Ten year comparative analysis of sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch in patients with BMI ≥ 50 kg/m2

Decision-making Considerations in Revisional Bariatric Surgery

OBJECTIVE

With drastic variations in bariatric practices, consensus is lacking on an optimal approach for revisional bariatric surgeries.

MATERIALS AND METHODS

The authors reviewed and consolidated bariatric surgery literature to provide specific revision suggestions based on each index surgery, including adjustable gastric band (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS), single anastomosis duodenal-ileal bypass with sleeve (SADI-S), one anastomosis gastric bypass (OAGB), and vertical banded gastroplasty (VBG).

RESULTS

AGB has the highest weight recurrence rate and can be converted to RYGB, SG, and BPD-DS. After index SG, common surgical options include a resleeve or RYGB. The RYGB roux limb can be distalized and pouch resized in context of reflux, and the entire anatomy can be revised into BPD-DS. Data analyzing revisional surgery after a single anastomosis duodenal-ileal bypass with sleeve was limited. In patients with one anastomosis gastric bypass and vertical banded gastroplasty anatomy, most revisions were the conversion to RYGB.

CONCLUSIONS

As revisional bariatric surgery becomes more common, the best approach depends on the patient's indication for surgery and preexisting anatomy.

One-Stage Vs. Two-Step One Anastomosis Duodenal Switch (OADS/SADI-S): A Safety and Efficacy Single-Center Propensity-Score Matched Analysis

INTRODUCTION

One Anastomosis Duodenal Switch (OADS/SADI-S) is used both as a one stage and a second-step procedure, either planned or revisional after a failed sleeve gastrectomy. However, there is lack of adjusted comparative evidence validating its use.

MATERIAL AND METHODS

Propensity-score matched comparison between patients submitted to one-stage vs. two-step OADS, adjusted by age, gender, and initial body mass index (BMI).

RESULTS

One hundred ninety-five patients (130 one-stage and 65 two-step OADS) were included, with mean initial BMI 52.4 kg/m2. Overall complication rate was 6.6% in the short-term (3.3% Clavien-Dindo ≥ III), and 7.3% in the long-term, with no differences between groups. Follow-up at 1 and 3 years was 83.6% and 61.5%. After one-stage OADS, total weight loss was 36.6 ± 8.2% at 1 year and 30.4 ± 10.3% at 3 years, vs. 30.2 ± 9.4% and 25.6 ± 10.2% after two-steps OADS (p = 0.021). Resolution rates of diabetes mellitus, hypertension, dyslipidemia, and obstructive sleep apnea were 86.4%, 80.4%, 78.0%, and 73.3%, with no differences between groups.

CONCLUSION

One-stage OADS is a safe and effective bariatric technique for patients with grade III and IV obesity. The two-step strategy does not reduce postoperative risks and may compromise weight loss results at mid-term.

Ten-Year Outcomes Following Roux-en-Y Gastric Bypass vs Duodenal Switch for High Body Mass Index: A Randomized Clinical Trial

Importance

Results from long-term follow-up after biliopancreatic diversion with duodenal switch (DS) are scarce.

Objective

To compare weight loss, health outcomes, and quality of life 10 years or more after Roux-en-Y-gastric bypass (RYGB) and DS surgery in patients with severe obesity-that is, a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 50 to 60.

Design, Setting, and Participants

This open-label randomized clinical trial was conducted at 2 academic bariatric centers in Sweden and Norway. Sixty patients with a BMI of 50 to 60 were included from March 1, 2006, to August 31, 2007. Data were analyzed from August 12, 2022, to January 25, 2023.

Interventions

Laparoscopic RYGB or laparoscopic DS.

Main Outcomes and Measures

The main outcome was change in BMI after 10 or more years. Secondary outcomes included anthropometric measures, lipid and glycemic profiles, bone mass density, adverse events, gastrointestinal tract symptoms, and health-related quality of life.

Results

Forty-eight of the original 60 patients (80%) were assessed after a median of 12 (range, 9-13) years (mean [SD] age, 48.0 [6.0] years; 35 women [73%]). At follow-up, the mean BMI reductions were 11.0 (95% CI, 8.3-13.7) for RYGB and 20.3 (95% CI, 17.6-23.0) for DS, with a mean between-group difference of 9.3 (95% CI, 5.4-13.1; P < .001). Total weight loss was 20.0% (95% CI, 15.3%-24.7%) for RYGB and 33.9% (95% CI, 27.8%-40.0%) for DS (P = .001). Mean serum lipid levels, except high-density lipoprotein cholesterol and hemoglobin A1c, improved more in the DS group during follow-up. Bone mass was reduced for both groups from 5 to 10 years, with lower bone mass after DS at 10 years. Quality-of-life scores (Obesity-Related Problem Scale and the 36-Item Short Form Health Survey) were comparable across groups at 10 years. The total number of adverse events was higher after DS (135 vs 97 for RYGB; P = .02). More patients in the DS group developed vitamin deficiencies (21 vs 11 for RYGB; P = .008) including 25-hydroxyvitamin D deficiency (19 for DS vs 9 for RYGB; P = .005). Four of 29 patients in the DS group (14%) developed severe protein-caloric malnutrition, of whom 3 (10%) underwent revisional surgery.

Conclusions and Relevance

In this randomized clinical trial, BMI reduction was greater after DS, but RYGB had a better risk profile over 10 years. Biliopancreatic diversion with DS may not be a better surgical strategy than RYGB for patients with a BMI of 50 to 60.

Trial Registration

ClinicalTrials.gov Identifier: NCT00327912.

Bariatric surgery is as safe as other common operations: an analysis of the ACS-NSQIP

BACKGROUND

Metabolic and Bariatric Surgery (MBS) is the most effective management for patients with obesity and weight-related medical conditions. Nonetheless, some primary care physicians (PCPs) and surgeons from other specialties are reluctant to refer patients for MBS due to safety concerns.

OBJECTIVES

To compare the outcomes of patients who underwent MBS with those who underwent other common operations.

SETTING

American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP).

METHODS

Patients who underwent laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB), classified as MBS, were compared to nine frequently performed procedures including hip arthroplasty and laparoscopic cholecystectomy, appendectomy, colectomy, hysterectomy, and hernia repairs, among others. A multivariable logistic regression was constructed to compare outcomes including readmission, reoperation, extended length of stay (ELOS) (>75th percentile or ≥3 days) and mortality.

RESULTS

A total of 1.6 million patients were included, with 11.1% undergoing MBS. The odds of readmission were marginally lower in the cholecystectomy (adjusted odds ratio [aOR] = .88, 95% confidence interval (CI) [.85, .90]) and appendectomy (aOR = .88, 95% CI [.85, .90]) cohorts. Similarly, odds of ELOS were among the lowest, surpassed only by same-day procedures such as cholecystectomies and appendectomies. The MBS group had significantly low odds of mortality, comparable to safe anatomical procedures such as hernia repairs. Infectious and thrombotic complications were exceedingly rare and amongst the lowest after MBS.

CONCLUSIONS

MBS demonstrates a remarkably promising safety profile and compares favorably to other common procedures in the short-term. PCPs and surgeons from other specialties can confidently refer patients for these low-risk, lifesaving operations.

Analysis of the 1-year efficacy of four different surgical methods for treating Chinese super obese (BMI ≥ 50 kg/m2) patients

This study aimed to retrospectively analyze the perioperative and postoperative follow-up data of patients with super obesity who had undergone RYGB, SG, BPD/DS, and SADI-S. A retrospective observational study was conducted to analyze the perioperative and postoperative follow-up data of 60 patients with super obesity who had undergone bariatric surgery. A total of 34 men and 26 women were included in this study. The participants had an average preoperative BMI of 53.81 ± 3.25 kg/m2. The body weight and BMI of all four patient groups decreased significantly at 3, 6, and 12 months postoperatively compared with the preoperative values. Additionally, the TWL (%) and EWL (%) of all four groups increased gradually over the same period. Compared with the preoperative values, the systolic and diastolic blood pressure, glycosylated hemoglobin, uric acid, triglycerides, and total cholesterol decreased to varying degrees in the four groups 1 year postoperatively. RYGB, SG, BPD/DS, and SADI-S are all safe and effective in treating super obese patients and improving their metabolic diseases to a certain extent.

Reflux After Sleeve Gastrectomy: Safety and Effectiveness of Laparoscopic Ligamentum Teres Cardiopexy, a Single-Center Experience

BACKGROUND

Obesity is a well-known risk factor for gastroesophageal reflux disease (GERD). Even though symptoms may be mitigated or resolved with the weight loss caused by sleeve gastrectomy (SG), it may be associated with higher incidences of postoperative GERD. Ligamentum teres cardiopexy (LTC) is an alternative to Roux-en-Y gastric bypass, the gold standard treatment for GERD.

METHODS

This study was a retrospective single-center chart review, all patients in this cohort underwent LTC to treat refractory GERD at our institution. The option for LTC was presented after patients' refusal to undergo RYGB conversion. We collected baseline characteristics, standard demographics, pre-operative tests and imaging, and SG information, as well as intraoperative and perioperative data regarding LTC, and postoperative complications.

RESULTS

Our cohort included 29 patients; most were Caucasian (44.8%) females (86.2%). The mean weight and BMI before LTC were 216.5 ± 39.3 lb and 36.1 ± 5.4 kg/m2, respectively. Mean total body-weight loss (TBWL) at 12 and 24 months were 28.7% ± 9.5% and 28.4% ± 12.4%, respectively. The mean interval between the index bariatric surgery and LTC was 59.9 ± 34.9 months, mean operative time was 67 ± 18.2 min, and median length of stay (LOS) was 1 day (IQR = 1-2 days). Twelve patients (57.1%) were able to discontinue antisecretory medications, while 9 (42.9%) still required them to remain asymptomatic. Mortality and reoperation rates were 0% and the incidence of complication was 19.4% (n = 6).

CONCLUSIONS

LTC is a safe and effective surgical alternative to treat refractory GERD symptoms after SG.

Comparative multicenter analysis of sleeve gastrectomy, gastric bypass, and duodenal switch in patients with BMI ≥70kg/m2: a 2-year follow-up

Patients undergoing metabolic and bariatric surgery (MBS) with body mass index (BMI) ≥ 70 kg/m2 are considered a high-risk group. There is limited literature to guide surgeons on the perioperative safety as well as the different procedural outcomes of MBS in this cohort. Our aim is to compare the safety profiles, early- and medium-term outcomes of sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and duodenal switch (DS) in patients with BMI ≥ 70 kg/m2. A total of 156 patients with BMI ≥ 70kg/m2 underwent MBS (SG = 40, RYGB = 40, and DS = 76). Mean baseline BMI was 75.5 kg/m2. Total weight loss (%TWL) at 24 months was highest in the DS group compared to RYGB (40.6% versus 33.8%, P value = .03) and SG (40.6% versus 28.5%, P value = .006). There was no significant difference in %TWL between RYGB and SG (33.8% versus 28.5%, P value = .20). The 30-day complication rates were similar [SG (7.5%), RYGB (10%), and DS (9.2%) (P value = 1.0)]. There was one reported leak (DS). The 30-day mortality was zero. MBS is safe and effective in patients with BMI ≥ 70 kg/m2. All procedures had comparable safety profiles and complication rates. While DS achieved the highest %TWL at 24 months, similar comorbidity resolution rates among the procedures attenuate its clinical significance.

Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60 kg/m2): a Modified Delphi Study

BACKGROUND

Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60 kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology.

METHODS

A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70% of experts' votes was achieved.

RESULTS

A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations.

CONCLUSION

This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population.

Evaluation of Long-Term Nutrition Outcomes After Duodenal Switch: A Systematic Review and Meta-Analysis

BACKGROUND

Biliopancreatic diversion with duodenal switch (BPD-DS) is the most effective and durable metabolic and bariatric surgery to achieve a target weight loss. However, many surgeons are hesitant to adopt BPD-DS due to a lack of training, technical complexity, and long-term nutrition deficiencies. This meta-analysis aimed to investigate long-term nutrition outcomes after primary BPD-DS in the management of obesity.

METHODS

Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles from their inception to February 2023 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) system. The review was registered prospectively with PROSPERO (CRD42023391316).

RESULTS

From 834 studies screened, 8 studies met the eligibility criteria, with a total of 3443 patients with obesity undergoing primary BPD-DS. At long-term follow-up (≥5 years), 25.4% of patients had vitamin A deficiency (95% CI: -.012, .520, I2 = 94%), and 57.3% had vitamin D deficiency (95% CI: .059, 1.086, I2 = 86%). Calcium deficiency was observed in 125 patients (22.2%, 95% CI: .061, .383, I2 = 97%), and 69.7% had an abnormal parathyroid hormone level (95% CI: .548, .847, I2 = 78%). Ferritin level was abnormal in 30 patients (29.0%, 95% CI: .099, .481, I2 = 79%).

CONCLUSIONS

Despite displaying comparable nutrition-related outcomes to mid-term follow-up, our study demonstrated that BPD-DS could result in a high level of long-term nutrition deficiency after BPD-DS for selected patients. However, further randomized controlled studies with standardized supplementation regimens and improvement in compliance are necessary to evaluate and prevent long-term nutritional deficiencies after BPD-DS.

Management of Malnutrition and Hepatic Impairment After Duodenal Switch

BACKGROUND

Malnutrition and liver impairment after duodenal switch (DS) are possible and undesired complications, often conservatively treated. However, in specific cases, surgical revision may be necessary. This study aims to describe outcomes achieved by two bariatric surgery centers and address effectiveness and safety of revisional surgical procedures to resolve these complications.

METHODS

A retrospective chart review was performed in two bariatric surgery centers from 2008 to 2022. Patients who required revisional surgery to treat malnutrition and/or liver impairment refractory to nutritional and total parenteral nutrition intervention (TPN) after duodenal switch were included. No comparisons were performed due to the descriptive nature of this study.

RESULTS

Thirteen patients underwent revisional surgery, the mean age was 44.7, the 53.8% were females, and the mean preoperative BMI was 54.7 kg/m2; the mean time between DS and revisional procedure was 26.5 months, and 69.1% of patients were placed on TPN. One patient developed hepatic encephalopathy; one patient presented with ascites, pleural effusion, and renal insufficiency, undergoing reoperation after revisional procedure due to a perforated ileal loop. Mortality rate was 0%; all patients regained weight after the revisional procedure, and the mean total protein and albumin blood levels 12 months after surgery were 6.3 and 3.6 g/dl, respectively.

CONCLUSIONS

While refractory malnutrition and/or liver failure are rare among patients post-DS, if underdiagnosed and untreated, this can lead to irreversible outcomes and death. All revisional procedures included in this study resulted in improvement of the nutritional status and reversal of liver impairment, with low complication rates.

Third time's a charm: band to sleeve to bypass

BACKGROUND

Adjustable gastric bands (AGB) are frequently converted to sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) due to weight recurrence or band complications. Such conversions carry a higher-risk than primary procedures. Some patients undergo two conversions-from AGB to SG, and subsequently from SG to RYGB. This presents a unique situation with limited literature on indications and complication rates associated with these double conversions.

METHODS

We examined the 2020-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use File to evaluate conversions from AGB to SG and then to RYGB. Patient and operative characteristics, along with outcomes, were evaluated. Descriptive statistics were applied.

RESULTS

We identified 276 patients who underwent a conversion from AGB to SG and then to RYGB. The primary reason for the second conversion (SG to RYGB) was gastroesophageal reflux disease (GERD) at 55.1%, followed by inadequate weight loss or weight regain (IWL/WR) at 36.9%. The remaining reasons included dysphagia, nausea, vomiting, or others. Patients converted for IWL/WR demonstrated a higher baseline body mass index and prevalence of sleep apnea compared to other cohorts (both p < 0.001). Meanwhile, patients in the "other reasons" group had the highest rate of open surgical approaches (9.1%) and concurrent lysis of adhesions (p = 0.001 and p = 0.022), with correspondingly higher rates of anastomotic leak, reoperations, serious complications, and mortality.

CONCLUSIONS

Patients undergoing double conversions (AGB to SG to RYGB) do so primarily for GERD or IWL/WR. Further research is required to better define the optimal primary operation for each patient, aiming to reduce the necessity for multiple conversions.

Recent advances in bariatric surgery: a narrative review of weight loss procedures

Bariatric surgery has emerged as a highly effective option for individuals with obesity, offering significant and sustainable weight loss outcomes. This surgical approach involves various procedures that alter the anatomy of the gastrointestinal tract, leading to reduced food intake and nutrient absorption. Established procedures such as sleeve gastrectomy, gastric bypass, adjustable gastric banding, and biliopancreatic diversion with duodenal switch have proven track records. In contrast, emerging options like intragastric balloons, AspireAssist devices, and endoscopic sleeve gastroplasty show promise but require further investigation. Numerous studies have highlighted the remarkable benefits of bariatric surgery, not only in weight loss but also in the resolution of obesity-related comorbidities and significant improvements in quality of life. However, successful outcomes rely on a multidisciplinary approach, encompassing preoperative evaluation, patient selection, comprehensive postoperative care, nutritional support, and psychological counseling. Regular follow-up and adherence to postsurgical recommendations are crucial for sustained weight loss and positive long-term results. As bariatric surgery continues to evolve, tailored procedures based on individual needs and ongoing research hold the potential for even more refined and effective approaches. Through this ongoing advancement, bariatric surgery is poised to offer improved patient outcomes, transforming lives for those grappling with the challenges of obesity.

Long-Term Outcomes of Sleeve Gastrectomy: Weight Recurrence and Surgical Non-responders

INTRODUCTION

Sleeve gastrectomy (SG) is an effective procedure with remarkable weight loss and low complication rates. However, up to 30% of cases require revisional surgery in non-responders or patients who experience weight recurrence. We aim to report the rate of weight recurrence/non-responders (WR/NR) in patients who underwent SG and had more than 5 years of follow-up.

METHODS

We performed a multicenter retrospective study of patients who underwent initial SG from 2008 to 2017. Patient demographics and weight loss outcomes up to 12 years after SG were collected. Surgical non-responders were defined as 20% weight regain compared to maximum weight loss. A chi-square test for categorical variables and a two-sample t-test for continuous variables were used. Data are summarized as mean ± standard deviation.

RESULTS

From a total of 1263 patients, we included 339 patients (78% female, age 47.3 ± 11.2 years; baseline weight 125.8 ± 27.6 kg) with at least 5 years of follow-up (mean follow-up of 7.1 ± 1.8 years) (Table 1). Surgical non-response was demonstrated in 15.9% of patients (n=54) and 64.0% (n=217) had weight recurrence after SG (Fig. 1). There was a statistically significant difference in history of hypertension (p=0.046) and diabetes (p=0.032) as well as %TBWL at 1 year (p=0.005) and at longest follow-up (p<0.001) between patients who experienced WR/NR and those who did not.

CONCLUSIONS

Only 20% of patients who underwent SG and followed up for more than 5 years were able to maintain appropriate weight loss.

The role of diabetes severity scores in predicting disease remission in patients with BMI > 50 kg/m2 undergoing Roux-En-Y gastric bypass and sleeve gastrectomy: a multi-centered study

BACKGROUND

Roux-En-Y gastric bypass (RYGB) and Sleeve Gastrectomy (SG) have shown to be two of the most effective interventions to enhance weight loss and associated type-2 diabetes mellitus (T2DM) remission. However, a significant number of patients, particularly with BMI ≥ 50 kg/m2, do not achieve T2DM remission after bariatric surgeries. The individualized metabolic surgery (IMS) and Robert et al. scores are two scores that characterize T2DM severity and predict disease remission after bariatric surgeries. We aim to assess the validity of these scores in predicting T2DM remission in our cohort of patients with BMI ≥ 50 kg/m2 with long-term follow-up.

METHODS

This is a retrospective cohort study of all patients with T2DM, have a BMI ≥ 50 kg/m2, and underwent RYGB or SG in two different US bariatric surgery centers of excellence. The study endpoints included validating the IMS and Robert et al. scores in our cohort and evaluating the presence of any significant differences between RYGB and SG in terms of T2DM remission predicted by each of these scores. Data are presented as mean (standard deviation).

RESULTS

A total of 160 patients (66.3% females, mean age 51.0 [11.8] years) had IMS score and 238 patients (66.4% females, age 50.8 [11.4] years) had Robert et al. score data. Both scores predicted T2DM remission in our patients with BMI ≥ 50 kg/m2 with ROC AUC 0.79 for the IMS score and 0.83 for Robert et al. score. Patients with lower IMS scores and higher Robert et al. scores had higher T2DM remission rates. RYGB and SG had similar T2DM remission rates over the long-term follow-up.

CONCLUSION

We demonstrate the ability of the IMS and Robert et al. scores to predict T2DM remission in patients with BMI ≥ 50 kg/m2. T2DM remission was shown to decrease with more severe IMS scores and lower Robert et al. scores.

Bariatric surgery and left ventricular assist device in patients with heart failure: A systematic review and meta-analysis

BACKGROUND

The role of metabolic and bariatric surgery (MBS), in synergy with left ventricular assist device (LVAD) implantation, in the scope of end-stage heart failure management for patients with severe obesity is not well elucidated.

METHODS

We conducted a meta-analysis using Cochrane, Embase, PubMed, and Scopus databases to include articles from their inception to November 2022.

RESULTS

A total of 271 patients who underwent MBS during or after the LVAD implantation were included from eleven separate studies. After surgery, 67.4% of patients were listed on the heart transplant waitlist with 32.5% undergoing a successful transplant. We reported a mean listing time of 13.8 months. Finally, the pooled postoperative complication rate, 30-day readmission rate, and one-year mortality rate were 47.6%, 23.6% and 10.2% respectively.

CONCLUSIONS

MBS and LVAD is a safe and effective approach to bridge patients with severe obesity and end-stage heart failure for definitive heart transplantation.

Management of abdominal wall hernias in patients with severe obesity

Obesity is a risk factor for abdominal wall hernia development and hernia recurrence. The management of these two pathologies is complex and often entwined. Bariatric and ventral hernia surgery require careful consideration of physiologic and technical components for optimal outcomes. In this review, a multidisciplinary group of Society of American Gastrointestinal and Endoscopic Surgeons' bariatric and hernia surgeons present the various weight loss modalities available for the pre-operative optimization of patients with severe obesity and concurrent hernias. The group also details the technical aspects of managing abdominal wall defects during weight loss procedures and suggests the optimal timing of definitive hernia repair after bariatric surgery. Since level one evidence is not available on some of the topics covered by this review, expert opinion was implemented in some instances. Additional high-quality research in this area will allow for better recommendations and therefore treatment strategies for these complex patients.

Marginal Ulcers after Roux-en-Y Gastric Bypass: Etiology, Diagnosis, and Management

Marginal ulcer (MU) is a potential complication following Roux-en-Y gastric bypass (RYGB), with a mean prevalence of 4.6%. Early identification and prompt intervention are crucial to mitigating further complications. The pathophysiology of MU is complex and involves multiple factors, including smoking, Helicobacter pylori infection, non-steroidal anti-inflammatory drug (NSAID) use, and larger pouch size. Patients with MU may experience acute or chronic abdominal pain. Rarely, they may present with a complication from the ulceration, such as bleeding, perforation, or strictures. Following diagnosis by endoscopy, management of MU typically involves modification of risk factors and medical therapy focused on proton pump inhibitors. In case of complicated ulcers, surgical intervention is often required for the repair of the perforation or resection of the stricture. For recurrent or recalcitrant ulcers, endoscopic coverage of the ulcer bed, resection of the anastomosis, and abdominal or thoracoscopic truncal vagotomy may be considered. This review aims at providing an overview of the etiology, diagnosis, and management of MU after RYGB.

Diabetes Mellitus Remission in Patients with BMI > 50 kg/m2 after Bariatric Surgeries: A Real-World Multi-Centered Study

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a common comorbidity associated with obesity, particularly in patients with body mass index (BMI) ≥ 50 kg/m². We aim to study real-world T2DM long-term remission in patients with BMI ≥ 50 kg/m² following Roux-En-Y gastric bypass (RYGB) or sleeve gastrectomy (SG).

METHODS

This was a retrospective study of the electronic medical records of all patients with BMI ≥ 50 kg/m², T2DM, and have undergone RYGB or SG at three tertiary referral centers in the United States. We assessed the change in T2DM outcomes after bariatric surgery using a matched paired t-test for continuous variables and Bowker and Pearson test for categorical variables. We performed a multivariate logistic regression to determine predictors of remission.

RESULTS

A total of 279 patients with T2DM (65% females, mean age 51.0 ± 11.7 years, 89% white, BMI 56.6 ± 5.9 kg/m²) were analyzed. Long-term T2DM remission (≥ 5 years) was demonstrated in 47% of patients. The duration of T2DM (p < 0.0001), number of T2DM medications (p = 0.003) and weight loss (p = 0.048) were the only independent factors for long-term T2DM remission.

CONCLUSIONS

In this cohort of patients with BMI ≥ 50 kg/m², RYGB and SG demonstrated significant and similar long-term T2DM remission rates and weight loss outcomes.

Predictors of marginal ulcer after gastric bypass: a systematic review and meta-analysis

INTRODUCTION

Marginal ulcer (MU) is a common complication following Roux-en-Y gastric bypass (RYGB) with an incidence rate of up to 25%. Several studies have evaluated different risk factors associated with MU with inconsistent findings. In this meta-analysis, we aimed to identify the predictors of MU after RYGB.

METHODS

A comprehensive literature search of PubMed, Embase, and Web of Science databases was conducted through April 2022. All studies that used a multivariate model to assess risk factors for MU after RYGB were included. Pooled odds ratios (OR) with 95% confidence intervals (CI) for risk factors reported in ≥ 3 studies were obtained within a random-effects model.

RESULTS

Fourteen studies with 344,829 patients who underwent RYGB were included. Eleven different risk factors were analyzed. Meta-analysis demonstrated that Helicobacter pylori (HP) infection (OR 4.97 [2.24-10.99]), smoking (OR 2.50 [1.76-3.54]), and diabetes mellitus (OR 1.80 [1.15-2.80]), were significant predictors of MU. Increased age, body mass index, female gender, obstructive sleep apnea, hypertension, and alcohol use were not predictors of MU. There was a trend of an increased risk of MU associated with nonsteroidal anti-inflammatory drugs (OR 2.43 [0.72-8.21]) and a lower risk of MU with proton pump inhibitors use (OR 0.44 [0.11-2.11]).

CONCLUSIONS

Smoking cessation, optimizing glycemic control, and eradication of HP infection reduce the risk of MU following RYGB. Recognition of predictors of MU after RYGB will allow physicians to identify high-risk patients, improve surgical outcomes, and reduce the risk of MU.

Duodenal switch without versus with laparoscopic cholecystectomy: a perioperative risk comparative analysis of the MBSAQIP database (2015-2019)

BACKGROUND

The results of concurrent cholecystectomy with Roux-en Y gastric bypass and sleeve gastrectomy have been well elucidated. Large-scale data on the outcomes of concomitant cholecystectomy during biliopancreatic diversion with duodenal switch (BPD-DS) are still lacking. Our study aimed to explore whether simultaneous cholecystectomy with BPD-DS alters the 30-day postoperative outcomes.

METHODS

We conducted a retrospective analysis of the MBSAQIP database between 2015 and 2019. Propensity-score matching (PSM) in BPD-DS with cholecystectomy (Group 1) and BPD-DS without cholecystectomy (Group 2) cohorts was performed (PSM ratio 1:2). The two groups were matched for a total of 21 baseline variables including age, gender, BMI, ASA class, and other medical comorbidities and conditions. The 30-day postoperative morbidity, mortality, reoperation, reintervention, and readmissions were obtained.

RESULTS

Initially, 568 patients in Group 1 and 5079 in Group 2 were identified. After performing PSM, 564 and 1128 patients respectively were compared. The BPD-DS with cholecystectomy group reported a higher rate of reoperation and reintervention compared to BPD-DS alone (3.9% versus 2.4% and 3.2% versus 2%, respectively), even though it did not reach statistical significance. The intervention time was significantly higher in Group 1 compared to Group 2 (192.4 ± 77.6 versus 126.4 ± 61.4 min). Clavien-Dindo complications (1-5) were similar between these two PSM cohorts.

CONCLUSION

Concomitant cholecystectomy during BPD-DS increases operative times but does not affect the other outcomes. Based on our results, the decision of cholecystectomy at the time of BPD-DS should be left to the surgeon's judgment.

Impact of Chronic Immunosuppression on Short-, Mid-, and Long-Term Bariatric Surgery Outcomes

INTRODUCTION

Bariatric surgical outcomes depend heavily on proper healing of gastrointestinal anatomy, metabolic alterations, and patient lifestyle modifications which are all negatively impacted by immunosuppression and underlying inflammatory diseases. There is a lack of literature exploring how patients with diseases requiring immunosuppression respond to bariatric surgical intervention in the long term.

METHODS

A retrospective analysis of chronically immunosuppressed patients who underwent primary bariatric surgeries at Mayo Clinic was conducted (2008-2020). Data collected included patient demographics, BMI, underlying disease, and immunosuppression regimen and complications at 3, 6, 12, 24, and 60 months.

RESULTS

We identified a total of 89 (RYGB = 49, SG = 34, BPD/DS = 6) patients on chronic immunosuppression who underwent bariatric surgery at our center. RYGB (N = 49), 38.2% had a SG (N = 34) and 6.7% had a BPD/DS (N = 6). Rheumatoid arthritis and renal transplantation were the most underlying condition at 20.22% each (N = 18). There were a total of 2 (2.25%) intraoperative complications. In the immediate post-operative period, there were 15 (16.5%) minor complications. In follow-up, 6.1% of RYGB patients experienced marginal ulcerations, while no gastrointestinal leaks occurred. The mean pre-surgical BMI was 48.29 kg/m² (SD = 18.41). Percent total weight loss (%TWL) and BMI reduction were 30.89% and 14.83 kg/m² (SD = 9.07) at 12 months and 29.48% and 14.43 kg/m² (SD = 13.46) at 60 months, respectively. The mean follow-up time was 30.49 months.

CONCLUSIONS

Bariatric surgery remains safe and effective therapy for chronically immunosuppressed patients with excellent long-term outcomes for patients with moderate to severe obesity.

Single Versus Double Anastomosis Duodenal Switch in the Management of Obesity: A Meta-analysis and Systematic Review

BACKGROUND

Biliopancreatic diversion with duodenal switch (BPD-DS) is an effective yet technically challenging bariatric surgery with many complications. Alternatively, single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) was recently introduced as a simplified bariatric procedure. This meta-analysis aimed to assess the safety and efficacy of SADI-S compared with BPD-DS in the management of patients with obesity.

METHODS

Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles from their inception to May 2022 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis system. The review was registered prospectively with PROSPERO (CRD42022333521).

RESULTS

From 123 studies screened, 6 studies met the eligibility criteria, with a total of 1847 patients with obesity undergoing either SADI-S (n=818) or BPD-DS (n=1029). Preoperative body mass index was similar between the 2 groups, and the BPD-DS group had a greater % excess body mass index loss (EBMIL) (MD=-10.16%, 95% confidence interval: -11.80, -8.51, I2=0%) at 2 years compared with the SADI-S group. There was no difference observed in preoperative comorbidities and remission, including diabetes, hypertension, and dyslipidemia between SADI-S and BPD-DS cohorts. Compared with BPD-DS, SADI-S had shorter hospital stays (MD=-1.36 d, 95% CI: -2.39, -0.33, I2=86%), and fewer long-term (>30 d) complications (OR=0.56, 95% CI: 0.42, 0.74, I2=20%). Conversely, among nutritional deficiency outcomes, the SADI-S group had few patients with abnormal vitamin D (OR=0.51, 95% CI: 0.36, 0.72, I2=0%) values than the BPD-DS group.

CONCLUSIONS

SADI-S has shown to be a possible alternative treatment option to BPD-DS in managing patients with obesity. Despite the promising results, further randomized controlled studies with more extended follow-up periods are necessary to ascertain the safety and efficacy of the treatment.

Does BMI Matter? A 10-Year Single Institutional Experience on 571 Bariatric Surgery Patients With BMI >50 kg/m2

INTRODUCTION

Patients undergoing bariatric surgery with body mass index (BMI) >50 kg/m2 are at a higher risk of surgical morbidity when compared with less obese patients, however, there is limited data correlating surgical risk and efficacy with increasing BMI in patients with severe obesity. We hypothesize that regardless of the degree above 50 kg/m2 their BMI, patients with severe obesity respond similarly to bariatric surgery.

MATERIALS AND METHODS

We performed a retrospective analysis of patients with BMI >50 kg/m2 who underwent biliopancreatic diversion with duodenal switch, Roux-en-Y gastric bypass, or sleeve gastrectomy at a single institution. Outcomes were compared in patients with a BMI between 50 and 60 kg/m2 to patients with a BMI >60 kg/m2 and included percent total weight loss as well as early and late complications. Statistical analyses were performed using logistic regression, univariate, and multivariate models.

RESULTS

There were 571 patients with BMI >50 kg/m2 who underwent bariatric surgery at our center, 170 (29.8%) had a BMI >60 kg/m2. Percent total weight loss was statistically significant between the BMI 50 and 60 kg/m2 and BMI >60 kg/m2 groups at 24 months (P=0.047) but not at 60 months (P=0.54). No significant difference was found in the incidence of early complications in a univariate (P=0.46) or a multivariate (P=0.06) analysis. The BMI >60 subgroup was associated with a higher rate of late complications in univariate analysis (heart rate=2.37; 1.03-5.47, P=0.04), but not in multivariate analysis (P=0.78).

CONCLUSIONS

Efficacy and complication rates of bariatric surgeries are similar in patients with BMI 50 to 60 kg/m2 and >60 kg/m2, providing evidence supporting similar management of patients despite specific subgroups.