned for LSG were preoperatively checked by ultrasonography (USG). Patients who had no documented gallbladder pathology before LSG and who had USG at 12th month and 2 years follow-up after LSG were included in the study. The incidences of newly developed cholelithiasis, cholecystectomy, and endoscopic retrograde cholangiopancreatography (ERCP) requirement in patients who did not receive any UDCA treatment (pre-2015 protocol, n = 128) was compared with the corresponding numbers in patients who regularly used 500 mg/day oral UDCA for 6 months after the LSG (post-2015 protocol, n = 152). Results: Between January 2012 and October 2018, 717 LSGs were performed in two centers and after exclusions, 280 patients were eligible for evaluation. Sixty-four of 280 (23%) patients developed cholelithiasis after LSG and cholecystectomy was performed in 24 patients (8.6%) for symptomatic cholelithiasis. In the non-UDCA group, 48 patients developed cholelithiasis (n = 48/128, 37.5%) compared with 16 patients in the UDCA group (n = 16/152, 10.5%) (P < .001). Compared with 5 patients in the UDCA group, 19 patients underwent cholecystectomy (39.6%) in the non-UDCA group due to symptomatic cholelithiasis (P = .55) and 5 of these patients also required an ERCP. No ERCP became necessary in the UDCA group (P = .2). Conclusions: An almost fourfold decrease in the rate of new gall stone formation with 500 mg daily UDCA treatment was impressive and may suggest routine UDCA treatment after LSG. Given the rate of exclusions and follow-up differences among the groups, certainly, randomized trials, with less exclusion are needed to provide conclusive evidence.

Metabolic Effects of Sleeve Gastrectomy with Transit Bipartition in Obese Females with Type 2 Diabetes Mellitus: Results After 1-Year Follow-up

PURPOSE

To present the early metabolic effects of sleeve gastrectomy with transit bipartition (SG + TB) procedure in female obese patients with type 2 diabetes mellitus (T2DM).

METHODS

This prospective clinical study was carried out between January 2016 and June 2017. Inclusion criteria were female participants under 60 years old with T2DM, body mass index ≥ 40 kg/m² and HbA1c level ≥ 8%. All patients underwent to SG + TB procedure. Primary outcomes were the glycemic control variables, and the secondary outcomes were weight loss and dyslipidemia levels up to the last follow-up point.

RESULTS

A total of 35 female participants with an average age of 48.8 ± 6.0 years old and a mean preoperative BMI of 42.0 ± 1.3 kg/m² were included during the study period. Diabetic remission was achieved in 88.6% of patients (n = 31) on the third month without any antidiabetic medications. The mean postoperative BMI of patients was 24.8 ± 1.6 kg/m², and dyslipidemia levels were significiantly lower at the last follow-up point of all patients.

CONCLUSIONS

SG + TB procedure may be a potent therapeutic option for the treatment of obese patients with T2DM.

Farnesoid X receptor contributes to body weight-independent improvements in glycemic control after Roux-en-Y gastric bypass surgery in diet-induced obese mice

Objective

Roux-en-Y gastric bypass surgery (RYGB) can achieve long-term remission of type 2 diabetes. However, the specific molecular mechanism through which this occurs has remained largely elusive. Bile acid signaling through the nuclear hormone receptor farnesoid X receptor (FXR) exerts beneficial effects after sleeve gastrectomy (VSG), which has similar effects to RYGB. Therefore, we investigated whether FXR signaling is necessary to mediate glycemic control after RYGB.

Methods

RYGB or sham surgery was performed in high-fat diet-induced obese FXR−/− (knockout) and FXR+/+ (wild type) littermates. Sham-operated mice were fed ad libitum (S-AL) or by weight matching (S-WM) to RYGB mice via caloric restriction. Body weight, body composition, food intake, energy expenditure, glucose tolerance tests, insulin tolerance tests, and homeostatic model assessment of insulin resistance were performed.

Results

RYGB surgery decreases body weight and fat mass in WT and FXR-KO mice. RYGB surgery has similar effects on food intake and energy expenditure independent of genotype. In addition, body weight-independent improvements in glucose control were attenuated in FXR −/− relative to FXR +/+ mice after RYGB. Furthermore, pharmacologic blockade of the glucagon-like peptide-1 receptor (GLP-1R) blunts the glucoregulatory effects of RYGB in FXR +/+ but not in FXR −/− mice at 4 weeks after surgery.

Conclusions

These results suggest that FXR signaling is not required for the weight loss up to 16 weeks after RYGB. Although most of the improvements in glucose homeostasis are secondary to RYGB-induced weight loss in wild type mice, FXR signaling contributes to glycemic control after RYGB in a body weight-independent manner, which might be mediated by an FXR-GLP-1 axis during the early postoperative period.

•

The reduction in body weight after RYGB is independent of FXR, which is mainly due to a decrease in net energy intake.

•

RYGB prevents the weight loss-induced decrease observed in nonsurgical weight-matched mice in both genotypes.

•

FXR signaling contributes to glycemic control after RYGB in a body weight-independent manner.

•

The early body weight-independent improvements in glucose homeostasis after RYGB might be mediated by an FXR-GLP-1 axis.

Health-related quality of life after sleeve gastrectomy equal to Roux-en-Y gastric bypass patients?

PURPOSE

Sleeve gastrectomy (SG) is the most popular type of bariatric surgery. It has often been compared to Roux-en-Y gastric bypass (RYGB) in terms of clinical outcomes. However, health-related quality of life (HRQoL) has been sparsely studied after SG. The goal was to study HRQoL after SG using a generic (RAND-36) and an obesity-specific (impact of weight on quality of life-lite, IWQOL-lite) questionnaire and to compare the results with RYGB.

METHODS

HRQoL and weight were measured before and 9, 15, and 24 months after surgery. RAND-36 physical health summary (PHS) and mental health summary (MHS), and IWQOL-lite total score were calculated. A mixed model analysis was conducted to study the change in HRQoL and compare SG with RYGB.

RESULTS

A total of 219 patients (8.7%) underwent a SG and 2309 patients (91.3%) a RYGB. PHS, MHS, and IWQOL-lite significantly improved after SG when comparing baseline to all follow-up moments (p < 0.001 in all). There were no significant differences when comparing SG with RYGB: change in PHS (β - 0.10, 95% CI - 1.24 to 1.04, p = 0.861), MHS (β - 0.51, 95% CI - 1.56 to 0.52, p = 0.330), and IWQOL-lite (β 0.310, 95% CI - 0.85 to 1.47, p = 0.601).

CONCLUSION

HRQoL significantly improved after SG. In the included populations, weight loss was comparable and the extent to which HRQoL improved did not differ between SG and RYGB, when measured with the RAND-36 or IWQOL-lite. This might be partly caused by the fact that these questionnaires do not assess specific bariatric HRQoL and/or complaints.

Outcomes of laparoscopic sleeve gastrectomy by means of esophageal manometry and pH-metry, before and after surgery

INTRODUCTION

Gastroesophageal reflux is a major problem after sleeve gastrectomy. There is still insufficient understanding of how it occurs and whether it is due to the sphincter length, relaxation, or pressure differences.

AIM

This study evaluates the effect on the lower esophageal sphincter of the laparoscopic sleeve gastrectomy (LSG) technique applied in surgery in cases of morbid obesity using ambulatory 24-h pH monitoring (APM) and esophageal manometry (EM).

MATERIAL AND METHODS

A retrospective examination was carried out on the APM and EM tests performed preoperatively and postoperatively in cases of LSG. The parameters examined were the body mass index (BMI), amplitude pressure of the esophagus (AP), total length of the lower esophageal segment (LESL), resting pressure of the LES (LESP), residual pressure of the LES (LESR), relaxation time of the LES, intragastric pressure, and the DeMeester score.

RESULTS

A total of 62 cases with available data were evaluated. A statistically significant difference was determined between the preoperative values and the 3-month postoperative values of BMI, LESP, and relaxation time of the LES. A statistically significant increase was determined in the DeMeester score, and the increase in the total number of reflux episodes longer than 5 min was found to be the most responsible for this increase. No significant difference was determined in the other parameters.

CONCLUSIONS

The LSG was found to cause a reduction in LESP, and an increase in acid reflux causing an extended relaxation time of the LES. This was confirmed by the increase seen in the DeMeester score.

Cardiovascular risk reduction following metabolic and bariatric surgery

Cardiovascular disease (CVD) is the world’s leading cause of mortality and obesity is a well-recognized risk factor of CVD. Early detection and management of CVD is critical to reduce CVD risk. Especially in patients suffering from obesity with obesity-related CVD risk factors such as hypertension (HTN), dyslipidemia, and diabetes mellitus (DM). A substantial and sustained decrease in body weight after metabolic and bariatric surgery is associated with a significant reduction of cardiovascular risk factors. This article reviews CVD risk models, mechanisms of CVD risk associated with obesity, and overall CVD risk reduction between different metabolic and bariatric procedures.

Comparative risk of fracture for bariatric procedures in patients with obesity: A systematic review and Bayesian network meta-analysis

OBJECTIVE

Bariatric surgery (malabsorptive [i.e., biliopancreatic diversion, BPD], restrictive [i.e., sleeve gastrectomy, SG; adjustable gastric banding, AGB] and mixed [i.e., gastric bypass, GB] procedures) has been reported to be associated with an increased risk of fracture; however, which procedure poses the greatest risk of fracture is still controversial. The aim of the current meta-analysis was to investigate the degree of fracture risk after different bariatric procedures.

MATERIAL AND METHODS

Electronic databases, including Medline/PubMed, EMBASE and Cochrane library, were systematically searched from inception to July 11, 2019 with no language restrictions to retrieve randomized controlled trials (RCTs) or cohort studies evaluating the impact of any kind of bariatric surgery on postoperative fractures in patients with obesity. Pairwise meta-analysis and Bayesian network meta-analysis were performed to pool the outcome estimates of interest, including fracture incidence and fracture risk. The values of the surface under the cumulative ranking (SUCRA) probability for fracture risk were calculated and sorted according to the different surgical procedures.

RESULTS

A total of twelve studies published between 2010 and 2019, comprising 159,916 participants with obesity were identified for the analysis. The incidence of fracture increased from 3% (95% confidence interval [CI] 2-4%) in patients with non-surgical intervention (drug treatment, alteration in life style and diet control) to 5% (95% CI 4-7%) in those who had undergone bariatric surgery (pooled relative risk [RR] = 1.41 95% CI: 1.22-1.63). Network meta-analysis revealed that based on the SUCRA ranking of the different surgical procedures, the malabsorptive procedure had the highest possibility of increased fracture risk in patients with obesity (74.75%), followed by the mixed procedures (73.85%), nonsurgical intervention (43.55%) and the restrictive procedure (7.85%); for different surgery types. The BPD group had the highest possibility of increased fracture risk (99.49%), followed by the GB (74.92%), nonsurgical intervention (44.49%), AGB (26.64%) and SG (4.45%) groups.

CONCLUSIONS

Significant differences exist among different bariatric surgeries impacting on fracture risk. The malabsorptive and mixed procedures, but not the restrictive procedure, increase the postoperative risk of fracture. Considering the weight-reduction effects and fracture risk, the sleeve gastrectomy procedure may be the best choice for patients with obesity, especially those who are susceptible to osteoporosis.

Is Roux-en-Y gastric bypass advantageous?-surgical outcomes in obese patients with type-2 diabetes after gastric bypass versus sleeve gastrectomy, a matched retrospective study

Background

There are few comparative studies of the clinical outcomes after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). The aim of the study was to compare diabetes- and metabolic disorder-related outcomes following RYGB and SG, based on data for matched participants.

Methods

This was a retrospective matched study using data from 2011–2018. Patients with type-2 diabetes undergoing RYGB (n=35) were matched with up to 2 RYGB participants (n=56) regarding age, sex, body mass index, hemoglobin A1c level, medication use, diabetes duration, and blood pressure.

Results

All surgeries were performed laparoscopically without complications or malnutrition during 24 months of follow-up. Both surgical procedures achieved excellent diabetes remission and weight loss. RYGB was associated with a significantly higher diabetes medication discontinuation rate 24 months postoperatively (RYGB: 87.5% vs. SG: 68.6%; P<0.05), better reduction in serum cholesterol and low-density lipoprotein-c levels, as well as better diabetes control compared with SG. The incidence of microvascular and macrovascular complications showed no significant difference between two groups.

Conclusions

In this matched retrospective study, although RYGB and SG were both excellent surgeries for treating obesity in patients with type-2 diabetes, RYGB was associated with better results compared with SG regarding dyslipidemia remission and metabolic disorder-related medication reduction.

Impact of bariatric surgery on cancer risk reduction

Obesity is second only to tobacco as a preventable cause of cancer in the US. By multifactorial and often additive mechanisms, obesity leads to the development and promotion of 40% of the cancers diagnosed in this country, including post-menopausal breast, endometrial, colorectal, kidney, liver and pancreatic cancers, among others. Though prevention of obesity should be the ultimate goal of thoughtful and effective healthcare practices, it remains a highly prevalent condition, and morbid obesity (BMI ≥40 Kg/m²) can be refractory to lifestyle interventions in many cases. Currently bariatric surgery is an effective treatment strategy for individuals who suffer from morbid obesity or obesity with associated co-morbidities and fail to lose weight under a medically supervised diet and exercise program. The current review addresses seminal studies that have investigated the potential cancer prevention effects of bariatric surgery, demonstrating a positive impact mostly in post-menopausal breast and endometrial cancers. The controversial association between bariatric surgery and increased colorectal cancer (CRC) risk is also recognized and discussed. Finally, while bariatric surgery should not be routinely recommended as a cancer prevention strategy, it has the potential to decrease the risk for certain types of cancers as a collateral beneficial effect.

How many sleeve gastrectomies are done at nonaccredited centers in Texas?

BACKGROUND

The American College of Surgeons created the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) to improve the safety of surgery and track outcomes of patients undergoing metabolic and bariatric surgery. The MBSAQIP captures all surgical procedures performed at accredited centers (AC) but not all metabolic and bariatric surgery cases performed in the United States. Texas has a large statewide administrative database that tracks nearly all surgical procedures performed in the state and we proposed using this database to assess the number of sleeve gastrectomies (SG) and whether they were performed at an AC or not.

OBJECTIVE

Our objective was to determine the percentage of SG that are performed in MBSAQIP ACs.

SETTING

University surgical department, United States.

METHODS

The Texas Inpatient and Outpatient Public Use Data Files (PUDF) for the year 2017 were examined. We used the Current Procedural Terminology and International Classification of Diseases version 10 codes for SG, 43775 and 0 DB64 Z3, respectively. We compared the PUDF facility list to a list of MBSAQIP ACs in Texas.

RESULTS

There were 4549 SG performed in Texas in 2017 reported in the Outpatient PUDF. Of these, 80.8% of cases were performed at ACs. Of the 136 facilities in the outpatient PUDF performing SG, 58 were MBSAQIP accredited. In the Inpatient PUDF for 2017 there were 11,287 SG, of which 9829 (87%) were performed at ACs. Of 153 centers performing SG, 77 were MBSAQIP accredited. There was a higher percentage of adjustable band conversions to SG at non-ACs in the Outpatient PUDF than the Inpatient PUDF.

CONCLUSION

The MBSAQIP database is missing almost 20% of outpatient SG performed in Texas and 13% of inpatient SG. Administrative databases can be used to externally validate the MBSAQIP.

Predictors of suicidal ideation one-year post-bariatric surgery: Results from the Toronto Bari-Psych Cohort Study

OBJECTIVE

Previous studies have shown higher rates of death by suicide, suicide attempts, suicidal ideation and non-suicidal self-directed violence (NS-SDV) in bariatric surgery patients.

METHODS

Data came from the Toronto Bari-Psych Cohort study of adult patients who underwent bariatric surgery between 2010 and 2016. The MINI International Neuropsychiatric Interview was used to obtain lifetime psychodiagnostic data. Information about lifetime suicidal ideation, suicide attempts, NS-SDV and hospitalizations related to any of these phenomena was collected during clinical interview. Pre-surgery sociodemographic data, lifetime psychiatric disorders, mental health symptoms, mental health treatment, suicidal ideation and surgical complications were covariates. Logistic regression analyses were used to examine the relationship between these variables and suicidal ideation one-year post-surgery.

RESULTS

Among a total of 284 participants, 4.2% reported a past suicide attempt and 15.1% reported past suicidal ideation. One-year post-surgery, no suicide attempts were reported. In the multivariate regression model, a history of suicidal ideation was the strongest predictor of suicidal ideation one-year post-surgery (p < 0.01), followed by younger age (p = 0.05). Mental health symptoms decreased from pre to post-surgery.

CONCLUSION

One-year post-surgery, a history of suicidal ideation was the strongest predictor of post-surgery suicidal ideation. Results should be interpreted with caution given the short duration of follow-up.

Quality of Life and Gastrointestinal Symptoms Following Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy: a Systematic Review

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the most common bariatric operations performed worldwide. Quality of life (QoL) is a crucial outcome metric. An electronic systematic search using PubMed, EMBASE, and Web of Science of studies comparing QoL after LSG and LRYGB was performed. QoL after both LSG and LRYGB considerably improves regardless the type of surgery. The QoL has a slight downward trend from the second to the fifth year postoperatively, but it remains higher than the baseline. LSG patients are more likely to suffer from gastroesophageal symptoms (GES). GES represent the only significant difference between the two procedures. A routine screening with gastroscopy and 24 h pH metry to help tailor the most appropriate surgical approach is advised.

Usefulness of Abdominal Drain in Laparoscopic Roux-en-Y Gastric Bypass: A Randomized Controlled Trial

Background: Laparoscopic Roux-en-Y gastric bypass (RYGB) is one of the most common procedures to treat morbid obesity. Abdominal drains are often placed during the operation to detect complications earlier. The aim of this study was to assess the benefit of routine drain placement during laparoscopic RYGB. Materials and Methods: A consecutive series of patients undergoing laparoscopic RYGB between 2017 and 2018 was analyzed. The sample was randomized before the procedure into two groups: with abdominal drain (G1) and without abdominal drain placement (G2). Patients with intraoperative complications were excluded from the randomization. Postoperative complications and pain (visual analogue scale) were compared between groups. Results: A total of 84 patients were included; 45 belonged to G1 and 39 to G2. Mean age (G1 44 years versus G2 48 years) and body mass index (G1 43 kg/m² versus G2 44 kg/m²) were similar in both groups. There were no significant differences between groups in preoperative comorbidities. Mean operative time was 92 minutes in both groups. Mean pain score at postoperative day 0 was similar in both groups (G1 3.2 versus G2 3.5, P = .58), but was higher in G1 at postoperative day 1 (G1 3.1, G2 1.1, P = .02). Postoperative Clavien-Dindo I-II complications were similar in both groups (G1 9% versus G2 1%, P = .37). No major complications, reoperations, or 30-day mortality occurred in the entire cohort. Conclusions: Drain placement in laparoscopic RYGB was associated with greater postoperative pain and did not show benefits in early detection of postoperative complications. Routine placement of abdominal drain in laparoscopic RYGB might not be recommended.

Safety and efficacy of laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass: A systematic review and meta-analysis

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are widely performed to cure obesity and obesity-related diseases. Our aim was to compare these two procedures.

MATERIALS AND METHODS

An electronic literature search was performed from inception to December 2018. The clinical outcomes between LSG and LRYGB were pooled using software RevMan5.3.

RESULTS

A total of 1076 patients from 11 studies were analysed. LSG had shorter operation time (mean difference [MD] = -33.81; 95% confidence interval [CI], -46.04 to -21.57; P < .00001) and less early complications rate (risk ratio [RR] = 0.55; 95% CI, 0.36-0.84; P = .005) compared with LRYGB. There were no significant difference about the readmission rate (RR = 0.57; 95% CI, 0.21-1.54; P = .27) and re-operation rate (RR = 0.43; 95% CI, 0.14-1.27; P = .13) between LSG and LRYGB. The conversion to open rate and mortality rate within 30 days was low in both LSG and LRYGB. Mean hospital stay in LSG group (0.3-5.2 d) seems shorter than that in the LRYGB group (2.3-6.6 d). As to the effect of LSG and LRYGB on the percentage of excess weight loss (EWL), there was no significant difference between these two surgeries in EWL (MD = -4.05; 95% CI, -8.89 to 0.80; P = .10). LSG was equal to LRYGB on remission of T2DM (RR = 0.94; 95% CI, 0.84-1.06; P = .31).

CONCLUSIONS

Both LSG and LRYGB can be performed with very low conversion to open rate and mortality rate. The readmission rate and re-operation rate are comparable between these two surgeries. The efficacy of these two surgeries on EWL and T2DM is equivalent, but LSG has an advantage over LRYGB in operation time and early complications rate.

Surgical strategy for gastroesophageal reflux disease in patients with obesity

Gastroesophageal reflux disease (GERD) and obesity have become serious problems affecting global health. The surgical treatment strategy for GERD patients with obesity is still a difficult point. In particular, obesity exacerbates the occurrence of GERD, and simple anti-reflux surgery has limited efficacy in obese patients. Currently, bariatric surgery is a good choice for the treatment of such patients, and Roux-en-Y gastric bypass is the best choice. Revisional surgery remains to be standardized for serious complications in postoperative patients. In addition, the new anti-reflux bariatric surgery that has been emerging in recent years is expected to be an effective alternative treatment for GERD patients with obesity.

Measuring quality of life in bariatric surgery: a multicentre study

BACKGROUND

Current studies mainly focus on total weight loss and comorbidity reduction. Only a few studies compare Quality of Life (QoL) after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). This study was conducted to examine the extent of improvement in QoL on different domains after primary bariatric surgery and compare these results to Dutch reference values.

METHODS

The study included prospectively collected data from patients who underwent primary bariatric surgery in five Dutch hospitals. The RAND-36 questionnaire was used to measure the patient's QoL; preoperatively and twelve months postoperatively. Postoperative scores were compared to Dutch reference values, standardized for age, using t-test. A difference of more than 5% was considered a minimal important difference. A multivariate linear regression analysis was used to compare SG and RYGB on the extent of improvement, adjusted for case-mix factors.

RESULTS

In total, 4864 patients completed both the pre- and postoperative questionnaire. Compared with Dutch reference values, patients postoperatively reported clinically relevant better physical functioning (RYGB + 6.8%), physical role limitations (SG + 5.6%; RYGB + 6.2%) and health change (SG + 77.1%; RYGB + 80.0%), but worse general health perception (SG - 22.8%; RYGB - 17.0%). Improvement in QoL was similar between SG and RYGB, except for physical functioning (β 2.758; p-value 0.008) and general health perception (β 2.607; p-value < 0.001) for which RYGB patients improved more.

CONCLUSIONS

SG and RYGB patients achieved a better postoperative score in physical functioning, physical role limitations and health change compared to Dutch reference values, and a worse score in general health perception.

Morbid obesity and dyslipidaemia: The impact of bariatric surgery

Obesity prevalence has presented an exponential increase in the last decades, becoming a first order public health issue. Dyslipidemia of obesity, characterized by low levels of high density lipoprotein (HDL) cholesterol, hypertriglyceridemia and small and dense low-density lipoprotein (LDL) particles, is partly responsible for the high residual cardiovascular risk of this clinical situation. On the other hand, bariatric surgery (BS) is the most effective treatment for obesity, obtaining a greater weight loss than achieved with conventional medical therapy and favoring the improvement or remission of associated comorbidities. The most commonly used BS techniques nowadays are laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). Both of these procedures have obtained similar results in terms of weight loss and comorbidity remission such as type2 diabetes mellitus or hypertension. A differential feature between both techniques could be the different impact on the lipoprotein profile. In this respect, previous studies with short and mid-term follow-up have proved LRYGB to be superior to LSG in total and LDL cholesterol reduction. Results regarding triglycerides and HDL cholesterol are contradictory. Therefore, we consider of interest to review the effects of BS at short and mid-term follow-up on lipoprotein profile, as well as the remission rates of the different lipid abnormalities and the possible related factors.