Trends in Utilization and Relative Complication Rates of Bariatric Procedures

Bariatric surgery: trends in utilization, complications, conversions and revisions

BACKGROUND

Sleeve gastrectomy (SG) increased in popularity after 2010 but recent data suggest it has concerning rates of gastroesophageal reflux and need for conversions. This study aims to evaluate recent trends in the utilization of bariatric procedures, associated complications, and conversions using an administrative claims database in the United States.

METHODS

We included adults who had bariatric procedures from 2000 to 2020 with continuous enrollment for at least 6 months in the MarketScan Commercial Claims and Encounters database. Index bariatric procedures and subsequent revisions or conversions were identified using CPT codes. Baseline comorbidities and postoperative complications were identified with ICD-9-CM and ICD-10 codes. Cumulative incidences of complications were estimated at 30-days, 6-months, and 1-year and compared with stabilized inverse probability of treatment weighted Kaplan-Meier analysis.

RESULTS

We identified 349,411 bariatric procedures and 5521 conversions or revisions. The sampled SG volume appeared to begin declining in 2018 while Roux-en-Y gastric bypass (RYGB) remained steady. Compared to RYGB, SG was associated with lower 1-year incidence [aHR, (95% CIs)] for 30-days readmission [0.65, (0.64-0.68)], dehydration [0.75, (0.73-0.78)], nausea or vomiting [0.70, (0.69-0.72)], dysphagia [0.55, (0.53-0.57)], and gastrointestinal hemorrhage [0.43, (0.40-0.46)]. Compared to RYGB, SG was associated with higher 1-year incidence [aHR, (95% CIs)] of esophagogastroduodenoscopy [1.13, (1.11-1.15)], heartburn [1.38, (1.28-1.49)], gastritis [4.28, (4.14-4.44)], portal vein thrombosis [3.93, (2.82-5.48)], and hernias of all types [1.36, (1.34-1.39)]. There were more conversions from SG to RYGB than re-sleeving procedures. SG had a significantly lower 1-year incidence of other non-revisional surgical interventions when compared to RYGB.

CONCLUSIONS

The overall volume of bariatric procedures within the claims database appeared to be declining over the last 10 years. The decreasing proportion of SG and the increasing proportion of RYGB suggest the specific complications of SG may be driving this trend. Clearly, RYGB should remain an important tool in the bariatric surgeon's armamentarium.

Cumulative Incidence of Venous Thromboembolic Events In-Hospital, and at 1, 3, 6, and 12 Months After Metabolic and Bariatric Surgery: Systematic Review of 87 Studies and Meta-analysis of 2,731,797 Patients

Systematic review/meta-analysis of cumulative incidences of venous thromboembolic events (VTE) after metabolic and bariatric surgery (MBS). Electronic databases were searched for original studies. Proportional meta-analysis assessed cumulative VTE incidences. (PROSPERO ID:CRD42020184529). A total of 3066 records, and 87 studies were included (N patients = 4,991,683). Pooled in-hospital VTE of mainly laparoscopic studies = 0.15% (95% CI = 0.13-0.18%); pooled cumulative incidence increased to 0.50% (95% CI = 0.33-0.70%); 0.51% (95% CI = 0.38-0.65%); 0.72% (95% CI = 0.13-1.52%); 0.78% (95% CI = 0-3.49%) at 30 days and 3, 6, and 12 months, respectively. Studies using predominantly open approach exhibited higher incidence than laparoscopic studies. Within the first month, 60% of VTE occurred after discharge. North American and earlier studies had higher incidence than non-North American and more recent studies. This study is the first to generate detailed estimates of the incidence and patterns of VTE after MBS over time. The incidence of VTE after MBS is low. Improved estimates and time variations of VTE require longer-term designs, non-aggregated reporting of characteristics, and must consider many factors and the use of data registries. Extended surveillance of VTE after MBS is required.

Updates in Bariatric Surgery

Bariatric surgery is currently the most effective long-term treatment for morbid obesity as well as type-2 diabetes mellitus. The field of metabolic and bariatric surgery has seen tremendous growth over the past decade with dramatically reduced risks. This article aims to provide an update on bariatric surgery, highlighting the latest outcomes, improvements, and challenges in the field. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) released a major update to the indications for bariatric surgery at BMI ≥35 kg/m2 regardless of co-morbidities and 30-34.9 kg/m2 with obesity-related comorbidities. Sleeve gastrectomy has emerged as the most popular bariatric procedure in the last 10 years with its remarkable efficacy and safety profile. The implementation of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and Enhanced Recovery After Surgery (ERAS) protocols have significantly improved the quality of care for all bariatric patients. The recent introduction and FDA approval of Glucagon-Like Peptide-1 (GLP-1) agonists for chronic obesity has garnered significant media coverage and popularity, but no guidelines exist regarding its use in relation to bariatric surgery. This update underscores the need for tailored approaches, ongoing research, and the integration of evidence-based medicine and innovations to enhance patient care.

Extended Post Discharge Prophylaxis for Venous Thromboembolism Prevention After Bariatric Surgery

PURPOSE

The utility of routine post-discharge VTE prophylaxis after bariatric surgery remains a matter of debate. While inpatient chemical prophylaxis decreases the risk of fatal pulmonary embolism, most thromboembolic events occur after discharge and carry high morbidity and mortality. To address this risk, apixaban was introduced as extended prophylaxis for 30 days after surgery.

MATERIALS AND METHODS

The study ranges between 1/2014 and 7/2022. Apixaban was incorporated as routine extended prophylaxis protocol in 05/2017 and is dosed at 2.5 mg BID for 30 days. There were two study groups: those who received apixaban on discharge (n = 1443; 60%) and those who did not (n = 953; 40%). Patients with concern for postoperative bleeding (hypotension, unexplained tachycardia with hematocrit drop > 6%, hematocrit drop > 9%), or on preoperative anticoagulant/antiplatelet therapy (except aspirin), were not discharged on apixaban. Post-discharge VTE, readmission, transfusion, and reoperation rates were compared between groups.

RESULTS

There were 2396 consecutive primary bariatric operations: sleeve gastrectomy (1949; 81%), Roux-en-Y gastric bypass (419; 18%), and duodenal switch (28; 1%). There were no post-discharge VTEs in patients treated with apixaban vs. five (0.5%) VTEs in patients who did not receive treatment; p = 0.02. There was a higher incidence in post-discharge bleeding events in the apixaban group (0.5 vs 0.3%; p = 0.75), mostly requiring readmission for monitoring without intervention or transfusion. In the apixaban group, one patient underwent EGD for bleeding while another required blood transfusion; there were no reoperations for bleeding.

CONCLUSION

There were no post-discharge VTEs in patients who received apixaban. Treatment was associated with a higher risk of self-resolving bleeding events. This study adds to the increasing body of evidence supporting the benefit of routine, extended oral chemoprophylaxis after bariatric surgery.

Achieving durable compliance with venous thromboembolism prophylaxis in bariatric surgery: 3-year data from a major academic medical center

BACKGROUND

Metabolic and bariatric surgery (MBS) venous thromboembolism (VTE) prescribing practices vary widely. Our institutional VTE prophylaxis protocol has historically been unstandardized.

OBJECTIVES

To create a standardized MBS VTE prophylaxis protocol, track protocol compliance, and identify barriers to protocol compliance and address them with Plan-Do-Study-Act (PDSA) cycles.

SETTING

Single Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited academic hospital.

METHODS

We conducted a retrospective study for all patients undergoing MBS (January 2019 to September 2022). A multidisciplinary group of bariatric clinicians reviewed literature and developed the following standardized VTE prophylaxis protocol: 5000 units preoperative subcutaneous (SC) heparin within 60 minutes of anesthesia induction and postoperative 40 mg SC low molecular weight heparin (LMWH) within 24 hours of surgery. This protocol was distributed to relevant clinical stakeholders. We assessed monthly compliance rates through chart review. Goal compliance was ≥90%. We identified sources of noncompliance and addressed them with PDSA methodology.

RESULTS

A total of 796 patients were included. Preoperative heparin administration increased from a mean of 47% (107/228) preintervention to 96% (545/568) postintervention (P < .0001), and postoperative LMWH administration increased from 71% (47/66) to 96% (573/597, P = .0002). These compliance rates were sustained for 3 years. Barriers to protocol noncompliance included order set timing errors (n = 45), surgeon error (n = 44), surgeon discretion (n = 40), and nursing error (n = 20). No change in bleeding or VTE rates was observed.

CONCLUSIONS

Developing a standardized VTE prophylaxis protocol, monitoring process measures, and engaging relevant stakeholders in PDSA cycles resulted in drastic and durable improvement in VTE prophylaxis compliance rates.

Rate of Cardiovascular Events and Safety Outcomes Seven Years Following Gastric Bypass Versus Sleeve Gastrectomy

Objective

The study aimed to assess major adverse cardiovascular events (MACEs), complications requiring revision surgery, and bariatric conversion surgery 7 years after gastric bypass (GB) and sleeve gastrectomy (SG) using real-world data.

Background

GB and SG both result in weight loss and improved cardiometabolic health. Whether the long-term rate of MACE differs between the 2 bariatric procedures is unclear.

Methods

In this population-based retrospective cohort study, we used inhospital National Health Registry data from January 2012 to December 2018. Patients undergoing GB were 1:1 propensity score-matched with patients who had SG. The primary outcome was the incidence of MACE, defined as acute myocardial infarction, ischemic stroke, cardiac arrest, or hospitalization for heart failure. Secondary outcomes encompassed individual MACE components, postoperative complications, and the need for bariatric conversion surgery.

Results

Among 5240 propensity score-matched pairs, the incidence rate per 1000 person-years of MACE was 2.8 among patients undergoing GB and 3.2 among those undergoing SG (hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.62-1.37). Single components of MACE were not different between both groups. Patients after GB had a higher risk of long-term postoperative complications requiring a revision surgery compared with those after SG (HR, 3.53 [95% CI, 2.78-4.49]). Bariatric conversion surgery was less frequently performed among patients undergoing GB compared with patients undergoing SG (HR, 0.09 [95% CI, 0.06-0.13]).

Conclusions

In this study, the performance of GB versus SG was associated with a similar risk of MACE. While postoperative complications were more frequent among patients undergoing GB, patients following SG had a higher probability of bariatric conversion surgery.

Effectiveness of Body Mass Index-Based Prophylactic Enoxaparin Dosing in Bariatric Surgery Patients

INTRODUCTION

Enoxaparin is administered for venous thromboembolic (VTE) prophylaxis in bariatric surgery patients. There is concern whether body mass index (BMI)-based enoxaparin dosing consistently achieves prophylactic targets in patients with severe obesity.

METHODS

This retrospective study included patients who underwent bariatric surgery at an academic medical center from Jan 2015-May 2021 and had an anti-Xa level drawn 2.5-6 h after ≥3 doses of BMI-based prophylactic enoxaparin. The primary outcome was the percentage of patients who achieved a target anti-Xa level. Secondary outcomes were prevalence of venous thromboembolic and bleeding events within 30 d post-operatively.

RESULTS

Overall, 137 patients were included. Mean BMI was 59.1 ± 10.4 kg/m², mean age was 43.9 ± 13.3 y and 110 patients (80.3%) were female. Target anti-Xa levels were achieved in 116 patients (84.7%); 14 (10.2%) were above target and 7 (5.1%) were below target. Patients with above target anti-Xa levels were significantly shorter in height than those within target range (167.1 versus 159.8 cm, P = 0.003). Five patients (3.6%) had a bleeding event; no thromboembolisms occurred. Anti-Xa levels correlated more strongly with enoxaparin dose per unit estimated blood volume (EBV) than dose per unit BMI (Rho = 0.54 versus Rho = 0.33).

CONCLUSIONS

Target range anti-Xa levels were achieved in 85% of patients using BMI-based enoxaparin dosing. Patients with above target anti-Xa levels were significantly shorter by nearly 3 inches, suggesting an increased risk of overdosing enoxaparin in shorter, obese patients. An EBV-based dosing regimen may better account for patient height and is supported by a greater correlation with anti-Xa levels with dosing based on EBV than BMI.

"Orphaned" Stomach-An Infrequent Complication of Gastric Bypass Revision

While generally safe, bariatric operations have a variety of possible complications. We present an uncommon complication after gastric bypass revision, namely the creation of an "orphaned" segment of remnant stomach that was left inadvertently in discontinuity, leading to recurrent intra-abdominal abscesses. Sinogram ultimately proved the diagnosis, and the issue was successfully treated using a combination of surgical and endoscopic methods to control the abscess and to allow internal drainage.

Comparative Safety and Effectiveness of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy for Weight Loss and Type 2 Diabetes Across Race and Ethnicity in the PCORnet Bariatric Study Cohort

Importance

Bariatric surgery is the most effective treatment for severe obesity; yet it is unclear whether the long-term safety and comparative effectiveness of these operations differ across racial and ethnic groups.

Objective

To compare outcomes of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) across racial and ethnic groups in the National Patient-Centered Clinical Research Network (PCORnet) Bariatric Study.

Design, Setting, and Participants

This was a retrospective, observational, comparative effectiveness cohort study that comprised 25 health care systems in the PCORnet Bariatric Study. Patients were adults and adolescents aged 12 to 79 years who underwent a primary (first nonrevisional) RYGB or SG operation between January 1, 2005, and September 30, 2015, at participating health systems. Patient race and ethnicity included Black, Hispanic, White, other, and unrecorded. Data were analyzed from July 1, 2021, to January 17, 2022.

Exposure

RYGB or SG.

Outcomes

Percentage total weight loss (%TWL); type 2 diabetes remission, relapse, and change in hemoglobin A1c (HbA1c) level; and postsurgical safety and utilization outcomes (operations, interventions, revisions/conversions, endoscopy, hospitalizations, mortality, 30-day major adverse events) at 1, 3, and 5 years after surgery.

Results

A total of 36 871 patients (mean [SE] age, 45.0 [11.7] years; 29 746 female patients [81%]) were included in the weight analysis. Patients identified with the following race and ethnic categories: 6891 Black (19%), 8756 Hispanic (24%), 19 645 White (53%), 826 other (2%), and 783 unrecorded (2%). Weight loss and mean reductions in HbA1c level were larger for RYGB than SG in all years for Black, Hispanic, and White patients (difference in 5-year weight loss: Black, -7.6%; 95% CI, -8.0 to -7.1; P < .001; Hispanic, -6.2%; 95% CI, -6.6 to -5.9; P < .001; White, -5.9%; 95% CI, -6.3 to -5.7; P < .001; difference in change in year 5 HbA1c level: Black, -0.29; 95% CI, -0.51 to -0.08; P = .009; Hispanic, -0.45; 95% CI, -0.61 to -0.29; P < .001; and White, -0.25; 95% CI, -0.40 to -0.11; P = .001.) The magnitude of these differences was small among racial and ethnic groups (1%-3% of %TWL). Black and Hispanic patients had higher risk of hospitalization when they had RYGB compared with SG (hazard ratio [HR], 1.45; 95% CI, 1.17-1.79; P = .001 and 1.48; 95% CI, 1.22-1.79; P < .001, respectively). Hispanic patients had greater risk of all-cause mortality (HR, 2.41; 95% CI, 1.24-4.70; P = .01) and higher odds of a 30-day major adverse event (odds ratio, 1.92; 95% CI, 1.38-2.68; P < .001) for RYGB compared with SG. There was no interaction between race and ethnicity and operation type for diabetes remission and relapse.

Conclusions and Relevance

Variability of the comparative effectiveness of operations for %TWL and HbA1c level across race and ethnicity was clinically small; however, differences in safety and utilization outcomes were clinically and statistically significant for Black and Hispanic patients who had RYGB compared with SG. These findings can inform shared decision-making regarding bariatric operation choice for different racial and ethnic groups of patients.

Postoperative bleeding and leaks in sleeve gastrectomy are independent of both staple height and staple line oversewing

BACKGROUND

Over 100,000 sleeve gastrectomy procedures are performed annually in the USA. Despite technological advances, postoperative bleeding and gastric staple line leak are complications of this procedure. We analyzed patient-specific and perioperative factors to determine their association with these complications.

METHODS

We performed a retrospective cohort analysis of patients who underwent sleeve gastrectomy between 2005 and 2019 at our institution. Patient demographics, comorbidities, and procedure details including type of energy device, staple type, staple height, staple line oversewing, and staple line clipping were compared using multiple logistic regression for combined postoperative complications (blood transfusion, bleeding, and staple line leak). Postoperative bleeding was defined by requiring blood transfusion and/or re-operation to control bleeding. Staple line leak was confirmed radiographically.

RESULTS

There were 1213 patients who underwent sleeve gastrectomy. Fifty-two high-risk patients were excluded due to cirrhosis, end-stage renal disease, and anticoagulation use for left ventricular assist device. Of the remaining 1161 patients, twenty-five (2.2%) received postoperative blood transfusion, nine (0.8%) had postoperative bleeding, two (0.2%) had staple line leak, and twenty-eight patients (2.4%) had combined postoperative complications. The median age was significantly higher for patients with combined postoperative complications (43 vs 49; p = 0.02). There was no difference in postoperative blood transfusion, bleeding, staple line leak, or combined postoperative complication with different energy devices (p = 0.92), staple types (p = 0.21), staple heights (p = 0.50), or staple line suturing/clipping (p = 0.95). In addition, there was no difference in bleeding when comparing staple line sewing techniques (p = 0.44). Predictably, patients with combined postoperative complications had increased length of stay (3 days vs 1 day; p < 0.001).

CONCLUSION

Sleeve gastrectomy procedure has tremendous variability in technique and devices used. We observed no difference in the combined postoperative complications of bleeding or staple line leak with respect to different energy devices, staple height, or oversewing of the gastric staple line. Patient selection is crucial, as patient age and coagulopathic comorbidities were found to lead to higher combined postoperative complications.

The influence of summer closure on serious postoperative complications in bariatric surgery

Introduction

Bariatric surgery is an effective method of treating obesity, with gastric bypass and sleeve gastrectomy being the most common techniques used worldwide. Despite the technical challenges in these methods, little is known about the effects of summer closure on the incidence of serious postoperative complications in surgeries performed shortly after summer vacation. This has therefore been studied in our large cohort.

Materials and methods

A retrospective cohort study based on data from the Scandinavian Obesity Surgery Registry was conducted. Patients who underwent a primary gastric bypass or sleeve gastrectomy operation between 2010 and 2019 were included. The rate of serious complications within 30 days after surgery for patients who underwent surgery the first month after summer closure was compared to those who underwent surgery during the rest of the year using the χ² test and adjusted logistic regression.

Results

The study included 42,404 patients, 36,094 of whom underwent gastric bypass and 6310 of whom received sleeve gastrectomy. Summer closure was associated with an increased risk for serious postoperative complications in gastric bypass surgery (adjusted odds ratio (adj-OR) = 1.17; 95% confidence interval (CI): 1.01–1.36). No statistically significant association was seen for sleeve gastrectomy (adj-OR = 1.17; 95% CI: 0.72–1.91), nor in overall complication rate.

Conclusions

Summer closure increases the risk of serious postoperative complications in gastric bypass surgery. No statistically significant association was found for sleeve gastrectomy surgery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-022-02566-w.

Cohort profile: The Bariatric Experience Long Term (BELONG): a long-term prospective study to understand the psychosocial, environmental, health and behavioural predictors of weight loss and regain in patients who have bariatric surgery

PURPOSE

The Bariatric Experience Long Term (BELONG) prospective study cohort was created to address limitations in the literature regarding the relationship between surgical weight loss and psychosocial, health, behaviour and environmental factors. The BELONG cohort is unique because it contains 70% gastric sleeve and 64% patients with non-white race/ethnicity and was developed with strong stakeholder engagement including patients and providers.

PARTICIPANTS

The BELONG cohort study included 1975 patients preparing to have bariatric surgery who completed a baseline survey in a large integrated health system in Southern California. Patients were primarily women (84%), either black or Hispanic (59%), with a body mass index (BMI) of 45.1±7.4 kg/m², age 43.3±11.5 years old, and 32% had at least one comorbidity.

FINDINGS TO DATE

A total of 5552 patients were approached before surgery between February 2016 and May 2017, and 1975 (42%) completed a baseline survey. A total of 1203 (73%) patients completed the year 1 and 1033 (74%) patients completed the year 3 postoperative survey. Of these survey respondents, 1341 at baseline, 999 at year 1, and 951 at year 3 were included in the analyses of all survey and weight outcome data. A total of 803 (60% of eligible patients) had survey data for all time points. Data collected were self-reported constructs to support the proposed theoretical model. Height, weight and BMI were abstracted from the electronic medical record to obtain the main outcomes of the study: weight loss and regain.

FUTURE PLANS

We will collect self-reported constructs and obtain height, weight and BMI from the electronic medical record 5 years after bariatric surgery between April 2022 and January 2023. We will also collect patient experiences using focus groups of 8-12 patients each throughout 2022.

Minimally Invasive Revisional Bariatric Surgery in a MBSAQIP Accredited High-Volume Center

Background

With the rising number of bariatric surgeries performed annually, there has also been an increase in revisional bariatric surgeries (RBS). The aim of this study is to evaluate the safety and postoperative outcomes of RBS performed with a minimally invasive approach.

Methods

Retrospective analysis on a prospectively collected database of patients who underwent minimally invasive RBS between 2012 and 2019. Primary endpoints were conversion rate, major morbidity, mortality, and 30-day reoperation rate. Comparative analysis of laparoscopic adjustable gastric banding (LAGB) conversion to sleeve gastrectomy (SG) vs. conversion to Roux-en-Y gastric bypass (RYGB) was performed.

Results

A total of 221 patients underwent minimally invasive RBS, 137 (62%) laparoscopically and 84 (38%) robotically. The most common RBS were LAGB to SG (59.3%) and LAGB to RYGB conversions (16.7%). The main indication was weight loss failure (88.7%). Conversion rate, major morbidity, and mortality were 0.9, 3.2, and 0.4%, respectively. Urgent reoperation was required in 3.2% of cases. Total weight loss at 1 and 2-years follow- were 14.3 and 17.3%, respectively. Comparative analysis of LAGB conversion to SG vs. RYGB showed similar major morbidity (SG: 2.3% vs. RYGB 0%, p = 1). Greater total weight loss was achieved in LAGB to RYGB conversions at 1-year (SG: 14.8% vs. RYGB 25.3%, p < 0.001).

Conclusions

Minimally invasive RBS can be performed safely in a broad patient population with low conversion and complication rates, and improved weight loss outcomes. LAGB to RYGB conversions are associated with greater weight loss. Further randomized trials are needed to draw more conclusive recommendations.

Application of the Caprini Risk Assessment Model to Select Patients for Extended Thromboembolism Prophylaxis After Sleeve Gastrectomy

BACKGROUND

The Caprini risk assessment model is a well-validated tool that identifies patients who would benefit from extended venous thromboembolism (VTE) prophylaxis beyond hospital discharge. VTE, particularly portal mesenteric vein thrombosis (PMVT), is a potentially devastating complication of laparoscopic sleeve gastrectomy (LSG); therefore, we sought to examine whether the model can be safely applied to LSG patients. We hypothesized that its use can minimize the incidence of postoperative VTE, including PMVT, without increasing the likelihood of bleeding complications.

MATERIALS AND METHODS

We conducted a retrospective chart review of those patients who underwent LSG at our institution from 2010 and 2018, at which time the Caprini risk assessment model was already our institutional standard. We determined the patients' Caprini scores at the time of discharge and whether patients at high risk of VTE were discharged from hospital on extended courses of VTE prophylaxis. We also recorded if bleeding complications or VTE events occurred in the first 180 days after LSG.

RESULTS

Six hundred thirty-eight patients underwent LSG, including 521 (81.7%) women, with an average preoperative body mass index (BMI) of 44.4 kg/m² (SD 6.8). One hundred fifty-eight (24.8%) patients had Caprini scores that warranted extended courses of VTE prophylaxis beyond hospital discharge. Three patients (0.47%) developed a postoperative VTE, but no patient developed PMVT. No bleeding complications were observed among patients who received extended VTE prophylaxis.

CONCLUSION

The Caprini risk assessment model can effectively identify patients after LSG who might benefit from extended courses of VTE prophylaxis. Extended VTE prophylaxis does not seem to confer increased bleeding risk in this patient population.

First fully endoscopic metabolic procedure with NOTES gastrojejunostomy, controlled bypass length and duodenal exclusion: a 9-month porcine study

We conducted a pilot study of a potential endoscopic alternative to bariatric surgery. We developed a Natural Orifice Transluminal Endoscopic Surgery (NOTES) gastric bypass with controlled bypass limb length using four new devices including a dedicated lumen-apposing metal stent (GJ-LAMS) and pyloric duodenal exclusion device (DED). We evaluated procedural technical success, weight change from baseline, and adverse events in growing Landrace/Large-White pigs through 38 weeks after GJ-LAMS placement. Six pigs (age 2.5 months, mean baseline weight 26.1 ± 2.7 kg) had initial GJ-LAMS placement with controlled bypass limb length, followed by DED placement at 2 weeks. Technical success was 100%. GJ-LAMS migrated in 3 of 6, and DED migrated in 3 of 5 surviving pigs after mucosal abrasion. One pig died by Day 94. At 38 weeks, necropsy showed 100–240 cm limb length except for one at 760 cm. Weight gain was significantly lower in the pigs that underwent endoscopic bypass procedures compared to expected weight for age. This first survival study of a fully endoscopic controlled bypass length gastrojejunostomy with duodenal exclusion in a growing porcine model showed high technical success but significant adverse events. Future studies will include procedural and device optimizations and comparison to a control group.

Vasoconstrictor nasal spray causing life-threatening complications after bariatric surgery: A case report

Introduction and importance

Bariatric surgery is an evolving surgical field with increasing cases per year, as obesity is prevalent, especially in developed countries. Complication diagnosis and management can be challenging. Marginal ulcers and anastomosis perforation are rare, but their incidence is likely underestimated.

Case presentation

To the best of our knowledge, we present the first case with a two and a half years history of recurrent ischemia, marginal ulcers, and recurrent perforation after laparoscopic omega loop gastric bypass, most likely due to an abuse of an over-the-counter (OTC) sympathomimetic nasal spray. The complications (Clavien-Dindo classification IIIb) caused the necessity of recurrent hospitalizations and diagnostic interventions and an open conversion into Roux-Y gastric bypass in a damage control manner.

Clinical discussion and conclusion

Conclusively, we advocate evaluating drug abuse, including OTC medications that patients might not report on a daily-based medical history, as an etiology for marginal ulcers and anastomosis perforation, especially in late and recurrent cases.

•

Abuse of OTC sympathomimetic nasal spray can cause recurrent gastrojejunal anastomosis ischemia.

•

Re-Do surgery cannot prevent recurrence of ischemia in these cases.

•

In recurrence of ischemia, detailed medical history, including OTC drugs, is crucial.

Comparative Safety of Sleeve Gastrectomy and Gastric Bypass Up to 5 Years After Surgery in Patients With Severe Obesity

Importance

Sleeve gastrectomy is the most widely used bariatric operation; however, its long-term safety is largely unknown.

Objective

To compare the risk of mortality, complications, reintervention, and health care use 5 years after sleeve gastrectomy and gastric bypass.

Design, Setting, and Participants

This retrospective cohort study included adult patients in a national Medicare claims database who underwent sleeve gastrectomy or gastric bypass from January 1, 2012, to December 31, 2018. Instrumental variables survival analysis was used to estimate the cumulative incidence of outcomes up to 5 years after surgery.

Exposures

Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

Main Outcomes and Measures

The main outcome was risk of mortality, complications, and reinterventions up to 5 years after surgery. Secondary outcomes were health care use after surgery, including hospitalization, emergency department (ED) use, and total spending.

Results

Of 95 405 patients undergoing bariatric surgery, 57 003 (60%) underwent sleeve gastrectomy (mean [SD] age, 57.1 [11.8] years), of whom 42 299 (74.2%) were women; 124 (0.2%) were Asian; 10 101 (17.7%), Black; 1951 (3.4%), Hispanic; 314 (0.6%), North American Native; 43 194 (75.8%), White; 534 (0.9%), of other race or ethnicity; and 785 (1.4%), of unknown race or ethnicity. A total of 38 402 patients (40%) underwent gastric bypass (mean [SD] age, 55.9 [11.7] years), of whom 29 050 (75.7%) were women; 109 (0.3%), Asian; 6038 (15.7%), Black; 1215 (3.2%), Hispanic; 278 (0.7%), North American Native; 29 986 (78.1%), White; 373 (1.0%), of other race or ethnicity; and 404 (1.1%), of unknown race or ethnicity. Compared with patients undergoing gastric bypass, at 5 years after surgery, patients undergoing sleeve gastrectomy had a lower cumulative incidence of mortality (4.27%; 95% CI, 4.25%-4.30% vs 5.67%; 95% CI, 5.63%-5.69%), complications (22.10%; 95% CI, 22.06%-22.13% vs 29.03%; 95% CI, 28.99%-29.08%), and reintervention (25.23%; 95% CI, 25.19%-25.27% vs 33.57%; 95% CI, 33.52%-33.63%). Conversely, patients undergoing sleeve gastrectomy had a higher cumulative incidence of surgical revision at 5 years (2.91%; 95% CI, 2.90%-2.93% vs 1.46%; 95% CI, 1.45%-1.47%). The adjusted hazard ratio (aHR) of all-cause hospitalization and ED use was lower for patients undergoing sleeve gastrectomy at 1 year (hospitalization, aHR, 0.83; 95% CI, 0.80-0.86; ED use, aHR, 0.87; 95% CI, 0.84-0.90) and 3 years (hospitalization, aHR, 0.94; 95% CI, 0.90-0.98; ED use, aHR, 0.93; 95% CI, 0.90-0.97) after surgery but similar between groups at 5 years (hospitalization, aHR, 0.99; 95% CI, 0.94-1.04; ED use, aHR, 0.97; 95% CI, 0.92-1.01). Total health care spending among patients undergoing sleeve gastrectomy was lower at 1 year after surgery ($28 706; 95% CI, $27 866-$29 545 vs $30 663; 95% CI, $29 739-$31 587), but similar between groups at 3 ($57 411; 95% CI, $55 239-$59 584 vs $58 581; 95% CI, $56 551-$60 611) and 5 years ($86 584; 95% CI, $80 183-$92 984 vs $85 762; 95% CI, $82 600-$88 924).

Conclusions and Relevance

In a large cohort of patients undergoing bariatric surgery, sleeve gastrectomy was associated with a lower long-term risk of mortality, complications, and reinterventions but a higher long-term risk of surgical revision. Understanding the comparative safety of these operations may better inform patients and surgeons in their decision-making.

Obesity, metabolic syndrome, and inflammation: an update for anaesthetists caring for patients with obesity

Our understanding of chronic inflammation in obesity is evolving. Suggested mechanisms include hypoxia of adipose tissue and a subsequent increase in circulating cytokines. It is now known that adipose tissue, far from being an inert tissue, produces and secretes multiple peptides that influence inflammation and metabolism, including substrates of the renin-angiotensin-aldosterone system (RAAS). RAAS blocking antihypertensive medication and cholesterol-lowering agents are now being evaluated for their metabolic and inflammation-modulating effects. Surgery also has pro-inflammatory effects, which may be exacerbated in patients with obesity. This narrative review will summarise the recent literature surrounding obesity, metabolic syndrome, inflammation, and interplay with the RAAS, with evidence-based recommendations for the optimisation of patients with obesity, prior to surgery and anaesthesia.

Robotic Revisional Bariatric Surgery: a High-Volume Center Experience

PURPOSE

The number of bariatric revisional procedures is growing. Scarce evidence is available regarding the role and postoperative outcomes of robotic-assisted revisional bariatric surgery (RRBS). The aim of this study is to evaluate the safety and postoperative outcomes of RRBS.

MATERIALS AND METHODS

A retrospective analysis of a prospectively collected database of patients who underwent RRBS between 2012 and 2019 was performed. Primary outcomes of interest were 30-day major morbidity, mortality, length of hospital stay (LOS), urgent reoperation rates, and percentage of total weight loss (%TWL).

RESULTS

RRBS was performed in 76 patients; among these 60 (78.9%) underwent conversion to Roux-en-Y gastric bypass (C-RYGB). Failed weight loss (76%) and gastroesophageal reflux (9.2%) were the main indications for revision. Primary bariatric procedures included gastric band (LAGB) (50%), sleeve gastrectomy (SG) (40.8%), and RYGB (6.6%). Major morbidity and mortality rates were 3.9% and 1.3%, respectively. Mean LOS was 2.1 days, and 3 patients (3.9%) required urgent reoperation. The %TWL at 3, 6, 12, and 24 months was 10.2%, 16.6%, 18.3%, and 22.4% respectively. Comparative analysis of C-RYGB after failed LAGB and SG showed similar morbidity. Higher readmission rates (SG: 22.2% vs. LAGB: 0%, p = 0.007) and lower %EWL at 3, 6, 12, and 24 months were found in C-RYGB after SG.

CONCLUSION

This is one of the largest single-center series of RRBS published in the literature; the data indicate that robotic approach for revisional bariatric surgery is safe and helps achieving further weight loss. RRBS outcomes might be influenced by the primary procedure.

Impact of Resection Volume/Stapler Firings-Ratio on Perioperative Complications and Weight Loss After Laparoscopic Sleeve Gastrectomy

Background

Major postoperative morbidity after laparoscopic sleeve gastrectomy (LSG) is often related to staple line leaks (SLL). Of note, a recent study suggested a central role of the absolute numbers of stapler firings as a predictive factor for postoperative morbidity due to SLL. In addition, a larger gastric remnant volume could be responsible for lower weight loss after LSG, and nevertheless, the gastric resection volume (GRV) is strictly related to the residual volume.

Methods

Prospectively, collected data of 384 consecutive patients with complete follow-up at 12 months after LSG at our institution were retrospectively analyzed. Patients were stratified according to three different variables (i.e., number of stapler firings, GRV, and GRV/stapler firings-ratio), and respective impact on postoperative complications and weight loss was analyzed.

Results

High absolute number of stapler firings was linked to increased intraoperative and postoperative bleeding and prolonged hospitalization, but was not associated with SLL, transfusion rate or revisional procedures. Absolute GRV showed no impact on both complications and outcome after LSG. Interestingly, higher ratio of GRV/stapler firings was not only linked to decreased intraoperative bleeding and shorter hospital stay but also to higher Excess Body Mass Index Loss (EBMIL) at 12 months after LSG.

Conclusions

Here, we introduce GRV/stapler firings-ratio as a simple predictive factor for identifying patients at risk for postoperative complications and impaired weight loss that is superior compared with absolute number of stapler firings or GRV alone.

Obesity and esophageal cancer: GERD, Barrett´s esophagus, and molecular carcinogenic pathways

INTRODUCTION

Increases in the rates of esophageal adenocarcinoma (EAC) have paralleled rises in the prevalence of overweight and obesity. Despite not being fully understood, obesity-related EAC seems to have different carcinogenic pathways.

AREAS COVERED

This comprehensive review will thoroughly evaluate the current literature, describing the underlying mechanisms that help understanding the strong association between obesity and esophageal cancer.

EXPERT COMMENTARY

The risk of esophageal cancer among obese individuals could be partially explained by several factors: high prevalence of GERD; linear association between central adiposity and Barrett´s esophagus development; low levels of adiponectin and high levels of leptin that alter cell proliferation processes; insulin-resistant state that creates a tumorigenesis environment; and changes in the esophageal microbiota due to unhealthy dietary habits that promote carcinogenesis. In addition, a large proportion of obese patients are undergoing sleeve gastrectomy which can worsen GERD or cause de novo reflux, esophagitis, and Barrett´s metaplasia.

Wernicke's Encephalopathy Presenting as Sensorineural Hearing Loss

Sleeve gastrectomy is a restrictive-type weight loss surgery that can result in nutritional deficiencies, such as vitamin B1 (thiamine) deficiency. Although Wernicke’s encephalopathy is a known complication following bariatric surgery, bilateral sensorineural hearing loss is a rare presenting symptom of this condition. We present a case of a patient two months postoperative following a sleeve gastrectomy whose chief complaint was hearing loss. While initial laboratory evaluation of her complaint showed elevated inflammatory markers, prompting an autoimmune workup, ultimately the diagnosis of Wernicke’s encephalopathy was confirmed by a low thiamine level and magnetic resonance imaging findings. A correction of the patient’s thiamine deficiency led to an improvement of her symptoms.

Sengstaken-Blakemore Tube as a Rescue Treatment for Hemorrhagic Shock Secondary to Laparoscopic Adjustable Gastric Banding Erosion

Gastrointestinal bleeding is an uncommon but potentially life-threatening complication of laparoscopic adjustable gastric banding (LAGB) erosion. We present the use of a Sengstaken-Blakemore tube as a treatment device for severe gastrointestinal bleeding secondary to persistent LAGB erosion. A 72-year-old woman post-LAGB placement presented with hemorrhagic shock from gastric band erosion that was not responsive to endoscopic and angiographic interventions. A salvage attempt to tamponade with a Sengstaken-Blakemore tube resulted in successful resuscitation of the patient. When used judiciously, balloon tamponade serves as a replicable technique to control severe gastric band erosion refractory to standard management.

Complications of bariatric surgery in adolescents

Over the past decade, outcomes data have demonstrated the benefit of bariatric surgery in achieving both sustained weight loss and reversal of co-morbidities. Comparing these data to contemporary known risks of adolescent bariatric surgery informs the patients and providers considering bariatric procedures and provides insight into potential ways to reduce and manage complications. The goal of this article is to review the common surgical and postoperative complications following bariatric procedures and discuss approaches to improve their safety. A systematic review identifying bariatric surgery complications in adolescents was conducted. The review focused on the data relevant to adolescent bariatric surgery. However, when necessary, adult studies were used to address the gaps in available pediatric information. The data pertaining to the intraoperative, short term, and long term surgically related and nutritional related complications show that complication are declining with increasing experience. Specific recommendations and strategies to avoid major complications of bariatric surgery in adolescents are offered.