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Loo JH, Chue KM, Lim CH, Toh BC, Kariyawasam GMD, Ong LWL, Tan JTH, Wong WK, Yeung BPM. Effectiveness of sleeve gastrectomy plus fundoplication versus sleeve gastrectomy alone for treatment of patients with severe obesity: a systematic review and meta-analysis. Surg Obes Relat Dis 2024; 20:532-543. [PMID: 38302307 DOI: 10.1016/j.soard.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 10/31/2023] [Accepted: 12/06/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (SG) is a widely performed bariatric surgery, but it is associated with an increased risk of gastroesophageal reflux (GERD) in the long term. The addition of fundoplication to laparoscopic SG may improve lower oesophageal sphincter function and reduce postoperative GERD. OBJECTIVES This systematic review and meta-analysis aims to compare the efficacy and safety of SG plus fundoplication (SG + F) versus SG alone for the treatment of patients with severe obesity (≥35 kg/m2). SETTING Meta-analysis. METHODS Three electronic databases were searched from inception until January 2023. Studies were included if they compared outcomes of SG + F versus SG in patients with severe obesity (≥35 kg/m2). The primary outcome was remission of GERD postoperatively. Secondary outcomes were the percentage of excess weight loss, percentage of total weight loss, postoperative complication rate, operative time, and length of stay. RESULTS A total of 5 studies with 539 subjects (212 SG + F and 327 SG alone) were included. The mean preoperative body mass index was 42.6 kg/m2. SG + F achieved higher remission of GERD compared with laparoscopic SG (odds ratio [OR] = 13.13; 95% CI, 3.54-48.73; I2 = 0%). However, the percentage of total weight loss was lower in the SG + F group (mean difference [MD] = -2.75, 95% CI, -4.28 to -1.23; I2 = 0%), whereas there was no difference in the percentage of excess weight loss (MD = -0.64; 95% CI, -20.62-19.34; I2 = 83%). There were higher postoperative complications in SG + F (OR = 2.56; 95% CI, 1.12-5.87; I2 = 0%) as well. There was no difference in operative time or length of stay between the 2 groups. CONCLUSION SG + F achieved better GERD remission but is associated with lesser weight loss and increased postoperative complications compared with SG alone. Further studies are required to ascertain the overall clinical benefit of SG + F for patients with severe obesity.
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Affiliation(s)
- Jing Hong Loo
- Yong Loo Lin School of Medicine, National University of Singapore, Republic of Singapore
| | - Koy Min Chue
- Upper Gastrointestinal and Bariatric Surgery Service, Department of General Surgery, Sengkang General Hospital, Republic of Singapore.
| | - Chin Hong Lim
- Upper Gastrointestinal and Bariatric Surgery Service, Department of General Surgery, Sengkang General Hospital, Republic of Singapore; Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Republic of Singapore
| | - Bin Chet Toh
- Upper Gastrointestinal and Bariatric Surgery Service, Department of General Surgery, Sengkang General Hospital, Republic of Singapore
| | | | - Lester Wei Lin Ong
- Upper Gastrointestinal and Bariatric Surgery Service, Department of General Surgery, Sengkang General Hospital, Republic of Singapore
| | - Jeremy Tian Hui Tan
- Upper Gastrointestinal and Bariatric Surgery Service, Department of General Surgery, Sengkang General Hospital, Republic of Singapore; Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Republic of Singapore
| | - Wai Keong Wong
- Upper Gastrointestinal and Bariatric Surgery Service, Department of General Surgery, Sengkang General Hospital, Republic of Singapore; Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Republic of Singapore
| | - Baldwin Po Man Yeung
- Upper Gastrointestinal and Bariatric Surgery Service, Department of General Surgery, Sengkang General Hospital, Republic of Singapore
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Kollmann L, Lock JF, Kollmann C, Vladimirov M, Germer CT, Seyfried F. Surgical treatment of internal hernia after Roux-en-Y gastric bypass - impact of institutional standards and surgical approach. Langenbecks Arch Surg 2023; 408:318. [PMID: 37589915 PMCID: PMC10435621 DOI: 10.1007/s00423-023-03049-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 08/08/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION Internal hernia is one of the most frequent long-term complications after laparoscopic gastric bypass surgery (RYGB). Surgical treatment of an internal hernia itself has risks that can largely be avoided by the implementation of institutional standards and a structured approach. MATERIAL AND METHODS From 2012 until 2022, we extracted all consecutive bariatric cases from the prospectively collected national database (StuDoQ). Data from all patients undergoing internal hernia repair were then collected from our hospital information management system and retrospectively analyzed. We compared patient characteristics and surgical outcome of patients before and after the implementation of standard operating procedures for institutional and perioperative aspects (first vs. second time span). RESULTS Overall, 37 patients were identified (median age 43 years, 86.5% female). Internal hernia was diagnosed after substantial weight loss (17.2 kg/m2) and on average about 34 months after RYGB. Baseline characteristics (age, sex, BMI, achieved total weight loss% and time interval to index surgery were comparable between the two groups). After local standardization, the conversion rate decreased from 52.6 to 5.6% (p = 0.007); duration of surgery from 92 to 39 min (p = 0.003), and length of stay from 7.7 to 2.8 days (p = 0.019). CONCLUSION In this study, we could demonstrate that the surgical therapy of internal hernia after gastric bypass can be significantly improved by implementing institutional and surgical standards. The details described (including a video) may provide valuable information for non-specialized surgeons to avoid pitfalls and improve surgical outcomes.
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Affiliation(s)
- Lars Kollmann
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Würzburg, Würzburg, Germany
| | - Johan F Lock
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Würzburg, Würzburg, Germany
| | - Cathérine Kollmann
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Würzburg, Würzburg, Germany
| | - Miljana Vladimirov
- Department of General, Visceral and Thoracic Surgery, Hospital of Nuernberg, Nuernberg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Würzburg, Würzburg, Germany
| | - Florian Seyfried
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Center of Operative Medicine (ZOM), University Hospital of Würzburg, Würzburg, Germany.
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Mithany RH, Shahid MH, Ahmed F, Javed S, Javed S, Khan AZ, Kaiser A. A Comparison Between the Postoperative Complications of Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Roux-en-Y Gastric Bypass (RNYGB) in Patients With Morbid Obesity: A Meta-Analysis. Cureus 2022; 14:e31309. [DOI: 10.7759/cureus.31309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 11/11/2022] Open
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Dreifuss NH, Xie J, Schlottmann F, Cubisino A, Baz C, Vanetta C, Mangano A, Bianco FM, Gangemi A, Masrur MA. Risk Factors for Readmission After Same-Day Discharge Sleeve Gastrectomy: a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Database Analysis. Obes Surg 2022; 32:962-969. [PMID: 35060023 PMCID: PMC8773397 DOI: 10.1007/s11695-022-05919-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/11/2022] [Accepted: 01/14/2022] [Indexed: 11/29/2022]
Abstract
Background Same-day discharge after sleeve gastrectomy (SG) is gaining popularity. We aimed to determine risk factors associated with readmission in patients who underwent same-day discharge SG. Methods We performed a retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for the period 2015–2018. Patients who underwent SG and were discharged the same day of the operation were included in the analysis. Multivariable logistic regression analysis was performed to determine risk factors for readmission. Results A total of 466,270 SG were performed during the study period; 14,624 (3.1%) patients were discharged the same day and were included in the analysis. Mean age was 43.4 (14.7–80) years and 11,718 (80.1%) were female. Mean preoperative BMI was 43.7 ± 7.4 kg/m2. Mean operative time was 58.3 ± 32.4 min. Thirty-day reoperation, reintervention, and mortality rates were 0.7%, 0.7%, and 0.1%, respectively. Readmission rates were similar in same-day discharge and inpatient SG (2.9% vs. 3%, p = 0.5). Female sex (OR 1.52, 95% CI 1.15–2.00), preoperative gastroesophageal reflux disease (OR 1.33, 95% CI 1.08–1.64), renal insufficiency (OR 3.06, 95% CI 1.01–9.32), and intraoperative drain placement (OR 1.78, 95% CI 1.37–2.31) were independent risk factors for readmission following same-day discharge SG. Conclusions
Same-day discharge SG appears to be safe and is associated with low readmission rates. However, the identification of preoperative and intraoperative variables associated with higher risk of readmission might help defining safer and more effective same-day discharge protocols. Graphical abstract ![]()
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Affiliation(s)
- Nicolas H Dreifuss
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, Clinical Sciences Building, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Chicago, IL, 60612, USA.
| | - Julia Xie
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, Clinical Sciences Building, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Chicago, IL, 60612, USA
| | - Francisco Schlottmann
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, Clinical Sciences Building, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Chicago, IL, 60612, USA
| | - Antonio Cubisino
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, Clinical Sciences Building, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Chicago, IL, 60612, USA
| | - Carolina Baz
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, Clinical Sciences Building, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Chicago, IL, 60612, USA
| | - Carolina Vanetta
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, Clinical Sciences Building, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Chicago, IL, 60612, USA
| | - Alberto Mangano
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, Clinical Sciences Building, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Chicago, IL, 60612, USA
| | - Francesco M Bianco
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, Clinical Sciences Building, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Chicago, IL, 60612, USA
| | - Antonio Gangemi
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, Clinical Sciences Building, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Chicago, IL, 60612, USA
| | - Mario A Masrur
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, Clinical Sciences Building, University of Illinois at Chicago, 840 S Wood Street, Suite 435 E, Chicago, IL, 60612, USA
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Gomes-Rocha SR, Costa-Pinho AM, Pais-Neto CC, de Araújo Pereira A, Nogueiro JPM, Carneiro SPR, Santos-Sousa HMTF, Lima-da-Costa EJ, Bouça-Machado R, Preto JR. Roux-en-Y Gastric Bypass Vs Sleeve Gastrectomy in Super Obesity: a Systematic Review and Meta-Analysis. Obes Surg 2021; 32:170-185. [PMID: 34642872 DOI: 10.1007/s11695-021-05745-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/29/2021] [Accepted: 10/05/2021] [Indexed: 11/28/2022]
Abstract
Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are safe procedures that may present sub-optimal results in superobesity (SO). A meta-analysis was performed aiming to summarize the available evidence on weight loss (primary outcome) and comorbidities resolution of LRYGB and LSG in patients with SO (BMI ≥ 50 kg/m2). From the 16 included studies, 7 integrated the meta-analysis. LRYGB showed a significantly higher weight loss at 6 to 12-months, but not after 24 months and a higher dyslipidemia resolution at 12 months. When compared with LSG, LRYGB achieved better weight loss after 6 and 12 months and higher dyslipidemia resolution after 1 year. There were no significant differences for resolution of the other co-morbidities studied.
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Affiliation(s)
- Sofia Raquel Gomes-Rocha
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - André Manuel Costa-Pinho
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal. .,Obesity Integrated Responsibility Unit (CRI-O), São João University Medical Center, 4099-001, Porto, Portugal.
| | | | - André de Araújo Pereira
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Surgery Department, São João University Medical Center, 4099-001, Porto, Portugal
| | - Jorge Pedro Martins Nogueiro
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Surgery Department, São João University Medical Center, 4099-001, Porto, Portugal
| | - Silvestre Porfírio Ramos Carneiro
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Surgery Department, São João University Medical Center, 4099-001, Porto, Portugal
| | - Hugo Miguel Teixeira Ferraz Santos-Sousa
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Obesity Integrated Responsibility Unit (CRI-O), São João University Medical Center, 4099-001, Porto, Portugal
| | - Eduardo Jorge Lima-da-Costa
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Obesity Integrated Responsibility Unit (CRI-O), São João University Medical Center, 4099-001, Porto, Portugal
| | | | - John Rodrigues Preto
- Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal.,Obesity Integrated Responsibility Unit (CRI-O), São João University Medical Center, 4099-001, Porto, Portugal
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Ali M, Khan SA, Mushtaq M, Haider SA. Comparison of Laparoscopic Sleeve Gastrectomy (LSG) with Laparoscopic Gastric Bypass (LRYGB) in Bariatric Surgery. Cureus 2021; 13:e14022. [PMID: 33889462 PMCID: PMC8057121 DOI: 10.7759/cureus.14022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Introduction The objective of our study was to compare the 30-day post-operative outcomes of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). Materials and Methods This randomized controlled study contained patients who underwent bariatric surgery from June 13, 2018 to October 12, 2019. A total of 116 patients having body mass index (BMI) > 35 kg/m2 (morbidly obese), age 18 to 65 years and with failure of conservative treatment were included. Group I patients underwent bariatric surgery using LRYGB technique while group II patients underwent bariatric surgery using the LSG technique. All patients were followed 30 days after surgery to determine early post-operative outcomes. Results The demographic profile, such as age and BMI, was similar between the groups. The mean operating time was 72 ±12 minutes in the LSG group and 156 ± 18 min in the LRYGB group (p-value 0.0001). Major complications were seen in five (8.62%) patients in LSG patients and in four (6.89%) patients in LRYGB group (p-value 0.12). Minor complications were seen in 21 (36.2%) patients in LSG group and in 19 (32.75%) patients in LRYGB group (p-value 0.15). The length of stay in the hospital in LSG group was 6.2±4.2 versus 9.4± 4.6 (p-value 0.0002). Conclusion Both LRYGB and LSG are effective and safe bariatric procedures with a similar incidence of major complications. However, LSG is associated with shorter operative time and hospital stay. Long-term follow-up studies are required to compare the effectiveness of these procedures.
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Affiliation(s)
- Manzar Ali
- General and Colorectal Surgery, Ibn-e-Siena Hospital and Research Institute, Multan, PAK
| | - Safdar Ali Khan
- General Surgery, Ibn-e-Siena Hospital and Research Institute, Multan, PAK
| | - Muhammad Mushtaq
- General Surgery, Ibn-e-Siena Hospital and Research Institute, Multan, PAK
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Comparison of the incidence of cholelithiasis after sleeve gastrectomy and Roux-en-Y gastric bypass: a meta-analysis. Surg Obes Relat Dis 2021; 17:1198-1205. [PMID: 33785273 DOI: 10.1016/j.soard.2021.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/28/2021] [Accepted: 02/04/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Bariatric surgery could increase the risk of cholelithiasis, although it is unclear whether the incidence rates of cholelithiasis are similar after different bariatric procedures. OBJECTIVES To compare the incidence rates of cholelithiasis after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) in people with obesity. SETTING Meta-analysis of cohort studies. METHODS We searched the PubMed and Web of Science databases for relevant studies before December 2020, and estimated the summary odds ratios (OR) and 95% confidence intervals (CI) using a random-effects model or fixed-effects model, according to the heterogeneity. RESULTS In total, 8 cohort studies were included in this meta-analysis, and 94,855 and 106,844 participants received SG and RYGB, respectively. Compared with those receiving RYGB, the summary results showed that participants receiving SG had a 35% lower rate of cholelithiasis (OR, .65; 95% CI, .49-.86). Also, the participants receiving SG had a significantly lower incidence of cholecystectomy than those receiving RYGB (OR, .54; 95% CI, .30-.99). In a subgroup analysis, SG was associated with a significantly lower incidence of subsequent cholelithiasis than RYGB in both Western and non-Western countries. SG led to a significantly lower incidence of cholelithiasis than RYGB only when the follow-up was <2 years instead of over 2 years. CONCLUSION Participants receiving SG had a significantly lower incidence of cholelithiasis than those receiving RYGB, particularly within the first 2 years after the bariatric surgery.
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Oor JE, Goense L, Wiezer MJ, Derksen WJM. Incidence and treatment of intussusception following Roux-en-Y gastric bypass: a systematic review and meta-analysis. Surg Obes Relat Dis 2021; 17:1017-1028. [PMID: 33632616 DOI: 10.1016/j.soard.2021.01.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 12/08/2020] [Accepted: 01/11/2021] [Indexed: 11/15/2022]
Abstract
Intussusception is a rare yet potentially life-threatening complication following Roux-en-Y gastric bypass (RYGB). Multiple case reports have described this complication, and recently, several retrospective studies have been published describing the surgical treatment of intussusception. The aim of this study was to determine the incidence of intussusception following RYGB and provide insight into outcomes of subsequent operative treatment. A systematic search was performed using the PubMed and Cochrane databases. Article selection was performed using the preferred reporting items for systematic reviews and meta-analyses criteria, and selecting articles describing the incidence of intussusception following RYGB. Data was pooled only when 3 or more comparable studies reported on the same outcome. The incidence of intussusception and outcomes of subsequent treatment were analyzed. Furthermore, all published case reports describing intussusception following RYGB were analyzed. A total of 74 studies published between 1991 and 2020 were included, describing 191 patients who underwent RYGB and developed intussusception. We retrieved 68 case reports, including 84 patients, and 6 retrospective studies describing outcomes of surgical treatment in 107 patients, which were used to pool data. There was a predominance of females among the included patients (85%-98%), and patients had significant weight loss following RYGB. The pooled incidence of intussusception following RYGB was .64%. Resection of the affected segment was performed in 34% of the patients. A pooled recurrence rate of 22% was found during follow-up. Resection and reconstruction of the jejunojejunostomy appears to be associated with the lowest risk of recurrence and acceptable complication rates. The pooled incidence of intussusception following RYGB is 0.64%. Typically, patients are female with significant weight loss after RYGB. Symptoms include abdominal pain, nausea, and vomiting. Diagnosis is based on clinical findings and computed tomography scans, warranting early surgical exploration due to the high risk for ischemia. Resection of the jejunojejunostomy appears to be associated with the lowest recurrence rates and acceptable complication rates.
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Affiliation(s)
- Jelmer E Oor
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands.
| | - Lucas Goense
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Marinus J Wiezer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Wouter J M Derksen
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
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Lewis KH, Callaway K, Argetsinger S, Wallace J, Arterburn DE, Zhang F, Fernandez A, Ross-Degnan D, Dimick JB, Wharam JF. Concurrent hiatal hernia repair and bariatric surgery: outcomes after sleeve gastrectomy and Roux-en-Y gastric bypass. Surg Obes Relat Dis 2021; 17:72-80. [PMID: 33109444 PMCID: PMC8116048 DOI: 10.1016/j.soard.2020.08.035] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/30/2020] [Accepted: 08/24/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hiatal hernias are often repaired concurrently with bariatric surgery to reduce risk of gastroesophageal reflux disease-related complications. OBJECTIVES To examine the association between concurrent hiatal hernia repair (HHR) and bariatric outcomes. SETTING A 2010-2017 U.S. commercial insurance claims data set. METHODS We conducted a retrospective cohort study. We identified adults who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) alone or had bariatric surgery concurrently with HHR. We matched patients with and without HHR and followed patients up to 3 years for incident abdominal operative interventions, bariatric revisions/conversions, and endoscopy. Time to first event for each outcome was compared using multivariable Cox proportional hazards modeling. RESULTS We matched 1546 SG patients with HHR to 3170 SG patients without HHR, and we matched 457 RYGB patients with HHR to 1156 RYGB patients without HHR. A total of 73% had a full year of postoperative enrollment. Patients who underwent concurrent SG and HHR were more likely to have additional abdominal operations (adjusted hazard ratio [aHR], 2.1; 95% CI, 1.5-3.1) and endoscopies (aHR, 1.5; 95% CI, 1.2-1.8) but not bariatric revisions/conversions (aHR, 1.7; 95% CI, .6-4.6) by 1 year after surgery, a pattern maintained at 3 years of follow-up. Among RYGB patients, concurrent HHR was associated only with an increased risk of endoscopy (aHR, 1.4; 95% CI, 1.1-1.8)) at 1 year of follow-up, persisting at 3 years. CONCLUSIONS Concurrent SG/HHR was associated with increased risk of some subsequent operative and nonoperative interventions, a pattern that was not consistently observed for RYGB. Additional studies could examine whether changes to concurrent HHR technique could reduce risk.
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Affiliation(s)
- Kristina H Lewis
- Department of Epidemiology & Prevention, Department of Implementation Science, Division of Public Health Sciences, Wake Forest University Health Sciences, Winston-Salem, North Carolina; Department of Surgery, Wake Forest University Health Sciences, Winston-Salem, North Carolina.
| | - Katherine Callaway
- Division of Health Policy & Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Stephanie Argetsinger
- Division of Health Policy & Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Jamie Wallace
- Division of Health Policy & Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - David E Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Fang Zhang
- Division of Health Policy & Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Adolfo Fernandez
- Department of Surgery, Wake Forest University Health Sciences, Winston-Salem, North Carolina
| | - Dennis Ross-Degnan
- Division of Health Policy & Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Justin B Dimick
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - J Frank Wharam
- Division of Health Policy & Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
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Short-Term Results Suggest That Sleeved Stomach without Resection Is as Effective as Sleeve Gastrectomy in Improving Glucose Control in Type 2 Diabetes Mellitus Sprague-Dawley Rat Model. BIOMED RESEARCH INTERNATIONAL 2020; 2020:9024923. [PMID: 32462030 PMCID: PMC7212312 DOI: 10.1155/2020/9024923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/27/2020] [Accepted: 03/25/2020] [Indexed: 11/17/2022]
Abstract
Background Although sleeve gastrectomy results in good weight loss and metabolic improvements, it is an irreversible procedure. Therefore, we attempted to assess the possibility of creating a sleeved stomach without resection. Material and Methods. A total of 22 male Sprague-Dawley rats with type 2 diabetes were randomly assigned into 3 different groups: (1) sleeve gastroplasty with gastric remnant-jejunal anastomosis (SGP, n = 8); (2) sleeve gastrectomy (SG, n = 8); and (3) SHAM (n = 6). Body weight, food intake, fasting blood glucose (FBG), hormonal analysis, and oral glucose tolerance test (OGTT) were performed and measured preoperatively and postoperatively. Results During the postoperative period, SGP and SG showed significantly lower food intake and body weight when compared with the preoperative levels, respectively (p value < 0.05). Postoperatively, SGP and SG showed improvements in FBG and glucose tolerance levels compared to their respective preoperative levels (p < 0.05). FBG and glucose tolerance levels did not differ between SGP and SG postoperatively. SG resulted in a reduction in fasting ghrelin levels when compared with the preoperative level (p < 0.05). Fasting insulin levels did not differ preoperatively and postoperatively among all groups. Postoperatively, fasting GLP-1 levels were higher in SGP and SG when compared with the preoperative levels, but no statistical significance was observed. Compared preoperatively, the SGP and SG procedures resulted in a decline in HOMA-IR at postoperative 6th week (p < 0.05). Conclusion Our animal experiment suggested that at least in the short term, sleeved stomach without resection resulted in similar weight loss and improved glucose control effects compared to sleeve gastrectomy.
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11
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Martinaitis L, Tuero C, Fortún Landecho M, Cienfuegos JA, Moncada R, Rotellar F, Silva C, Frühbeck G, Valentí V. The long-term benefits of bariatric surgery in elderly and super-obese populations. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 111:371-377. [PMID: 30829531 DOI: 10.17235/reed.2019.5917/2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE to assess the long-term benefits of bariatric surgery in super-obese (body mass index [BMI] ≥ 50) and in elderly obese (age > 60 years) populations. METHODS one hundred and twenty one patients who underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy in a university hospital were retrospectively subdivided into the following groups: BMI < 50 vs ≥ 50 and age < 60 vs ≥ 60 years. Weight loss, body composition and comorbidity outcomes were registered after one and six months and one, two, three and five years with 100%, 93%, 89%, 80%, 75% and 60% successful follow-up. RESULTS the percentage of excess BMI loss (%EBMIL) was comparable between BMI groups and age groups and the difference in the long-term follow up was not statistically significant (p > 0.05). Complication rates, comorbidity resolution, reduction in body fat and increase in fat-free mass were comparable between BMI groups and age groups. Gastric bypass resulted in a greater weight loss compared to sleeve gastrectomy. The % EBMIL was 65.2% vs 46.7% (p = 0.002), 65.8% vs 44.9% (p = 0.004), 64.4% vs 30.5% (p = 0.001), 55.6% vs 17.6% (p = 0.016) at one, two, three and five years postoperative, respectively. Similarly, in the super-obese group, weight loss was more pronounced after gastric bypass versus sleeve gastrectomy. CONCLUSIONS bariatric surgery in super-obese and elderly populations is an effective and safe weight loss measure with a good comorbidity resolution in the long-term. Gastric bypass is superior to sleeve gastrectomy in terms of long-term weight loss and comorbidity resolution in all the groups investigated.
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Affiliation(s)
| | - Carlota Tuero
- General Surgery, Clínica Universidad de Navarra, España
| | | | | | - Rafael Moncada
- Department of Anesthesiology, Clínica Universidad de Navarra
| | | | - Camilo Silva
- Department of Endocrinology, Clínica Universidad de Navarra, España
| | - Gema Frühbeck
- Department of Endocrinology, Clínica Universidad de Navarra, España
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Lewis KH, Arterburn DE, Callaway K, Zhang F, Argetsinger S, Wallace J, Fernandez A, Ross-Degnan D, Wharam JF. Risk of Operative and Nonoperative Interventions Up to 4 Years After Roux-en-Y Gastric Bypass vs Vertical Sleeve Gastrectomy in a Nationwide US Commercial Insurance Claims Database. JAMA Netw Open 2019; 2:e1917603. [PMID: 31851344 PMCID: PMC6991222 DOI: 10.1001/jamanetworkopen.2019.17603] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
IMPORTANCE There are few nationwide studies comparing the risk of reintervention after contemporary bariatric procedures. OBJECTIVE To compare the risk of intervention after Roux-en-Y gastric bypass (RYGB) vs vertical sleeve gastrectomy (VSG). DESIGN, SETTING, AND PARTICIPANTS This cohort study used a nationwide US commercial insurance claims database. Adults aged 18 to 64 years who underwent a first RYGB or VSG procedure between January 1, 2010, and June 30, 2017, were matched on US region, year of surgery, most recent presurgery body mass index (BMI) category (based on diagnosis codes), and baseline type 2 diabetes. The prematch pool included 4496 patients undergoing RYGB and 8627 patients undergoing VSG, and the final weighted matched sample included 4476 patients undergoing RYGB and 8551 patients undergoing VSG. EXPOSURES Bariatric surgery procedure type (RYGB vs VSG). MAIN OUTCOMES AND MEASURES The primary outcome was any abdominal operative intervention after the index procedure. Secondary outcomes included the following subtypes of operative intervention: biliary procedures, abdominal wall hernia repair, bariatric conversion or revision, and other abdominal operations. Nonoperative outcomes included endoscopy and enteral access. Time to first event was compared using multivariable Cox proportional hazards regression modeling. RESULTS Among 13 027 patients, the mean (SD) age was 44.4 (10.3) years, and 74.1% were female; 13.7% had a preoperative BMI between 30 and 39.9, 45.8% had a preoperative BMI between 40 and 49.9, and 24.2% had a preoperative BMI of at least 50. Patients were followed up for up to 4 years after surgery (median, 1.6 years; interquartile range, 0.7-3.2 years), with 41.9% having at least 2 years of follow-up and 16.3% having at least 4 years of follow-up. Patients undergoing VSG were less likely to have any subsequent operative intervention than matched patients undergoing RYGB (adjusted hazard ratio [aHR], 0.80; 95% CI, 0.72-0.89) and similarly were less likely to undergo biliary procedures (aHR, 0.77; 95% CI, 0.67-0.90), abdominal wall hernia repair (aHR, 0.60; 95% CI, 0.47-0.75), other abdominal operations (aHR, 0.71; 95% CI, 0.61-0.82), and endoscopy (aHR, 0.54; 95% CI, 0.49-0.59) or have enteral access placed (aHR, 0.58; 95% CI, 0.39-0.86). Patients undergoing VSG were more likely to undergo bariatric conversion or revision (aHR, 1.83; 95% CI, 1.19-2.80). CONCLUSIONS AND RELEVANCE In this nationwide study, patients undergoing VSG appeared to be less likely than matched patients undergoing RYGB to experience subsequent abdominal operative interventions, except for bariatric conversion or revision procedures. Patients considering bariatric surgery should be aware of the increased risk of subsequent procedures associated with RYGB vs VSG as part of shared decision-making around procedure choice.
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Affiliation(s)
- Kristina H. Lewis
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - David E. Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Katherine Callaway
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Fang Zhang
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Stephanie Argetsinger
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Jamie Wallace
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Adolfo Fernandez
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Dennis Ross-Degnan
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - James F. Wharam
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
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Antonopulos C, Rebibo L, Calabrese D, Ribeiro-Parenti L, Arapis K, Dhahri A, Coupaye M, Hansel B, Marmuse JP, Regimbeau JM, Msika S. Comparison of Repeat Sleeve Gastrectomy and Roux-en-Y Gastric Bypass in Case of Weight Loss Failure After Sleeve Gastrectomy. Obes Surg 2019; 29:3919-3927. [PMID: 31388964 DOI: 10.1007/s11695-019-04123-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Few series are available on the results of repeat sleeve gastrectomy (re-SG) and Roux-en-Y gastric bypass (RYGB) performed to manage the failure of primary sleeve gastrectomy (SG). The objective of this study was to compare the short- and medium-term outcomes of re-SG and RYGB after SG. MATERIAL & METHODS Between January 2010 and December 2017, patients undergoing re-SG (n = 61) and RYGB (n = 83) for failure of primary SG were included in this study. Revisional surgery was proposed for patients with insufficient excess weight loss (EWL ≤ 50%) or weight regain. The primary endpoint was the comparison of weight loss in the re-SG group and the RYGB group at the 1-year follow-up. The secondary endpoints were overall mortality and morbidity, specific morbidity, length of stay, weight loss, and correction of comorbidities. RESULTS The mean interval between SG and re-SG was 41.5 vs. 43.2 months between SG and RYGB (p = 0.32). The mean operative time was 103 min (re-SG group) vs. 129.4 min (RYGB group). One death (1.7%; re-SG group) and 25 complications (17.4%; 9 in the re-SG group, 16 in the RYGB group) were observed. At the 1 year, mean body mass index was 31.6 in the re-SG group and 32.5 in the RYGB group (p = 0.61) and excess weight loss was 69.5 vs. 61.2, respectively (p = 0.05). CONCLUSION Re-SG and RYGB as revisional surgery for SG are feasible with acceptable outcomes and similar results on weight loss on the first postoperative year.
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Affiliation(s)
- Christos Antonopulos
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat Claude Bernard University Hospital, 46 rue Henri Huchard, F-75018, Paris, France.,Department of Medical and Oral Sciences and Biotechnologies, "G.d'Annunzio" University, Via dei Vestini 31, 66100, Chieti, Italy
| | - Lionel Rebibo
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat Claude Bernard University Hospital, 46 rue Henri Huchard, F-75018, Paris, France.,SSPC (Simplification des Soins des Patients Complexes) - Clinical Research Unit, University of Picardie Jules Verne, 80054, Amiens Cedex 01, France.,Department of Digestive Surgery, Amiens University Medical Center, Avenue René Laennec, F-80054, Amiens Cedex 01, France
| | - Daniela Calabrese
- Department of Digestive and General Surgery, Louis Mourier University Hospital, 178 rue des Renouillers, F-92700, Colombes, France
| | - Lara Ribeiro-Parenti
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat Claude Bernard University Hospital, 46 rue Henri Huchard, F-75018, Paris, France
| | - Konstantinos Arapis
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat Claude Bernard University Hospital, 46 rue Henri Huchard, F-75018, Paris, France
| | - Abdennaceur Dhahri
- Department of Digestive Surgery, Amiens University Medical Center, Avenue René Laennec, F-80054, Amiens Cedex 01, France
| | - Muriel Coupaye
- Explorations Fonctionnelles Department, Louis Mourier Hospital, 178 rue des Renouillers, F-92700, Colombes, France
| | - Boris Hansel
- Department of Diabetes and Nutrition, Bichat Claude Bernard University Hospital, 46 rue Henri Huchard, F-75018, Paris, France
| | - Jean-Pierre Marmuse
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat Claude Bernard University Hospital, 46 rue Henri Huchard, F-75018, Paris, France
| | - Jean-Marc Regimbeau
- SSPC (Simplification des Soins des Patients Complexes) - Clinical Research Unit, University of Picardie Jules Verne, 80054, Amiens Cedex 01, France.,Department of Digestive Surgery, Amiens University Medical Center, Avenue René Laennec, F-80054, Amiens Cedex 01, France
| | - Simon Msika
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat Claude Bernard University Hospital, 46 rue Henri Huchard, F-75018, Paris, France. .,Department of Digestive and General Surgery, Louis Mourier University Hospital, 178 rue des Renouillers, F-92700, Colombes, France.
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14
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Rebibo L, Maurice KK, Nimier M, Ben Rehouma M, Montravers P, Msika S. Laparoscopic sleeve gastrectomy as day-case surgery: a review of the literature. Surg Obes Relat Dis 2019; 15:1211-1217. [PMID: 31060908 DOI: 10.1016/j.soard.2019.03.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 03/03/2019] [Accepted: 03/10/2019] [Indexed: 10/27/2022]
Abstract
Day-case surgery (DCS) in digestive surgery is a hot topic, and new indications for DCS in the field of gastrointestinal surgery have recently been described. Laparoscopic sleeve gastrectomy (LSG) has become a popular bariatric procedure in recent years. LSG is a reproducible, standardized procedure with a short operating time and possibly simple perioperative management. It therefore meets the criteria to be performed as a DCS procedure. Recently published series of LSG as DCS have demonstrated its feasibility. In this review on LSG performed as DCS, we focused on the management of risks associated with DCS and the results of such type of management. A literature search was conducted in the PubMed and Embase databases. Six studies were selected, comprising a total of 6227 patients. Most published series were retrospective single-center studies. Inclusion criteria were similar between most studies (primary sleeve gastrectomy for most series, patients with a body mass index ≥40 kg/m2 or a body mass index ≥35 kg/m2 in the presence of co-morbidities), while exclusion criteria were based on literature data for some studies (using series on risk factors for morbidity and mortality after Roux-en-Y gastric bypass) and personal experience for other series. The mortality rate of LSG as DCS ranges 0%-.08%, while the overall complication rate ranges 0%-10%. The unplanned overnight admission rate after LSG ranges .8%-8%. The unscheduled hospitalization rates range 2.1%-8.5%. LSG performed as DCS is feasible with good results, but cannot be proposed for all patients. Good selection is necessary in others to avoid increased risk of morbidity and mortality.
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Affiliation(s)
- Lionel Rebibo
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat Claude Bernard University Hospital, Paris, France; Université Paris Diderot - Sorbonne Paris Cité, Paris, France
| | - Karim K Maurice
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat Claude Bernard University Hospital, Paris, France; Department of General and Digestive Surgery, Kasr Al Ainy Hospital, Cairo University, Cairo, Egypt
| | - Martin Nimier
- Department of Anaesthesiology and Critical Care Medicine, Bichat-Claude Bernard University Hospital, Paris, France
| | - Mouna Ben Rehouma
- Department of Anaesthesiology and Critical Care Medicine, Bichat-Claude Bernard University Hospital, Paris, France
| | - Philippe Montravers
- Université Paris Diderot - Sorbonne Paris Cité, Paris, France; Department of Anaesthesiology and Critical Care Medicine, Bichat-Claude Bernard University Hospital, Paris, France
| | - Simon Msika
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat Claude Bernard University Hospital, Paris, France; Université Paris Diderot - Sorbonne Paris Cité, Paris, France.
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15
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Zurli L, Rebibo L, Msika S. Laparoscopic Management of Dilatation of Excluded Stomach After Roux-en-Y Gastric Bypass. Obes Surg 2019; 29:1429-1431. [PMID: 30671714 DOI: 10.1007/s11695-018-03690-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Roux-en-Y gastric bypass (RYGB) is considered as the gold standard for surgical management of morbid obesity due to its good results on weight loss and correction of comorbidities related to obesity and its few complication rates. Here, we describe a present strategy for dealing with an unusual complication after RYGB, responsible for chronic pain, as a chronic dilatation of excluded stomach. METHODS The video shows our laparoscopic treatment of an excluded gastric fundus dilatation. A 21-year-old woman with history of RYGB was admitted in our center for recurrent abdominal pain. Many consultations have been performed before for the same reason and without explanation for this chronic abdominal pain. RESULTS We found that a dilatation of the excluded gastric fundus was responsible for recurrent abdominal pain and thus required revisional surgery. An abdominal computed tomography with oral contrast study showed an atypical dilatation of the excluded stomach without gastro-gastric fistula or others abnormal findings. Intra-operative exploration then revealed multiple adhesions. During surgery, released of the excluded stomach allow to confirm a dilatation of the excluded fundus due to error in stapling when performing the vertical part of the gastric pouch of the RYGB. We resected the excluded dilated gastric fundus. An uneventful post-operative course enabled rapid discharge (post-operative day 3). CONCLUSION Dilatation of the excluded gastric pouch due to staple line misfiring during RYGB is a rare complication and can explain chronic abdominal pain. Laparoscopy can be useful to confirm the diagnosis and allow treatment using gastric resection in our case.
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Affiliation(s)
- Letizia Zurli
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, F-75018, Paris, France
| | - Lionel Rebibo
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, F-75018, Paris, France
| | - Simon Msika
- Department of Digestive, Esogastric and Bariatric Surgery, Bichat-Claude Bernard University Hospital, 46 rue Henri Huchard, F-75018, Paris, France.
- Service de Chirurgie Digestive, Œsogastrique et Bariatique, Hôpital Bichat Claude Bernard, Paris, France.
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16
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Arman GA, Himpens J, Bolckmans R, Van Compernolle D, Vilallonga R, Leman G. Medium-Term Outcomes after Reversal of Roux-en-Y Gastric Bypass. Obes Surg 2018; 28:781-790. [PMID: 28929425 DOI: 10.1007/s11695-017-2928-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) can be reversed into normal anatomy (NA) or into sleeve gastrectomy (NASG) to address undesired side effects. Concomitant hiatal hernia repair (HHR) may be required. Before reversal, some patients benefit from placement of a gastrostomy, mostly to predict the result of recreating the native anatomy. METHODS Retrospective study on mid-term effects of RYGB reversal to NA and NASG, including clinical and weight evolution, surgical complications, and incidence of gastro-esophageal reflux (GERD). RESULTS Undesired side effects leading to reversal included early dumping syndrome, hypoglycemia, malnutrition, severe diarrhea and excessive nausea and vomiting. Twenty-five participants to the study, 13 NA, 12 NASG, and 15 HHR. Mean follow-up time was 5.3 ± 2.3 years. Reversal corrected early dumping, malnutrition, diarrhea, and nausea/vomiting. For hypoglycemic syndrome, resolution rate was 6/8 (75%). NA caused significant weight regain (14.2 ± 13.7 kg, (p = .003)). NASG caused some weight loss (4.8 ± 15.7 kg (NS)). Gastrostomy placement gave complications at reversal in five of seven individuals. Eight patients suffered a severe complication, including leaks (one NA vs. three NASGs). Eight out of 14 (57.1%) patients who previously had never experienced GERD developed de novo GERD after reversal, despite HHR. CONCLUSIONS RYGB reversal is effective but pre-reversal gastrostomy and concomitant HHR may be aggravating factors for complications and development of de novo GERD, respectively.
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Affiliation(s)
- Gustavo Andrés Arman
- Division of Bariatric Surgery, AZ Sint-Blasius, Kroonveldlaan 50, 9200, Dendermonde, Belgium.
| | - J Himpens
- Division of Bariatric Surgery, AZ Sint-Blasius, Kroonveldlaan 50, 9200, Dendermonde, Belgium
| | - R Bolckmans
- Division of Bariatric Surgery, AZ Sint-Blasius, Kroonveldlaan 50, 9200, Dendermonde, Belgium
| | - D Van Compernolle
- Division of Bariatric Surgery, AZ Sint-Blasius, Kroonveldlaan 50, 9200, Dendermonde, Belgium
| | - R Vilallonga
- Division of Bariatric Surgery, AZ Sint-Blasius, Kroonveldlaan 50, 9200, Dendermonde, Belgium
| | - G Leman
- Division of Bariatric Surgery, AZ Sint-Blasius, Kroonveldlaan 50, 9200, Dendermonde, Belgium
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C-Reactive protein as a predictor of post-operative complications in bariatric surgery patients. Surg Endosc 2018; 33:2479-2484. [DOI: 10.1007/s00464-018-6534-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 10/12/2018] [Indexed: 01/17/2023]
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18
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Khan OA, McGlone ER, Maynard W, Hopkins J, Dexter S, Finlay I, Hewin D, Sedman P, Walton P, Somers S, Reddy M, Small P, Adamo M, Welbourn R. Single-stage conversions from failed gastric band to sleeve gastrectomy versus Roux-en-Y gastric bypass: results from the United Kingdom National Bariatric Surgical Registry. Surg Obes Relat Dis 2018; 14:1516-1520. [DOI: 10.1016/j.soard.2018.06.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 06/07/2018] [Accepted: 06/18/2018] [Indexed: 11/26/2022]
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Kersebaum JN, Schafmayer C, Ahrens M, Laudes M, Becker T, Beckmann JH. Duodenal intussusception of the remnant stomach after biliopancreatic diversion: a case report. BMC Surg 2018; 18:57. [PMID: 30107839 PMCID: PMC6092866 DOI: 10.1186/s12893-018-0392-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 08/08/2018] [Indexed: 11/10/2022] Open
Abstract
Background We present a rare case of an antegrade intussusception of the remnant stomach four years after a biliopancreatic diversion. Case presentation A 55-year-old female patient presented with epigastric pain in our emergency room. Laboratory parameters showed an anemia as well as elevated transaminases and hyperbilirubinemia. The CT scan showed an intussusception of the remnant stomach into the duodenum followed by cholestasis. At laparotomy the remnant stomach was resected. Conclusion Bowel obstruction and intussusception after bariatric surgery are a rare but often unrecognized complication. Sonography as well as a CT scan should be performed. The exploratory laparoscopy however is the most valuable diagnostic tool in patients with suspected intussusception, due to the high rate of non-specific symptoms and misinterpreted radiographic investigations.
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Affiliation(s)
- J-N Kersebaum
- Klinik für Allgemeine, Viszeral-, Transplantations-, Thorax- und Kinderchirurgie, Universitätsklinikum Schleswig- Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany.
| | - C Schafmayer
- Klinik für Allgemeine, Viszeral-, Transplantations-, Thorax- und Kinderchirurgie, Universitätsklinikum Schleswig- Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - M Ahrens
- Klinik für Allgemeine, Viszeral-, Transplantations-, Thorax- und Kinderchirurgie, Universitätsklinikum Schleswig- Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - M Laudes
- Klinik für Innere Medizin I, Universitätsklinikum Schleswig- Holstein, Campus Kiel, Kiel, Germany
| | - T Becker
- Klinik für Allgemeine, Viszeral-, Transplantations-, Thorax- und Kinderchirurgie, Universitätsklinikum Schleswig- Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - J H Beckmann
- Klinik für Allgemeine, Viszeral-, Transplantations-, Thorax- und Kinderchirurgie, Universitätsklinikum Schleswig- Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
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Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass. Data from IFSO-European Chapter Center of Excellence Program. Obes Surg 2017; 27:847-855. [PMID: 27761724 DOI: 10.1007/s11695-016-2395-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The purpose of this study is to compare sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGBP) performed in Institutions participating in IFSO-European Chapter, Center of Excellence (COE) program. METHODS Since the initiation of the program in January 2010, 6413 SGs and 10,622 RYGBPs performed as primary procedures by December 31, 2014, with at least 12-month follow-up, were retrospectively compared. RESULTS There were steadily increasing numbers of patients underwent SG from 2010 to 2015. Early (<30 days) postoperative complication rate of 3.02 % for RYGBP was significantly higher than 2.12 % seen after SG (p = 0.0006). Only two patients, one in each group, died in the first 30 postoperative days (0.016 % mortality for SG vs 0.009 % for RYGBP-NS). From SG group, 103 patients, 1.61 %, and 206 patients, 1.94 %, from RYGBP group required readmission following hospital discharge in the first 30 days following bariatric surgery-NS. From the readmitted patients in the SG group, 75.72 % were reoperated vs 50.50 % in the RYGBP group (p < 0.0001). SG patients were heavier (BMI 44.93 vs 43.96 kg/m2, p < 0.0001). However, significantly better % excess weight loss were seen following RYGBP in all postoperative years (60.36 vs 67.72 %, p = 0.002 at fifth year). Better remission rates were seen for diabetes, arterial hypertension, dyslipidemia, and sleep apnea syndrome after RYGBP in the first postoperative year. CONCLUSIONS Both procedures were performed with very low complications, mortality, readmissions, and reoperations rate. Better weight loss was observed following RYGBP, the first five postoperative years.
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A Retrospective 2-Year Follow-up of Late Complications Treated Surgically and Endoscopically After Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) and Laparoscopic Sleeve Gastrectomy (LSG) for Morbid Obesity. Obes Surg 2017; 28:1055-1062. [DOI: 10.1007/s11695-017-2967-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Lasnibat JP, Braghetto I, Gutierrez L, Sanchez F. SLEEVE GASTRECTOMY AND FUNDOPLICATION AS A SINGLE PROCEDURE IN PATIENTS WITH OBESITY AND GASTROESOPHAGEAL REFLUX. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2017; 30:216-221. [PMID: 29019565 PMCID: PMC5630217 DOI: 10.1590/0102-6720201700030012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 07/04/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Bariatric surgery in Chile has seen an exponential increase in recent years, especially in sleeve gastrectomy. Its use is currently discussed in patients suffering from gastroesophageal reflux disease. Different options have been considered for the management of these patients but up to now laparoscopic Roux-en-Y gastric bypass seems to be the best option. Sleeve gastrectomy plus concomitant fundoplication or hiatal hernia repair also has been suggested in patients having reflux or small hiatal hernia. AIM To present a cohort of obese patients with gatroesophageal reflux undergoing this procedure, which seeks to provide the benefits of both laparoscopic gastric sleeve (LSG) and antireflux surgery focused on the evaluation of presence of reflux and BMI after surgery, and to compare the result observed in this cohort with a previous group of obese patients without reflux submitted to sleeve gastrectomy alone. METHODS Retrospective case series in 15 patients who underwent this surgery between the years 2003 and 2012. Clinical records were analyzed and values of 24 hr pH monitoring, esophageal manometry and clinical outcome were recorded. Results were compared to a previous series of patients who underwent LSG. No statistical analyses were made. RESULTS Group A consisted of 15 patients submitted to LSG plus fundoplication. 93% (n=14) were female. Mean age was 46.2 years. Mean preoperative body mass index (BMI) was 33.9. All patients had altered pH monitoring and manometry preoperatively. There was one minor complication corresponding to a seroma. There was no perioperative mortality. Group B consisted of 23 obese patients who underwent LSG. These patients developed de novo reflux, hypotensive LES and esophagitis after the surgery. Group A patients showed improvement in esophageal pH monitoring and manometry at three months. During long-term follow-up, six underwent revision surgery, four for weight regain, one regained weight associated with symptomatic reflux, and one underwent re-intervention for reflux. CONCLUSIONS Good results are observed in the short-term follow up in both reflux resolution and weight loss. Nevertheless, results at long term are discouraging, with 53.3% of the patients requiring revision surgery during follow-up.
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Affiliation(s)
- Juan Pablo Lasnibat
- Department of Surgery, Faculty of Medicine, University Hospital Dr José J. Aguirre, Santiago, Chile
| | - Italo Braghetto
- Department of Surgery, Faculty of Medicine, University Hospital Dr José J. Aguirre, Santiago, Chile
| | - Luis Gutierrez
- Department of Surgery, Faculty of Medicine, University Hospital Dr José J. Aguirre, Santiago, Chile
| | - Felipe Sanchez
- Department of Surgery, Faculty of Medicine, University Hospital Dr José J. Aguirre, Santiago, Chile
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Gagner M. Strategies to decrease readmission after gastric bypass, in the long-term. Surg Obes Relat Dis 2017; 13:969-971. [PMID: 28366672 DOI: 10.1016/j.soard.2017.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 01/06/2017] [Accepted: 01/07/2017] [Indexed: 10/20/2022]
Affiliation(s)
- Michel Gagner
- Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Hopital du Sacre Coeur, Montreal, Canada.
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Impact of laparoscopic Roux-en-Y Gastric bypass versus sleeve gastrectomy on postoperative lipid values. Surg Obes Relat Dis 2017; 13:399-403. [DOI: 10.1016/j.soard.2016.09.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 08/19/2016] [Accepted: 09/20/2016] [Indexed: 01/04/2023]
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Rondelli F, Bugiantella W, Vedovati MC, Mariani E, Balzarotti Canger RC, Federici S, Guerra A, Boni M. Laparoscopic gastric bypass versus laparoscopic sleeve gastrectomy: A retrospective multicenter comparison between early and long-term post-operative outcomes. Int J Surg 2016; 37:36-41. [PMID: 27913235 DOI: 10.1016/j.ijsu.2016.11.106] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 11/22/2016] [Accepted: 11/25/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the most commonly performed procedures for morbid obesity. METHODS We performed a retrospective review of patients undergoing LRYGB or LSG between August 2000 and November 2014. RESULTS Data from 581 (280 LSG and 301 LRYGB) were gathered. Operating time (77.6 vs 250.5 min; p < 0.001), post-operative complication rate (3.9% vs 11.6%; p < 0.001), overall occlusions (p = 0.004), need for re-intervention (p < 0.001), hospital stay (5.7 vs 9.2 days; p < 0.001) and mean 1-year EWL (49% vs 61%; p = 0.001) resulted statistically significant lower in LSGs compared with LRYGBs. Not statistically significant differences were found about leakage, bleeding requiring transfusion, infections, short-term mortality and mean 2- and 3-years EWL. Upon univariate analysis, basal weight, basal BMI, age and gender were not associated with the rate of re-intervention and with the combination of re-intervention or death. CONCLUSIONS LRYGB resulted associated with higher post-operative morbidity rate and increased 1-year EWL than LSG. Prospective studies are needed to assess the impact of these two surgical procedures on the long-term weigh loss.
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Affiliation(s)
- Fabio Rondelli
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Italy; University of Perugia, Department of Surgical and Biomedical Sciences, Via G. Dottori, 06100, Perugia, Italy; General Surgery, "San Giovanni" Bellinzona e Valli Regional Hospital, 6500, Bellinzona, Switzerland
| | - Walter Bugiantella
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Italy; PhD School of Biotechnologies, Department of Experimental Medicine, University of Perugia, Italy.
| | - Maria Cristina Vedovati
- University of Perugia, Department of Medicine, Internal and Cardiovascular Medicine and Stroke Unit, "Santa Maria della Misericordia" Hospital, Via G. Dottori, 06100, Perugia, Italy
| | - Enrico Mariani
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Italy
| | | | - Sara Federici
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Italy
| | - Adriano Guerra
- General Surgery, "San Giovanni" Bellinzona e Valli Regional Hospital, 6500, Bellinzona, Switzerland
| | - Marcello Boni
- General Surgery, "San Giovanni Battista" Hospital, AUSL Umbria 2, Via M. Arcamone, 06034, Foligno, Italy
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Martín-Núñez GM, Cabrera-Mulero A, Alcaide-Torres J, García-Fuentes E, Tinahones FJ, Morcillo S. No effect of different bariatric surgery procedures on LINE-1 DNA methylation in diabetic and nondiabetic morbidly obese patients. Surg Obes Relat Dis 2016; 13:442-450. [PMID: 27986580 DOI: 10.1016/j.soard.2016.10.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 10/13/2016] [Accepted: 10/19/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Bariatric surgery (BS) is proposed as a highly effective therapy for reducing weight and improving obesity-related co-morbidities. The molecular mechanisms involved in the metabolic improvement after BS are not completely resolved. Epigenetic modifications could have an important role. OBJECTIVE The aim of this study was to evaluate the effect of different BS procedures (Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy) on global DNA methylation (long interspersed nucleotide element 1 [LINE-1]) in a group of nondiabetic and diabetic severely obese patients. SETTING University hospital, Spain. METHODS This study included 60 patients (30 nondiabetic and 30 diabetic severely obese patients) undergoing BS: 31 patients underwent Roux-en-Y gastric bypass and 29 underwent laparoscopic sleeve gastrectomy. Before and 6 months post-BS, anthropometric data, blood pressure, and metabolic parameters were determined. LINE-1 DNA methylation was quantified by pyrosequencing. We used the methylation levels of tumor necrosis factor-α as a control gene promoter. RESULTS There were no differences between LINE-1 methylation levels at baseline and at 6 months after surgery (66.3±1.6 versus 66.2±2.06). Likewise, there was no statistically significant difference on LINE-1 methylation levels when we stratified according to metabolic status (diabetic versus nondiabetic), nor was there regarding the BS procedure. A strong correlation was shown between LINE-1 methylation levels and weight at baseline both in diabetic and nondiabetic obese patients (r = .486; P<.001). Tumor necrosis factor-α methylation levels increased significantly after BS in the group of diabetic obese patients. CONCLUSION After BS, global LINE-1 methylation is not modified in the short term. More studies are required to determine if LINE-1 is a stable epigenetic marker, or, on the contrary, if it is susceptible to modification by external factors such as changes in lifestyle or a surgical intervention.
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Affiliation(s)
- G M Martín-Núñez
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Clínico Virgen de la Victoria, Málaga, Spain
| | - A Cabrera-Mulero
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Clínico Virgen de la Victoria, Málaga, Spain
| | - J Alcaide-Torres
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Clínico Virgen de la Victoria, Málaga, Spain
| | - E García-Fuentes
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario, Málaga, Spain; CIBER Pathophysiology of Obesity and Nutrition, Málaga, Spain
| | - F J Tinahones
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Clínico Virgen de la Victoria, Málaga, Spain; CIBER Pathophysiology of Obesity and Nutrition, Málaga, Spain.
| | - S Morcillo
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Clínico Virgen de la Victoria, Málaga, Spain; CIBER Pathophysiology of Obesity and Nutrition, Málaga, Spain.
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Celio AC, Wu Q, Kasten KR, Manwaring ML, Pories WJ, Spaniolas K. Comparative effectiveness of Roux-en-Y gastric bypass and sleeve gastrectomy in super obese patients. Surg Endosc 2016; 31:317-323. [PMID: 27287899 DOI: 10.1007/s00464-016-4974-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 05/09/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND The disproportionate increase in the super obese (SO) is a hidden component of the current obesity pandemic. Data on the safety and efficacy of bariatric procedures in this specific patient population are limited. Our aim is to assess the comparative effectiveness of the two most common bariatric procedures in the SO. METHODS Using the Bariatric Outcomes Longitudinal Database from 2007 to 2012, we compared SO patients (BMI ≥ 50) undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Stepwise logistic regression modeling was used to calculate a propensity score to adjust for patient demographics and comorbidities. RESULTS We identified 50,987 SO patients who underwent RYGB (N = 42,119) or SG (N = 8868). There was no difference in adjusted overall 30-day complication rate comparing RYGB and SG patients (11.5 vs. 11.1 %, p = 0.250). RYGB patients had higher adjusted rates of 30-day mortality (0.3 vs. 0.2 %, p = 0.042), reoperation (4.0 vs. 2.4 %, p < 0.001), and readmission (6.9 vs. 5.5 %, p < 0.001) compared to SG patients. The percent of total weight loss (%TWL) was significantly higher for RYGB patients compared to SG at 3 months (14.1 vs. 13.1 %, p < 0.001), 6 months (25.2 vs. 22.4 %, p < 0.001), and 12 months (34.5 vs. 29.7 %, p < 0.001). RYGB patients had increased resolution of all measured comorbidities: diabetes mellitus (61.6 vs. 50.8 %, p < 0.001), hypertension (43.1 vs. 34.5 %, p < 0.001), gastroesophageal reflux disease (53.9 vs. 32.5 %, p < 0.001), hyperlipidemia (39.7 vs. 32.5 %, p < 0.001), and obstructive sleep apnea (42.8 vs. 40.6 %, p = 0.058) at 12 months compared to SG patients. CONCLUSIONS There are significant differences in comorbidity improvement and resolution as well as weight loss between RYGB and SG in the SO population. There was no difference in overall 30-day complications, but more RYGB patients required readmission and reoperation. However, RYGB was considerably more effective in controlling obesity-related comorbidities. Our results favor performance of RYGB in SO patients of appropriate risk.
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Affiliation(s)
- Adam C Celio
- Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Blvd, Greenville, NC, 27834, USA
| | - Qiang Wu
- Department of Biostatistics, College of Allied Health Sciences, East Carolina University, Greenville, NC, USA
| | - Kevin R Kasten
- Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Blvd, Greenville, NC, 27834, USA
| | - Mark L Manwaring
- Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Blvd, Greenville, NC, 27834, USA
| | - Walter J Pories
- Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Blvd, Greenville, NC, 27834, USA
| | - Konstantinos Spaniolas
- Department of Surgery, Brody School of Medicine at East Carolina University, 600 Moye Blvd, Greenville, NC, 27834, USA.
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