Sleeve gastrectomy for morbid obesity

Imaging Pearls and Pitfalls Following Common and Rare Bariatric Procedures

Bariatric surgery is an effective approach to management of morbid obesity. Given its increasing popularity worldwide, post-operative imaging of patients following bariatric surgery is frequently encountered in clinical practice. In this article we review the physiological principles, normal post-operative anatomy, and imaging appearance of common bariatric procedures (Roux-en-Y gastric bypass, vertical sleeve gastrectomy, and laparoscopic adjustable gastric banding) as well as less common bariatric procedures (including intragastric balloon and biliopancreatic diversion with duodenal switch). Technical considerations and imaging pearls for identifying perioperative and late complications following bariatric procedures will be illustrated through fluoroscopic upper GI studies and computed tomography case examples. Familiarity with expected anatomy and imaging appearances following bariatric procedures allows the radiologist to play a key role in early identification and management of postoperative complications.

Mechanisms through which laparoscopic sleeve gastrectomy mitigates atherosclerosis risk: a focus on visceral adipose tissue

Bariatric surgery is currently considered the key treatment method for patients with obesity and related complications. Among the various surgeries, laparoscopic sleeve gastrectomy (LSG) is the most widely used. Obesity is a multifactor chronic disease characterized by the accumulation of visceral adipose tissue (VAT), leading to susceptibility to cardiac metabolic diseases. Many mechanisms, including abnormal lipid metabolism, insulin resistance, inflammation, endothelial dysfunction, adipocytokine imbalance and inflammasome activation, have been identified as the basis for the relationship between obesity and atherosclerosis. Bariatric surgery, such as LSG, reduces the risk of atherosclerosis in people living with obesity by reducing energy intake, disrupting energy balance and reducing the secretion of intestinal hormones to intervene in these risk factors. This review explores the current understanding of how LSG affects VAT and its impact on the risk of atherosclerosis.

Impact of immunosuppression medication management on short-term complications following sleeve gastrectomy

BACKGROUND

Sleeve gastrectomy (SG) is the most performed bariatric procedure in the United States due to its favorable safety profile. However, managing patients on chronic immunosuppressive therapy (CIT) during bariatric surgery poses challenges, particularly in balancing surgical outcomes with the risks associated with CIT interruption. This study aims to compare the short-term outcomes of SG in patients who temporarily discontinued CIT versus those who continued it perioperatively.

METHODS

A retrospective review was conducted of 75 patients on CIT who underwent SG at a single academic center between 2008 and 2022. Patients were categorized based on perioperative CIT management: 20 (26.7%) interrupted CIT and 55 (73.3%) continued therapy. Data on patient demographics, CIT indications, operative details, and short-term outcomes, including complications and readmissions, were analyzed.

RESULTS

The most common CIT indication was organ transplantation (61.4%), predominantly in the non-interruption group, while rheumatoid arthritis was the leading indication (50%) among patients who interrupted CIT. Early complications (≤ 30 days) were significantly higher in the non-interruption group (20% vs. 5%, p = 0.031), with bleeding being the most frequent (7 cases), followed by wound infections (4 cases). In contrast, the interruption group experienced only one complication, a wound infection. Weight outcomes were similar between groups, with no significant differences in percentage of total weight loss (%TWL) at 3 or 6 months. Notably, the interruption group had no 30-day readmissions or reoperations, compared to 16.4% and 5.5%, respectively, in the non-interruption group.

CONCLUSIONS

Temporary interruption of CIT in SG patients is associated with lower early complication rates and improved short-term outcomes. These findings highlight the importance of individualized perioperative CIT management and suggest potential benefits of CIT interruption when clinically feasible.

Unlocking Fertility: How Nitric Oxide Pathways Connect Obesity and Reproductive Health-The Role of Bariatric Surgery

This study examines the relationship between obesity, oxidative stress, and reproductive dysfunction. It focuses on the effects of sleeve gastrectomy on gene expression and hormone profiles in 29 women with severe obesity (BMI ≥ 40 kg/m2). Pre- and post-surgical investigations revealed significant differences in major gene expressions and hormonal markers. CART expression reduced significantly from 0.27 ± 4.43 to -3.42 ± 1.14 (p < 0.001), while leptin expression decreased from -1.87 ± 1.75 to -0.13 ± 1.55 (p < 0.001), indicating better metabolic regulation. In contrast, eNOS expression increased considerably from -4.87 ± 1.70 to 1.18 ± 2.31 (p = 0.003), indicating improved endothelial function and nitric oxide bioavailability, which is critical for vascular health and reproduction. Correlation research before surgery indicated no significant relationships between eNOS, CART, or leptin and clinical indicators, implying that these genes function independently in pre-surgical metabolism. While most associations remained negligible after surgery, a significant negative connection between eNOS expression and SHBG levels appeared (r = -0.365, p = 0.049), indicating potential interactions in hormonal regulation pathways following metabolic improvements. These findings emphasize the importance of bariatric surgery in reducing the negative effects of obesity on reproductive health by altering critical cellular pathways. Significant increases in CART, leptin, and eNOS expression indicate reduced oxidative stress, improved vascular tone, and hormonal balance, all of which contribute to increased reproductive capacity. This study sheds light on the molecular processes that link obesity, metabolic health, and fertility, underlining bariatric surgery's therapeutic potential for women experiencing obesity-related infertility.

Comparative analysis of readmission rates and outcomes: Sleeve gastrectomy with versus without Nissen fundoplication using a National Database

Laparoscopic sleeve gastrectomy (LSG) is the most frequently performed bariatric procedure. To study the safety of LSG done with Nissen Fundoplication (NF) in patients affected by obesity and GERD and assess the complication rate. A retrospective cohort study using the Nationwide Readmissions Database from 2016 to 2019. A total of 236111 patients underwent LSG with and without NF. A matched cohort of 1096 without NF and 548 with NF was obtained. The median age of patients was 47 years old. Median length of hospital stay was higher in the LSG with NF group. Median total charge was higher in the LSG with NF group. There was no statistically significant difference in 30-day readmission rates in patients with obesity and GERD who received LSG with NF compared to those who received LSG alone. Complications after both procedures were low, which highlights the safety of both procedures.

A Study of Omentum Reduction on the Improvement of Nausea and vomiting and Gastroesophageal Reflux Symptoms After Laparoscopic Gastric Sleeve Resection

OBJECTIVE

To investigate the effect of omentum reduction in laparoscopic sleeve gastrectomy (LSG) on the improvement of postoperative nausea and vomiting and gastroesophageal reflux symptoms.

METHODS

A retrospective study was performed on the case data of 198 obese patients who underwent LSG in the Department of Obesity and Metabolic Diseases of Xiaolan People's Hospital of Zhongshan from March 2021 to March 2022 and were divided into omentum reduction group and control group, with 99 cases in each group, and the preoperative body mass index (BMI) of the patients was recorded. Age, gender, comorbidities, and comparative analysis of operation time, blood loss, length of hospital stay, postoperative nausea and vomiting score, gastroesophageal reflux GerdQ score, postoperative pain score, weight, and postoperative complications were analyzed.

RESULTS

There were no significant differences in preoperative BMI, age, gender and comorbidities between the two groups (P > 0.05), but there were significant differences in intraoperative blood loss and operation time (P < 0.05). There were differences in postoperative nausea and vomiting scores and VAS pain scores between the two groups (P < 0.05). The GerdQ scores of the omental reduction group were 8.11 ± 2.84 points at 1 year, and those in the control group were 7.56 ± 2.67 points, which were 3.97 ± 4.09 points higher than those in the preoperative omentum reduction group and 3.42 ± 3.41 in the control group, with no significant difference (P > 0.05). There was no significant difference in the postoperative excess weight loss rate %EWL and postoperative complications (p > 0.05).

CONCLUSION

Omentum reduction can improve short-term nausea and vomiting after LSG, but it cannot significantly improve long-term reflux symptoms.

Incidence of Postoperative Diabetes Mellitus After Roux-en-Y Reconstruction for Gastric Cancer: Retrospective Single-Center Cohort Study

Background

Sleeve gastrectomy is an effective surgical option for morbid obesity, and it improves glucose homeostasis. In patients with gastric cancer and type 2 diabetes mellitus (DM), gastrectomy, including total gastrectomy, is beneficial for glycemic control.

Objective

This study aims to clarify the effects of gastrectomy and different reconstructive techniques on the incidence of postoperative DM in patients with gastric cancer.

Methods

This retrospective, single-center, cohort study included 715 patients without DM who underwent total gastrectomy at the Tokyo Metropolitan Bokutoh Hospital between August 2005 and March 2019. Patients underwent reconstruction by Roux-en-Y (RY) gastric bypass or other surgical techniques (OT), with DM onset determined by hemoglobin A1c levels or medical records. Analyses included 2-sample, 2-tailed t tests; χ2 tests; and the Kaplan-Meier method with log-rank tests to compare the onset curves between the RY and OT groups, along with additional curves stratified by sex. A Swimmer plot for censoring and new-onset DM was implemented.

Results

Stratified data analysis compared the RY and OT reconstruction methods. The hazard ratio was 1.52 (95% CI 1.06-2.18; P=.02), which indicated a statistically significant difference in the incidence of new-onset diabetes between the RY and OT groups in patients with gastric cancer. The hazard ratio after propensity score matching was 1.42 (95% CI 1.09-1.86; P=.009).

Conclusions

This first-of-its-kind study provides insight into how different methods of gastric reconstruction affect postoperative diabetes. The results suggest significant differences in new-onset DM after surgery based on the reconstruction method. This research highlights the need for careful surgical planning to consider potential postoperative DM, particularly in patients with a family history of DM. Future studies should investigate the role of gut microbiota and other reconstructive techniques, such as laparoscopic jejunal interposition, in developing postoperative DM.

Cholelithiasis, Gut Microbiota and Bile Acids after Bariatric Surgery-Can Cholelithiasis Be Prevented by Modulating the Microbiota? A Literature Review

BACKGROUND

Cholelithiasis is one of the more common complications following bariatric surgery. This may be related to the rapid weight loss during this period, although the exact mechanism of gallstone formation after bariatric surgery has not been fully elucidated.

METHODS

The present literature review focuses on risk factors, prevention options and the impact of the gut microbiota on the development of gallbladder stones after bariatric surgery.

RESULTS

A potential risk factor for the development of cholelithiasis after bariatric surgery may be changes in the composition of the intestinal microbiota and bile acids. One of the bile acids-ursodeoxycholic acid-is considered to reduce the concentration of mucin proteins and thus contribute to reducing the formation of cholesterol crystals in patients with cholelithiasis. Additionally, it reduces the risk of both asymptomatic and symptomatic gallstones after bariatric surgery. Patients who developed gallstones after bariatric surgery had a higher abundance of Ruminococcus gnavus and those who did not develop cholelithiasis had a higher abundance of Lactobacillaceae and Enterobacteriaceae.

CONCLUSION

The exact mechanism of gallstone formation after bariatric surgery has not yet been clarified. Research suggests that the intestinal microbiota and bile acids may have an important role in this.

Early changes of microRNAs in blood one month after bariatric surgery

BACKGROUND

Changes in microRNAs (miRNAs) are relevant to bariatric surgery and its comorbidities. The characteristics of changes in miRNAs of the early postoperative period following both bariatric procedures, sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), as well as the factors that related to the effectiveness of early weight loss remain unclear.

METHODS

We recruited 18 patients who performed SG and 15 patients who performed RYGB. Their preoperative and 1-month postoperative clinical data and fasting serum samples were collected, and the latter were analyzed by RNA-sequencing. Differential expression analysis of miRNAs was performed by the R-tool. Functional classification annotation and pathway enrichment analysis of targeted genes were analyzed by KOBAS software. The change profiles of miRNAs for both surgeries and their correlation with clinical characteristics and weight loss effectiveness were further analyzed.

RESULTS

A total of 85 differentially expressed miRNAs were identified before and after SG, while a total of 76 were found before and after RYGB. The target genes of these miRNAs were similar in the Gene Ontology enrichment analysis in SG and RYGB, and the enrichment analysis in the Kyoto Encyclopedia of Genes and Genomes was mainly related to metabolic pathways. Hsa-miR-493-5p, hsa-miR-184, and hsa-miR-3199 exhibited similar changes in SG and RYGB, and the former two were correlated with clinical characteristics. Hsa-miR-6729-5p, hsa-miR-4659b-5p, and hsa-miR-2277-5p were correlated with the weight loss effectiveness of SG, while hsa-miR-4662a-5p was correlated with the weight loss effectiveness of RYGB.

CONCLUSIONS

Short-term metabolic improvement and weight loss occurring after SG and RYGB surgery might be related to changes in miRNAs, which act on multiple biological pathways by regulating genes. In addition, some clinical characteristics and miRNAs were related to the effectiveness of early weight loss after SG and RYGB surgery.

CLINICAL TRIAL REGISTRATION

ChiCTR2200058333.

Vitamin D and the Metabolic Phenotype in Weight Loss After Bariatric Surgery: A Longitudinal Study

PURPOSE

To evaluate the influence of vitamin D (VD) concentrations coupled with metabolic phenotypes preoperatively and 6 months after Roux-en-Y gastric bypass (RYGB) on body variables and weight loss.

MATERIALS AND METHODS

A longitudinal, retrospective, analytical study comprising 30 adult individuals assessed preoperatively (T0) and 6 months (T1) after undergoing Roux-en-Y gastric bypass. The participants were distributed preoperatively into metabolically healthy obese (MHO) and metabolically unhealthy obese individuals (MUHO) according to the HOMA-IR classification, as well as the adequacy and inadequacy of vitamin D concentrations in the form of 25(OH)D. All participants were assessed for weight, height, body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHtR), visceral adiposity index (VAI), body circularity index (BCI), body adiposity index (BAI), weight loss, and assessment of 25(OH)D and 1,25(OH)2D concentrations using high-performance liquid chromatography with an ultraviolet detector (HPLC-UV). The statistical program used was SPSS version 21.

RESULTS

VD adequacy and a healthy phenotype in the preoperative period may play an important role concerning body fat distribution, as the body averages for WHtR (0.020*) and BCI (0.020*) were lower in MHO participants. In comparison, those with VD inadequacy and MUHOs had higher BAI averages (0.000*) in the postoperative period. Furthermore, it is possible that VD inadequacy before and after RYGB, even in the presence of an unhealthy phenotype, may contribute to the increase in VAI values (0.029*) after this surgery. Only those with inadequate VD and MUHOs had higher 25(OH)D concentrations. Besides, this unhealthy phenotype had a greater reduction in BMI in the early postoperative period (p < 0.001).

CONCLUSION

This study suggests that VD adequacy and the presence of a healthy phenotype appear to have a positive impact on the reduction of visceral fat in the context of pre- and postoperative obesity. In addition, there was a greater weight reduction in those with VD inadequacy and in MUHO, which suggests that the volumetric dilution effect of VD and catabolism after bariatric surgery is more pronounced in this specific metabolic phenotype.

Application of Biomarkers in Obese Infertile Women: A Genetic Tool for a Personalized Treatment

This study investigates links between CART and leptin gene expression, FSH receptor Asn680Ser polymorphism, and reproductive hormones in morbidly obese patients under 40 years old, facing infertility, and undergoing bariatric surgery. A total of 29 women were included in this study. A hormonal profile along with detection of CART and leptin gene expression was evaluated before and after bariatric surgery. Additionally, the presence or absence of Asn680Ser of the FSHR gene was studied. Following bariatric surgery, a mean reduction in BMI (16.03 kg/m2) was observed in all women. FSH levels preoperatively varied significantly among genotypes, with medians of 8.1, 9.5, and 10.3 for individuals without polymorphism, heterozygotes, and homozygotes, respectively (p = 0.0408). Post surgery, marginal differences in FSH levels were observed (5.8, 7.1, and 8.2, respectively) (p = 0.0356). E2 and LH levels exhibited no significant genotype-based differences pre and post surgery. Presurgical E2 levels were 29.6, 29.8, and 29.6, respectively (p = 0.91634), while postsurgical levels were 51.2, 47.8, and 47 (p = 0.7720). LH levels followed similar patterns. Our findings highlight bariatric surgery's positive impact on BMI reduction and its potential connection to genetic markers, hormones, and infertility. This suggests personalized treatments and offers a valuable genetic tool for better fertility outcomes in obese individuals.

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.

Prospective Study on the Correlation between CART and Leptin Gene Expression, Obesity, and Reproductive Hormones in Individuals Undergoing Bariatric Surgery

Obesity, a global health concern affecting 650 million individuals of all ages worldwide, prompts health complications, including fertility issues. This research investigates the impact of bariatric surgery on morbidly obese females under 40, examining the relationship between CART and leptin gene expressions and reproductive hormones. Post-surgery, a significant reduction in BMI (16.03 kg/m2, n = 29) was observed, accompanied by notable hormonal changes. FSH levels showed a mean difference of 3.18 ± 1.19 pre- and post-surgery (p < 0.001), LH levels exhibited a mean difference of 2.62 ± 1.1 (p < 0.001), E2 levels demonstrated a mean difference of 18.62 ± 5.02 (p < 0.001), and AMH levels showed a mean difference of 3.18 ± 1.19 (p < 0.001). High CART and leptin expressions before treatment correlated with lower expressions after treatment. These findings, rooted in statistically significant correlations (CART: rs = 0.51, p = 0.005; leptin: rs = 0.75, p < 0.001), shed light on potential molecular pathways connecting gene expressions with reproductive hormones post-bariatric surgery. Our study uniquely investigates the interplay between genetic markers, infertility, and bariatric surgery in women. It stands out by providing distinctive insights into the development of personalized treatment strategies for obesity-related infertility, contributing to a deeper understanding of this complex medical issue.

A comparative study between staple line reinforcement during laparoscopic sleeve gastrectomy and no reinforcement: an Egyptian experience

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become an increasingly popular bariatric procedure. LSG still conveys some risks, including early staple line complications such as bleeding and leaks. It has been proposed that staple line complications can be reduced by staple line reinforcement (SLR). This study aimed to compare the short-term efficacy and safety of the SLR during LSG by oversewing versus no SLR in an Egyptian cohort over a period of 11 years.

PATIENTS AND METHODS

This is a retrospective study that analyzed data from patients undergoing LSG by the same surgeon over a period of 11 years. The patients' early postoperative complications were compared according to performing SLR.

RESULTS

The SLR group showed significantly longer surgery time (p = 0.021) and a lower rate of postoperative bleeding (p = 0.027). All leakage cases occurred in the non-SLR group (0.7% vs. 0.0%) without statistical significance (p = 0.212). The two mortality cases occurred in the non-SLR group. The LOS was comparable in the two groups (p = 0.289).

CONCLUSION

This study confirms the short-term benefits of SLR by oversewing during LSG in terms of a lower incidence of 30-day morbidity, particularly bleeding, and lower rates of reoperation, with a clinically questionable longer operation time.

One-anastomosis gastric bypass (OAGB) versus Roux-en-Y gastric bypass (RYGB) as revisional procedures after failed laparoscopic sleeve gastrectomy (LSG): systematic review and meta-analysis of comparative studies

INTRODUCTION

The aim of this study was to compare weight loss and gastroesophageal reflux disease (GERD) remission after one-anastomosis gastric bypass (OAGB) versus Roux-en-Y gastric bypass (RYGB) as revisional procedures after laparoscopic sleeve gastrectomy (LSG).

METHODS

In PubMed, Embase, and Cochrane Library, a search was performed using the terms "Roux-en-Y gastric bypass versus one anastomosis gastric bypass," "revisional surgery," and "sleeve gastrectomy." Only original articles in English language comparing OAGB and RYGB were included. No temporal interval was set. The primary outcome measure was weight loss (%TWL). The secondary endpoints were leak, bleeding, marginal ulcer, and GERD. PRISMA flowchart was used. Differences in continuous and dichotomous outcome variables were expressed as mean difference (MD) and risk difference (RD) with 95% CI, respectively. Heterogeneity was assessed by using I2 statistic.

RESULTS

Six retrospective comparative articles were included in the present meta-analysis. Weight loss analysis showed a MD = 5.70 (95% CI 4.84-6.57) in favor of the OAGB procedure with a statistical significance (p = 0.00001) and no significant statistical heterogeneity (I2 = 0.00%). There was no significant RD for leak, bleeding, or marginal ulcer after the two revisional procedures. After conversion to OAGB, remission from GERD was 68.6% (81/118), and it was 80.6% (150/186) after conversion to RYGB with a RD = 0.10 (95% CI -0.04, 0.24), no statistical significance (p = 0.19), and high heterogeneity (I2 = 96%). De novo GERD was 6.3% (16/255) after conversional OAGB, and it was 0.5% (1/180) after conversion to RYGB with a RD = -0.23 (95% CI -0.57, 0.11), no statistical significance (p = 0.16), and high heterogeneity (I2 = 92%).

Long-Term Results of Laparoscopic Sleeve Gastrectomy: a Review of Studies Reporting 10+ Years Outcomes

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure worldwide. Systematic search of Pubmed, Cochrane, and Embase was performed in order to find all the articles reporting 10+ years of LSG results. Eleven studies including 1020 patients met the inclusion criteria. Overall weighted mean %TWL was 24.4% (17-36.9%), and remission rates from TD2M to HTN were 45.6% (0-94.7%) and 41.4% (0-78.4%), respectively. De novo GERD had an overall prevalence of 32.3% (21.4-58.4%), and five cases (0.5%) of Barrett's disease were reported. Revisional surgery was required for 19.2% (1-49.5%) of patients, Roux-en-Y gastric bypass being the most common secondary procedure.

Bibliometric and Correlation Analysis of Bariatric Surgery Researches in Asia-Pacific from 2000 to 2021

INTRODUCTION

Bariatric surgery has grown in popularity over the past two decades, especially in the Asia-Pacific. Correspondingly, researchers' interest in this field has also increased. This study aims to perform a bibliometric analysis of publications from Asia-Pacific represented by the International Federation for the Surgery of Obesity and Metabolic Disorders Asia-Pacific Chapter (IFSO-APC) and investigate the relevant factors that might affect the publications.

METHODS

The search terms for bariatric surgery were searched in Web of Science focusing on the period 2000-2021. Bibliometric analysis was performed after screening the search results. Univariate and multivariate regression analyses were performed on the number of publications and corresponding indicators obtained from official agencies.

RESULTS

A total of 9,547 publications in IFSO-APC were retrieved, of which China had the largest number with 2,782 publications. Authors and journals with major contributions were listed. The authors' or affiliations' cooperation networks mainly were limited to domestic. "Bariatric surgery" was the most frequent keyword with 2,063 times and also the largest cluster. "Morbid obesity" was the strongest citation bursts. Multivariate analysis found that the number of publications in each country/region was associated with body mass index ≥25 kg/m2, gross domestic product, and total population.

CONCLUSION

Generally, Asia-Pacific represented by IFSO-APC scientific publications on bariatric surgery has grown significantly in the last two decades, but cooperation between countries/regions should be strengthened. "Morbid obesity" is the focus and frontier of research in this field.

First-in-Human Side-to-Side Magnetic Compression Duodeno-ileostomy with the Magnet Anastomosis System

PURPOSES

Classical gastrointestinal anastomoses are formed with sutures and/or metal staples, resulting in significant bleeding and leak rates. This study evaluated the feasibility and safety of the novel magnet anastomosis system (MS) to create a side-to-side duodeno-ileal (DI) diversion for weight loss and type 2 diabetes (T2D) resolution.

MATERIALS AND METHODS

Patients with severe obesity (body mass index (BMI) ≥ 35 kg/m2 with/without T2D (HbA1C ≥ 6.5%)) underwent the study procedure, a side-to-side MS DI diversion, with a standard sleeve gastrectomy (SG). A linear magnet was delivered by flexible endoscopy to a point 250 cm proximal to the ileocecal valve; a second magnet was positioned in the first part of the duodenum; the bowel segments containing magnets were apposed, initiating gradual anastomosis formation. Laparoscopic assistance was used to obtain bowel measurements, obviate tissue interposition, and close mesenteric defects.

RESULTS

Between November 22 and 26, 2021, 5 female patients (mean weight 117.6 ± 7.1 kg, BMI (kg/m2) 44.4 ± 2.2) underwent side-to-side MS DI + SG. All magnets were successfully placed, expelled without re-intervention, and formed patent durable anastomoses. Total weight loss at 12 months was 34.0 ± 1.4% (SEM); excess weight loss, 80.2 ± 6.6%; and BMI reduction, 15.1. Mean HbA1C (%) dropped from 6.8 ± 0.8 to 4.8 ± 0.2; and glucose (mg/dL), from 134.3 ± 17.9 to 87.3 ± 6.3 (mean reduction, 47.0 mg/dL). There was no anastomotic bleeding, leakage, obstruction, or infection and no mortality.

CONCLUSIONS

Creation of a side-to-side magnetic compression anastomosis to achieve duodeno-ileostomy diversion in adults with severe obesity was feasible and safe, achieved excellent weight loss, and resolved type 2 diabetes at 1-year follow-up.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT05322122.

Future of bariatric surgery beyond simple weight loss: Metabolic surgery

Anatomical modifications implemented during bariatric surgery not only result in weight loss, but also lead to metabolic corrections that translate into better glycemia stability and improvement in cardiovascular and liver disorders. The logical extension of surgical indications beyond mere reduction of the body mass index (BMI) (i.e. patients with<35kg/m2) is a hot topic today in France and worldwide. Metabolic surgeries make use of multiple modalities (endoscopic, mini-invasive, invasive) that should be carried out by trained physicians and within the same type of multidisciplinary formation as that for bariatric surgery. The aim of this update is to describe the physiological mechanisms that result in the benefits of bariatric surgery, the various procedures currently available and the perspectives for this new field in visceral and digestive surgery.

Effect of post-gastric sleeve pyloric length on control of type II diabetes mellitus

Background

Although the effectiveness and safety of laparoscopic sleeve gastrectomy (LSG) have been demonstrated, there is still debate about the best surgical method, with the resection distance from pylorus (DP) being among the most contentious topics. In patients who had LSG for morbid obesity, the effect of the resection distance from the pylorus on the management of type II diabetes mellitus during the postoperative phase was examined.

Patients and methods

After receiving each patient’s agreement, a total of 46 obese individuals were enrolled. Patients were prospectively randomized into two groups, group A (‘AP group’) and group B (‘AR group’), based on the distance between the initial reload firing and the pylorus (4 cm for group A and 2 cm for group B, respectively). Blood sugar levels were measured three, six months, and one year following LSG. After a year of follow-up, the percentage of excess weight loss (%EWL) was calculated.

Results

Postoperative weight was statistically significant lower and EWL% was statistically significant higher in group B: LSG ‘2 cm’ compared to group A: LSG ‘4 cm’. As regard outcomes of type 2 diabetes mellitus after LSG, in spite of nonsignificant statistical value, we reported that there was higher frequency of complete remission after 3, 6 and 12 months in group B: LSG ‘2 cm’ compared to group A: LSG ‘4 cm’ and cases with complete remission were associated with significant higher EWL%.

Conclusion

Patients undergoing laparoscopic sleeve gastrectomy are recommended to have shorter resection distance from pylorus (DP) done. It has been linked to superior surgical results, weight reduction, and diabetes mellitus management with no problems recorded.

Weight Regain After Bariatric Surgery: Scope of the Problem, Causes, Prevention, and Treatment

PURPOSE OF REVIEW

Although bariatric surgery is the most effective treatment of severe obesity, a proportion of patients experience clinically significant weight regain (WR) with further out from surgery. The purpose of this review is to summarize the prevalence, predictors, and causes of weight regain.

RECENT FINDINGS

Estimating the prevalence of WR is limited by a lack of consensus on its definition. While anatomic failures such as dilated gastric fundus after sleeve gastrectomy and gastro-gastric fistula after Roux-en-Y gastric bypass can lead to WR, the most common causes appear to be dysregulated/maladaptive eating behaviors, lifestyle factors, and physiological compensatory mechanisms. To date, dietary, supportive, behavioral, and exercise interventions have not demonstrated a clinically meaningful impact on WR, and there is limited evidence for pharmacotherapy. Future studies should be aimed at better defining WR to begin to understand the etiologies. Additionally, there is a need for non-surgical interventions with demonstrated efficacy in rigorous randomized controlled trials for the prevention and reversal of WR after bariatric surgery.

Challenges in Bariatric Surgery: Outcomes in Patients Having Three or More Bariatric Procedures

INTRODUCTION

Over the last two decades, a progressive increase in failure rate of bariatric surgery (BS) has occurred in conjunction with an exponential increase in BS worldwide. Bariatric surgeons are confronted with challenging situations in patients with a complex bariatric history. In this study, we aim to evaluate the feasibility and outcomes of revisional BS in patients with at least two or more previous bariatric procedures.

METHODS

Data were retrospectively retrieved from a prospectively held database of bariatric procedures performed at our tertiary referral bariatric center and included procedures done from February 2013 up to April 2019 by a single center.

RESULTS

Thirty patients underwent a third bariatric procedure. The median age was 40 (18-57) and 54 (27-69) years at the time of the first and the last procedures, respectively. Laparoscopic adjustable gastric banding was the first procedure in 26 patients. The complication rate was 33%; no patient required additional surgery because of postoperative complications. A total weight loss of 29.6% and an excess loss of 53.4% were obtained at a mean follow-up of 61 months after the last redo bariatric procedure.

CONCLUSION

This study indicates that redo BS either conversional or revisional is feasible and effective in patients with a complex bariatric history including two or more previous procedures. Careful patients' selection is mandatory and extensive information should be given on the increased risk of postoperative complications.

Weight loss outcomes for patients undergoing conversion to Roux-en-Y-gastric bypass after sleeve gastrectomy

BACKGROUND

Despite excellent reported outcomes after laparoscopic sleeve gastrectomy (LSG), a percentage of patients go on to have a secondary bariatric surgery to manage side-effects or address weight regain after LSG. Reported weight loss outcomes for patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) after previous LSG are variable. We sought to determine the weight-loss outcomes of patients undergoing LRYGB after LSG in the largest bariatric surgical network in Canada and to determine whether outcomes differ according to indications for conversion.

METHODS

The Bariatric Registry is a multi-center database with prospectively collected standardized data on patients undergoing bariatric surgery at ten Bariatric Centers of Excellence within the Ontario Bariatric Network in Ontario, Canada. A retrospective analysis was performed of patients who underwent LRYGB after previous LSG between 2012 and 2019. Weight loss outcomes were compared between patients who underwent LRYGB for insufficient weight loss/weight regain and those who underwent conversion to LRYGB for other reasons.

RESULTS

Excluding patients with multiple revisions and those without follow-up data, 48 patients were included in the analysis: 33 patients (69%) underwent conversion to LRGYB for insufficient weight loss/weight regain (Group 1) and 15 patients (31%) underwent conversion for other reasons (Group 2). Mean body mass index (BMI) measured pre-LSG, pre-LRYGB, and at mid-term follow-up after LRYGB was 61, 48, and 43 kg/m² in Group 1 and 51, 39, and 34 kg/m² in Group 2, respectively. ΔBMI and %total weight loss (TWL) at mid-term follow-up were not significantly different between the groups.

CONCLUSIONS

Conversion to LRYGB after previous LSG resulted in an additional loss of 4 kg/m² in BMI points at mid-term follow-up. Patients lost a similar number of BMI points and cumulative %TWL was similar regardless of reason for conversion. This can help inform surgical decision-making in the setting of weight regain after LSG.

Poly(vinylidene fluoride) Intestinal Sleeve Implants for the Treatment of Obesity and Type 2 Diabetes

Currently, treatment of diabetes and associated obesity involves Roux-en-Y gastric bypass or sleeve gastrectomy to reduce the absorption of nutrients from the intestine to achieve blood glucose control. However, the surgical procedure and subsequent recovery are physically and psychologically burdensome for patients, with possible side effects, so alternative treatments are being developed. In this study, two methods, solution casting and machine direction orientation (MDO), were used to prepare intestinal implants made of poly(vinylidene fluoride) (PVDF) film and implant them into the duodenum of type 2 diabetic rats for the treatment of obesity and blood glucose control. The PVDF film obtained by the MDO process was characterized by FT-IR, Raman spectroscopy, XRD and piezoelectricity tests, which showed higher composition of β crystalline phase and better elongation and mechanical strength in specific directions. Therefore, the material was finally tested on rats after it was proven to be non-toxic by biological toxicity tests. The PVDF was implanted into alloxan-induced diabetic rats, which were used as a model of impaired insulin secretion due to pancreatic beta cell destruction rather than obesity-induced diabetes, and rats were tracked for 24 days, showing significantly improved body weight and blood glucose levels. As an alternative therapeutic option, intestinal sleeve implant showed future potential for application.

The Evolution of Bariatric Surgery-From Sewing Lips to Constructing the Sleeve

Bariatric surgery remains the most durable weight loss option to address morbid obesity, providing lasting reduction of debilitating chronic comorbidities. This is a review of the historical milestones that led up to the development of this surgical practice. We explore perceptions and interventions for obesity as early as the 10^th century, as well as pre-modern surgical perceptions and advancements in foregut and obesity surgery. Additionally, we recount select social and surgical landmarks in the modern bariatric era. The aim of this review is to reflect on and appreciate the centuries of progress that have led to such an instrumental branch of risk reductive surgery.

Evaluation of the effectiveness of weight loss and the return of lost weight after sleeve gastrectomy in the long term follow-up period

Sleeve gastrectomy, originally proposed as part of a two-stage operation, more than 15 years ago, is recognized as an independent, effective intervention for the treatment of obesity. The purpose of this review was to evaluate the effectiveness of sleeve gastrectomy based on data on long-term follow-up of patients. A search was performed in two databases, 33 literary sources were selected based on the results of the selection. In this review, the authors evaluated some parameters characterizing the effectiveness of sleeve gastrectomy in the long term after surgery. The percentage of follow-up of patients in the long-term period (follow up, %) varied from 5,6% to 97%, the expected decrease in % follow up over time did not occur. The authors have suggested similar results due to the heterogeneity of the data of the analyzed sources. By the five-year period, the detected average % of follow-up did not correspond to the optimal recommended level of follow-up for operated patients by this time. The most common criterion for assessing the return of weight is an increase in body weight by more than 10 kg from the lowest achieved. The prevalence of this phenomenon ranged from 26.3% to 44%. Among the reasons predisposing to weight loss are the initial high BMI, old age, dilatation of the formed stomach. In the absence of a universal definition of various terms (follow up, unsatisfactory result of surgery, weight loss, etc.), the results among the same patients when using different definitions will differ, there is a need to adopt standards when describing these phenomena. Despite the likelihood of weight loss after longitudinal resection, this operation is relatively simple from a technical point of view, safer, it can be used to improve the course of concomitant pathology (diabetes mellitus, hypertension), improve the quality and increase the life expectancy of patients.

Review of Our Experience Using Modified Staple Line Suturing Technique in Laparoscopic Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become the most common bariatric surgical method in recent years. Although LSG provides good outcomes, serious complications such as leakage, bleeding, and stenosis may develop postoperatively. Numerous staple line reinforcement methods have been used to reduce complications. Whether each one of these practices is effective remains controversial.

AIM

Our study aims to assess outcomes and safety of modified (purse-string+oversewing) staple line suturing technique for patients who underwent LSG.

MATERIALS AND METHODS

A total of 505 patients who underwent LSG with modified staple line suturing technique between March 2018 and February 2021 were included in this retrospective study. Age, sex, body mass index, operation time, perioperative and postoperative 30-day complications were recorded in all patients.

RESULTS

Of 505 patients (59.6% female) with a mean age of 37.6 years (minimum to maximum: 12 to 68 y) and median body mass index of 40.2 kg/m2 (minimum to maximum: 32 to 75 kg/m2) underwent LSG. LSG was performed as revision surgery in 17 (3.4%) patients. Five (1%) patients also underwent concomitant cholecystectomy. The mean operation time was 92 minutes (75 to 110 min) in our primary LSG cases. Operative complications included minor hepatic injury in 8 (1.6%) and anesthesia awareness in 3 (0.6%) patients. Postoperative complications included bleeding which occurred in 2 (0.4%) patients, portomesenteric vein thrombosis in 1 (0.2%), and minor wound infection in 3 (0.6%) patients. There was no leak, no stenosis, and no mortality.

CONCLUSION

Sleeve gastrectomy with modified staple line suturing technique is an effective method and could be safely applied with low morbidity.

The Impact of Drain and Reinforcement on the Outcomes of Bariatric Surgery: A Prospective Study

Purpose We aimed to investigate the impact of reinforcement and abdominal drains on the outcome of laparoscopic sleeve gastrectomy (LSG). Methods The present study was a prospective study that included obese patients scheduled to undergo LSG. Patients were assigned to receive drain, reinforcement, or both according to the surgeon's preference and followed up for one month after surgery. The present study's primary outcome was the identification of the association between intraoperative drain/reinforcement and the incidence of postoperative complications. Results A total of 125 (20.3%) patients received intraoperative drains. The proportion of postoperative morbidity was comparable between the drain and non-drain groups (3.2% versus 1.6%; p = 0.25). Patients in the drain group had similar incidence of blood transfusion (2.4% versus 1.7% in non-drain group; p = 0.43) and postoperative leakage (0.8% versus 0.2% in non-drain group; p = 0.36). The incidences of blood transfusion (p = 0.56) and reoperation (p = 0.98) were comparable between the drain and non-drain groups. There were no statistically significant differences between the drain and non-drain groups regarding postoperative mortality and wound infection (p > 0.05). On the other hand, 440 (71.3%) patients received reinforcement. The proportion of postoperative morbidity was comparable between the reinforcement and non-reinforcement groups (1.6% versus 2.8%, p = 0.07). Patients in the reinforcement group were less likely to develop postoperative bleeding (0.7% versus 4% in the non-reinforcement group; p = 0.004), while no significant difference was detected in terms of postoperative leakage (p = 0.33) and in-hospital mortality. Conclusion In conclusion, abdominal drainage did not reduce the complications of LSG patients. Reinforcement has some role in controlling the bleeding but not leaks. Both techniques did not significantly impact the mortality rate. In the future, additional, large randomized trials are needed to examine the gastrointestinal-related quality of life.

Ten-Year Results of Laparoscopic Sleeve Gastrectomy: Retrospective Matched Comparison with Laparoscopic Adjustable Gastric Banding-Is There a Significant Difference in Long Term?

BACKGROUND

The laparoscopic sleeve gastrectomy (LSG) is the most common bariatric procedure performed worldwide while the laparoscopic adjustable gastric banding (LAGB) has been almost abandoned. Aim of this study was to retrospectively assess 10-year outcomes of LSG through a matched comparison with LAGB.

MATERIALS AND METHODS

Retrospective search of prospectively maintained database of our university was carried out to find all patients that underwent LSG before December 2010. Each subject with LSG was matched one-to-one with a patient that had undergone LAGB in the same period with correspondent preoperative age, BMI, and sex.

RESULTS

A total of 76 patients underwent LSG before 2010 and were all included in this study; a matched group of 76 out of 178 LAGB patients with 10-year follow-up was retrieved from our database. Comparison between the two groups showed better outcomes after LSG at 1 and 5 years but weight loss was comparable with the LAGB group at 10 years (%TWL 22.2 ± 13 vs 21.2 ± 16.1; p = 0.89). No significant difference was found in conversion/removal rate (15.8% vs 18.4%; p = 0.67).

CONCLUSION

LSG is an effective stand-alone bariatric procedure with better outcomes than LAGB in medium term, but results are comparable at 10 years. Subjects undergoing LSG should be informed that conversion to RYGB or OAGB may be necessary to achieve further weight loss or to treat reflux.

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

INTRODUCTION

Bariatric surgery is the most effective modality to stably reduce weight and related comorbidities in patients suffering from class II and III obesity. Data comparing long-term safety and efficacy of the three most effective bariatric operations are limited in patients with BMI ≥ 50 kg/m², which complicate shared surgeon-patient decision making regarding optimal procedure selection.

METHODS

A retrospective analysis was performed on all patients with BMI ≥ 50 kg/m² who underwent biliopancreatic diversion with duodenal switch (BPD/DS), Roux-en-Y gastric bypass (RYGB), or sleeve gastrectomy (SG) at our institution between 2009 and 2019. Data collected from patients' electronic medical records included operative details as well as BMI and presence and resolution of obesity-related comorbidities at 0, 6, 12, 24, 48, and 60 months post-operatively.

RESULTS

Among 537 patients with BMI ≥ 50 kg/m² who had a primary bariatric procedure, 93 patients underwent BPD/DS (17.3%), 341 patients underwent RYGB (63.5%), and 103 patients underwent SG (19.2%). BMI decreased by 23.7 kg/m² in BPD/DS, 14.7 kg/m² in RYGB, and 13.6 kg/m² in SG cohorts at 60 months post-operatively (p < 0.0001). The greatest %TWL occurred in BPD/DS cohort (38.4%) followed by the RYGB (26.3%) and SG (23.6%) cohorts (p < 0.0001). The thirty-day complication rate was 12.9% for BPD/DS, 4.7% for RYGB, and 8.7% for SG (p = 0.015).

CONCLUSIONS

Our study demonstrated that the BPD/DS is the most effective operation at long-term reduction of BMI and achieved highest %TWL while SG and RYGB had similar results at 60 months post-op. BPD/DS is associated with increased early and late surgical complications compared to RYGB and SG.

Learning curve and global benchmark values of laparoscopic sleeve gastrectomy: results of first 100 cases of a newly trained surgeon in an Italian center of excellence

To evaluate whether the learning curve for sleeve gastrectomy could be completed after 50 cases. First 100 patients undergoing LSG under a newly trained laparoscopic surgeon were included in this study and divided into two groups of 50 consecutive patients each. Perioperative outcomes were compared to recently introduced global benchmarks. Short-term weight loss was calculated as Total Weight Loss Percent (%TWL) and complications were classified in accordance with the Clavien-Dindo classification. CUSUM analysis was performed for operative time and hospital stay. Mean preoperative age and BMI were 41.8 ± 10.3 years and 42.9 ± 5.4 kg/m2, respectively. Demographics and rate of patients with previous surgery were comparable preoperatively in the two groups. Mean operative time was 92.1 ± 19.3 min and hospital stay was 3.4 ± 0.6 days as per our standard protocol of discharge. Uneventful postoperative course was recorded in 93% of patients and only one case of staple line leak was registered in the first 50 cases (group 1). No statistical difference in BMI and %TWL was found between the two groups at any time of follow-up. Comparison between two groups showed a significant reduction in hospital stay and operative time after the first 50 LSGs (p < 0.05). LSG can be performed by newly trained surgeons proctored by senior tutors. At least 50 cases are needed to meet global benchmark cut-offs and few more cases may be required to reach the plateau of the learning curve.

State Scientific Institution “Center for Innovative Medical Technologies of the National Academy of Sciences of Ukraine”, Kiev, Ukraine, Todurov I, Kosiukhno S, State Scientific Institution “Center for Innovative Medical Technologies of the National Academy of Sciences of Ukraine”, Kiev, Ukraine, Perekhrestenko O, State Scientific Institution “Center for Innovative Medical Technologies of the National Academy of Sciences of Ukraine”, Kiev, Ukraine, Kalashnikov O, State Scientific Institution “Center for Innovative Medical Technologies of the National Academy of Sciences of Ukraine”, Kiev, Ukraine, Potapov O, State Scientific Institution “Center for Innovative Medical Technologies of the National Academy of Sciences of Ukraine”, Kiev, Ukraine, Plehutsa О, State Scientific Institution “Center for Innovative Medical Technologies of the National Academy of Sciences of Ukraine”, Kiev, Ukraine. DYNAMICS OF GLUCAGON-LIKE PEPTIDE-1 AFTER LAPAROSCOPIC SLEEVE GASTRECTOMY IN PATIENTS WITH TYPE 2 DIABETES MELLITUS ASSOCIATIONS WITH OBESITY

Laparoscopic sleeve gastrectomy (LSG) proved to be a valuable procedure for treating obesity complicated by type 2 diabetes mellitus (T2DM). The mechanism of T2DM resolution after LSG is not yet clearly defined. The objective of the study was to investigate the effect of LSG on the secretion of GLP-1 in patients with T2DM associated with obesity. Plasma GLP-1 levels were evaluated by starvation and 15, 30, 60 and 90 min after the standard carbohydrate preload for breakfast, which included 125 ml of balanced high energy Nutricia Nutridrink Protein. Evaluations were made on the eve of the procedure, for 4 days and 3 months after the operation. In 7 patients with T2DM were diagnosed for the first time, in 3 patients with diabetic history 2 years, in 1 patient – 3.5 years and in 1 patient – 10 years. Mean glycated hemoglobin before surgery was 7.7 ± 1.6%, 3 months after LSG – 5.9 ± 0.4%. The concentration of GLP-1 in 30 minutes before surgery was 6.7 ± 0.9 ng/ml. On the 4th day after LSG, the mean level of GLP-1 was 9.6 ± 0.2 ng/ml, which statistically differed from its level in the pre-operative period, and after 3 months the mean level of GLP-1 statistically increased to 13.7 ± 0.3 ng/ml. Thus LSG leads to an early and significant increase in post-prandial secretion GLP-1 in T2DM patients associated with obesity. The rapid postoperative improvement in signs of carbohydrate metabolism indicates the importance of the incretin effect LSG in the implementation of early compensation mechanisms for T2DM and explains the metabolic activity of this operation.

Vertical sleeve gastrectomy confers metabolic improvements by reducing intestinal bile acids and lipid absorption in mice

Vertical sleeve gastrectomy (VSG) is one of the most effective and durable therapies for morbid obesity and its related complications. Although bile acids (BAs) have been implicated as downstream mediators of VSG, the specific mechanisms through which BA changes contribute to the metabolic effects of VSG remain poorly understood. Here, we confirm that high fat diet-fed global farnesoid X receptor (Fxr) knockout mice are resistant to the beneficial metabolic effects of VSG. However, the beneficial effects of VSG were retained in high fat diet-fed intestine- or liver-specific Fxr knockouts, and VSG did not result in Fxr activation in the liver or intestine of control mice. Instead, VSG decreased expression of positive hepatic Fxr target genes, including the bile salt export pump (Bsep) that delivers BAs to the biliary pathway. This reduced small intestine BA levels in mice, leading to lower intestinal fat absorption. These findings were verified in sterol 27-hydroxylase (Cyp27a1) knockout mice, which exhibited low intestinal BAs and fat absorption and did not show metabolic improvements following VSG. In addition, restoring small intestinal BA levels by dietary supplementation with taurocholic acid (TCA) partially blocked the beneficial effects of VSG. Altogether, these findings suggest that reductions in intestinal BAs and lipid absorption contribute to the metabolic benefits of VSG.

Restored TDCA and valine levels imitate the effects of bariatric surgery

Background

Obesity is widespread and linked to various co-morbidities. Bariatric surgery has been identified as the only effective treatment, promoting sustained weight loss and the remission of co-morbidities.

Methods

Metabolic profiling was performed on diet-induced obese (DIO) mice, lean mice, and DIO mice that underwent sleeve gastrectomies (SGx). In addition, mice were subjected to intraperitoneal (i.p.) injections with taurodeoxycholic acid (TDCA) and valine. Indirect calorimetry was performed to assess food intake and energy expenditure. Expression of appetite-regulating hormones was assessed through quantification of isolated RNA from dissected hypothalamus tissue. Subsequently, i.p. injections with a melanin-concentrating hormone (MCH) antagonist and intrathecal administration of MCH were performed and weight loss was monitored.

Results

Mass spectrometric metabolomic profiling revealed significantly reduced systemic levels of TDCA and L-valine in DIO mice. TDCA and L-valine levels were restored after SGx in both human and mice to levels comparable with lean controls. Systemic treatment with TDCA and valine induced a profound weight loss analogous to effects observed after SGx. Utilizing indirect calorimetry, we confirmed reduced food intake as causal for TDCA/valine-mediated weight loss via a central inhibition of the MCH.

Conclusions

In summary, we identified restored TDCA/valine levels as an underlying mechanism of SGx-derived effects on weight loss. Of translational relevance, TDCA and L-valine are presented as novel agents promoting weight loss while reversing obesity-associated metabolic disorders.

Funding

This work has been supported in part by a grant from NIH (UO-1 A1 132898 to S.G.T., DP and MA). M.Q. was supported by the IFB Integrated Research and Treatment Centre Adiposity Diseases (Leipzig, Germany) and the German Research Foundation (QU 420/1-1). J.I. was supported by the Biomedical Education Program (BMEP) of the German Academic Exchange Service (DAAD). T.H. (HE 7457/1-1) and F.K. (KR 4362/1-1) were supported by the German Research Foundation (DFG). H.R.C.B. was supported the Swiss Society of Cardiac Surgery. Y.N. was supported by the Chinese Scholarship Council (201606370196) and Central South University. H.U., T.M. and R.M. were supported by the Osaka Medical Foundation. C.S.F. was supported by the German Research Foundation (DFG, SFB738, B3).

A review of commonly performed bariatric surgeries: Imaging features and its complications

Obesity is a disease that has achieved the level that can be considered an epidemic. According to the National Center for Health Statistics data, the prevalence of obesity has increased from 30.5% in 1999-2000 to 42.4% in 2017-2018. During the same period, severe obesity has increased from 4.7% to 9.2%. With the growing prevalence of obesity, related conditions such as coronary artery disease, diabetes, and strokes have also become more prevalent. In the past few years, the need for bariatric surgeries such as laparoscopic Roux-en-Y gastric bypass, sleeve gastrectomy, and laparoscopic adjustable gastric banding has increased considerably. With an increasing number of bariatric surgeries, multiple postoperative complications have become common. In this review, we have attempted to describe normal postsurgical anatomical findings after bariatric surgeries and pictorial review of a few common postoperative complications.

Splenic Abscess Following Sleeve Gastrectomy: A Systematic Review of Clinical Presentation and Management Methods

BACKGROUND

Splenic abscess is a rare complication following sleeve gastrectomy.

METHODS

We performed a systematic review to clarify its clinical significance, presentation, and management. PubMed, Embase, MEDLINE, Google Scholar, and the Cochrane Library were searched up to the 19th of July 2020. A total of 18 patients were included, of which 11 were female and 7 were male. The mean age was 34.1 ± 12.3 years, and the mean body mass index was 45.8 ± 7.6 kg/m². Type 2 diabetes mellitus was reported in 11.1% of patients and hypertension in 22.2%. Fever was the most common presenting symptom seen in 17 (94.4%) patients, followed by abdominal pain in 10 (55.6%). The mean duration from surgery to presentation was 98.6 ± 132.7 days (range 10-547 days). Computed tomography was used for investigations in 17/18 (94.4%) patients. Seven patients had reported leak, three reported bleeding, and 2 reported pleural effusion. Thirteen patients had unilocular abscess. All patients were treated with antibiotics. Four patients needed total parenteral nutrition, and three were given proton pump inhibitor. In total, 11 patients needed percutaneous drainage as a part of treatment and 11 patients needed total splenectomy and 1 needed partial splenectomy.

CONCLUSION

Splenic abscess following sleeve gastrectomy is a rare identity. The etiology of formation of splenic abscess needs further studies. A computed tomography of the abdomen with contrast is the preferred diagnostic tool. There is no gold standard treatment for splenic abscess.

Laparoscopic Vertical Sleeve Gastrectomy

Bariatric surgery has emerged as the most effective means of achieving weight loss. Obesity surgery is a quickly expanding field. Laparoscopic vertical sleeve gastrectomy is a great option for patients because it is simple, exceedingly safe, has a fairly defined postoperative complication profile, and is as effective as more complex bariatric surgery options. Specific consideration of patients' comorbidities, assessment of surgeon's skill, and knowledge of preoperative, perioperative, and postoperative course is a must for all surgeons who wish to perform this procedure. If properly used, vertical sleeve gastrectomy is a powerful tool in combating obesity and its deleterious effects.

Perioperative Practices Concerning Sleeve Gastrectomy - a Survey of 863 Surgeons with a Cumulative Experience of 520,230 Procedures

BACKGROUND

Sleeve Gastrectomy (SG) is the most commonly performed bariatric procedure worldwide. There is currently no scientific study aimed at understanding variations in practices concerning this procedure. The aim of this study was to study the global variations in perioperative practices concerning SG.

METHODS

A 37-item questionnaire-based survey was conducted to capture the perioperative practices of the global community of bariatric surgeons. Data were analyzed using descriptive statistics.

RESULTS

Response of 863 bariatric surgeons from 67 countries with a cumulative experience of 520,230 SGs were recorded. A total of 689 (80%) and 764 (89%) surgeons listed 13 absolute and relative contraindications, respectively. 65% (n = 559) surgeons perform routine preoperative endoscopy and 97% (n = 835) routinely use intraoperative orogastric tube for sizing the resection. A wide variation is observed in the diameter of the tube used. 73% (n = 627) surgeons start dividing the stomach at a distance of 3-5 cm from the pylorus, and 54% (n = 467) routinely use staple line reinforcement. Majority (65%, n = 565) of surgeons perform routine intraoperative leak test at the end of the procedure, while 25% (n = 218) surgeons perform a routine contrast study in the early postoperative period. Lifelong multivitamin/mineral, iron, vitamin D, calcium, and vitamin B12 supplementation is advocated by 66%, 29%, 40%, 38% and 44% surgeons, respectively.

CONCLUSION

There is a considerable variation in the perioperative practices concerning SG. Data can help in identifying areas for future consensus building and more focussed studies.

Role of Imaging in Bariatric Surgery: A Review of the Various Surgical Techniques and Their Complications

According to the World Health Organization, obesity has reached epidemic proportions globally, with at least 2.8 million people dying each year as a result of being overweight or obese. Bariatric surgery is being increasingly used as a form of treatment, particularly in those patients where lifestyle modifications are deemed insufficient. With the role of radiologists transitioning from a medical to a surgical evaluation in obesity, it is becoming increasingly important to familiarize oneself with the various imaging techniques used in the preoperative and postsurgical evaluation in such cases. This article aims to review the various surgeries performed, their normal imaging appearance, and the various complications that could be encountered.

Efficacy of laparoscopic sleeve gastrectomy for patient with morbid obesity and type 1 diabetes mellitus: a case report

Background

Bariatric surgery is effective for the treatment of patients with morbid obesity and type 2 diabetes mellitus (T2DM), for body weight loss and glycemic control. However, in Japan, there has been no previous report of the effectiveness bariatric surgery in a case of morbid obesity associated with acute onset type 1 diabetes mellitus (T1DM), in which pancreatic β-cells were destroyed and endogenous insulin was depleted.

Case presentation

A 36-year-old woman with morbid obesity and T1DM, diagnosed when she was 6 years, was admitted for bariatric surgery. At her first consultation, she had a body weight of 106.7 kg and a body mass index of 42.2 kg/m². Her HbA1c level was 9.0%, with a required daily insulin dose of 75 units. She underwent laparoscopic sleeve gastrectomy. At 1 year after surgery, her body weight had decreased to 81.0 kg and her body mass index to 32.2 kg/m². In addition, her daily required dose of insulin had decreased to 24 units, with an improvement in her HbA1c level to 7.7%.

Conclusions

Although further evidence needs to be accumulated, including long-term outcomes, laparoscopic sleeve gastrectomy may provide an effective treatment for patients with morbid obesity and T1DM for body weight loss, improvement in HbA1c level, and insulin dose reduction.

One Anastomosis Gastric Bypass after Sleeve Gastrectomy Failure: Does a Single Procedure Fit for all?

INTRODUCTION

Considering the multitude of bariatric procedures performed all over the world, the necessity of revisional surgery increased accordingly. Several authors argued that with the great diffusion of sleeve gastrectomy (SG), the number of patients who experienced a weight regain at long follow-up was congruous and physiologic, even if not negligible. Recent studies showed that one anastomosis gastric bypass (OAGB) was an effective and safe option also as redo surgery. The aim of the study was to evaluate effectiveness of OAGB as redo surgery after SG in term of anthropometric features and remission of comorbidities.

METHODS

Bariatric patients experiencing weight regain and insufficient weight loss after SG and undergoing OAGB as redo surgery were retrospectively analyzed. During post-OAGB outpatient visit weight, %EWL, BMI, comorbidities, and vitamin deficiencies were evaluated. A further visit was scheduled for the evaluation of postoperative esophagitis/gastritis at upper endoscopy.

RESULTS

Fifty-nine (Reviewer #3-1) patients underwent OAGB as redo-surgery consequently to the worsening of the bariatric outcomes at 29.42 ± 7.29 months from SG (mean weight, BMI and %EWL were 120.89 ± 16.79 kg, 43 ± 4.39 and 19.84 ± 30.29, respectively). Conversely, at a mean follow-up of 34.32 ± 1.71 months (Reviewer #3-3) after OAGB, no weight regain or insufficient weight loss cases were recorded (mean weight 71.25 ± 10.22 kg, mean BMI 24.46 ± 2.06 kg/m2, mean %EWL 69.49 ± 14.4, p < 0.0001) (Reviewer #3-2).

CONCLUSION

OAGB is a safe and effective bariatric procedure in terms of morbidity, mortality, and %EWL also as revision surgery after SG. Further larger studies are needed to address this issue.

The role of the surgical resection distance from the pylorus after laparoscopic sleeve gastrectomy: a prospective cohort study from an academic medical center in Egypt

BACKGROUND

Laparoscopic sleeve gastrectomy was recently described as an effective approach for the operative treatment of obesity, but the ideal procedure remains controversial. One of the most debated issues is the resection distance from the pylorus. We conducted this study to elucidate any potential differences in the short-term outcomes between 2 and 6 cm distance from the pylorus in laparoscopic sleeve gastrectomy.

METHODS

A prospective observational cohort study in a selected cohort of 96 patients was conducted from January 2018 to March 2019 in morbidly obese patients who had laparoscopic sleeve gastrectomy performed at Suez Canal University Hospital. Outcome was expressed by excess weight loss percentage, resolution of comorbidities, improvement of quality of life, and incidence of complications after laparoscopic sleeve gastrectomy. The morbidly obese patients (body mass index [BMI] > 40 kg/m² or > 35 kg/m² with obesity-related comorbidities) in the study were divided into two equal groups: (1) Group 1 (48 patients) underwent laparoscopic sleeve gastrectomy with a 2 cm distance from the pylorus resection distance and (2) Group 2 (48 patients) underwent laparoscopic sleeve gastrectomy with a 6 cm distance from the pylorus resection distance. Body weight, BMI, bariatric quality of life, lipid profile, and comorbidities were evaluated pre- and post-operatively for a duration of 12 months.

RESULTS

Statistically, no significant differences between the two study groups regarding the excess weight loss percentage, comorbidity resolution throughout the postoperative follow-up, enhancement of the quality of life score throughout the postoperative follow-up, or incidence of complications (25% in Group 1 versus 25% in Group 2, p > 0.05) were found.

CONCLUSION

Laparoscopic sleeve gastrectomy was an effective and safe management for morbid obesity and obesity-related comorbidities with significant short-term weight loss; it also improved weight-related quality of life and had an acceptable complication rate. The distance from the pylorus resection distance did not affect the short-term effects of laparoscopic sleeve gastrectomy regarding excess weight loss percentage, resolution of comorbidities, change in quality of life, or occurrence of complications.

Acute Hiatal Hernia with Incarcerated Proximal Half of Recent Sleeve Gastrectomy: Super Rare Complication

BACKGROUND

Vertical sleeve gastrectomy (VSG) has become the most commonly performed operation for the treatment of morbid obesity (JAMA. 312(9):959-61, 2014). Nevertheless, VSG is still associated with some early postoperative complications (JAMA. 312(9):959-61, 2014; Surg Obes Relat Dis. 9(5):816-29, 2013; Obes Surg. 27(8):1944-1951, 2017). Hiatal hernia is a complication that has been widely described in the literature, but not in the immediate postoperative course (Obes Surg. 17(7):962-9, 2007). We, herein, report a case of an acute postoperative hiatal hernia after sleeve gastrectomy.

METHODS

A 29-year-old female (BMI 38.54 kg/m²) presented to our center and her options for metabolic surgery were discussed. Laparoscopic sleeve gastrectomy (LSG) was the chosen procedure. Preoperative assessment includes a chest x-ray, and standard lab-work up was within a normal limit. Barium swallow did not show any evidence of hiatal hernia. She underwent a LSG. On POD 1, she was able to pass the bariatric clears trial and was discharged home. Three days after discharge, the patient was complaining of constant nausea and vomiting, and chest pain, and was diagnosed with acute hiatal hernia with the incarceration of the proximal sleeve. The patient was taken to the operating room.

RESULTS

Postoperatively, the patient started on the usual bariatric clinical pathway which she tolerated well and was discharged on the POD 4. The operative time was 156 min. The estimated blood loss was 50 ml.

CONCLUSIONS

Our report highlights the need for more broad differential diagnosis in early post sleeve gastrectomy patients. Those who are presented with nausea and vomiting in the early postoperative period should be evaluated for possible post sleeve hiatal hernia with a potential risk of strangulation.

Does Fixation of Gastric Sleeve Prevent Functional Stenosis in Sleeve Gastrectomy Patients?

AIM

The aim of this study is to determine whether gastric sleeve fixation prevents functional stenosis (twist or kink) and to investigate its effects on symptoms such as nausea and vomiting after laparoscopic sleeve gastrectomy (LSG).

METHODS

A total of 717 patients who underwent primary LSG for morbid obesity and completed at least 1 year of follow-up between 2012 and 2019 were included in the study. All operations were performed by the same surgical team using the same technique. The patients were divided into 2 groups, that is, group 1: standard LSG and group 2: gastric sleeve fixation with LSG. These 2 groups were compared in terms of demographic characteristics, baseline body mass index, follow-up duration, bleeding, leaks, gastric stenosis, postoperative nausea, vomiting, and the need for antiemetics. In the follow-up period, patients with suspected gastric stenosis underwent endoscopy and upper gastrointestinal series.

RESULTS

LSG was performed in 717 patients (55.2% female) with a mean age of 37.8±11.5 years and a median body mass index of 42.2 (30.2 to 74.2) kg/m2. The 241 patients in the first group underwent LSG without fixation, and the 476 patients in the second group with fixation. Functional stenosis was detected in 8 patients, all of whom were in group 1. One patient in group 1 had a leak on the background of functional stenosis. There was bleeding that required transfusion in 2 patients (group 1) and reoperation in 2 patients (group 2). None of the study patients died. During the in-hospital period, 122 (50.6%) patients in group 1 and 159 (33.4%) patients in group 2 had nausea and vomiting that required antiemetic treatment (P<0.001).

CONCLUSION

Gastric sleeve fixation in LSG prevents complications that may arise because of improper gastric mobilization. This method is effective in reducing nausea and vomiting in LSG patients.

Sleeve gastrectomy-induced endocrine changes in the remnant stomachs of premenopausal and postmenopausal rats: role of the estrogen receptors

BACKGROUND

Although alterations in the plasma levels of leptin, glucagon-like peptide-1, and gastrin were linked with bariatric surgery outcomes, gastric production of these peptides was not elucidated before.

OBJECTIVE

The aim was to evaluate the impact of estrogen depletion and estrogen receptors (ERs) on sleeve gastrectomy (SG)-induced alterations in gastric hormone production, gastric mucosal integrity, and bone mass.

SETTING

Physiology Research Lab at the University.

METHODS

Female Sprague-Dawley rats underwent ovariectomy or sham operation (control), and 2 months later SG or sham SG was performed. Rats received either nonselective agonist 17 β, ER-α agonist, ER-β agonist, or vehicle for 3 weeks. Trunk blood and gastric tissues were collected for biochemical measurements, while histopathologic examination was performed in gastric and femur samples.

RESULTS

In the presence of intact ovaries, SG-induced weight loss was accompanied by reductions in the gastric synthesis of leptin and gastrin, while gastric glucagon-like peptide-1 was additionally decreased when SG was performed at the postmenopausal state. SG elevated the depleted serum estradiol levels of menopause, implicating a beneficial effect, but the occurrence of severe gastric mucosal injury was triggered. On the other hand, using ER agonists upregulated gastrin-expressing cells, ameliorated gastric injury, and improved bone loss.

CONCLUSIONS

SG, either at premenopausal or postmenopausal state, resulted in considerable loss in bone mass, along with reductions in the gastric levels of gastrin and leptin. Functional status of the ovaries needs to be taken into consideration when monitoring the outcomes of SG, and ER agonists could be of value in controlling SG-induced complications.

Portal vein thrombosis in laparoscopic vertical gastrectomy - laparoscopic sleeve gastrectomy: a case series

Grade III obesity is defined as excessive accumulation of fat in the body in a person with a BMI>40kg/m² and is related to a series of comorbidities. It is therefore of fundamental importance that appropriate treatment is adopted to reduce its harmful effects on health. Laparoscopic vertical gastrectomy is well-established for treatment of grade III obesity. Although rare, portal vein thrombosis is one of the most serious of possible postoperative complications. In our study, eight cases are analyzed of laparoscopic vertical gastrectomy patients who developed portal vein thrombosis as a postoperative complication. In our series, we observed an increase in the incidence of portomesenteric venous thrombosis, especially among patients who did not follow the recommendations for oral hydration in the postoperative period. Most patients with this complication respond positively to anticoagulation, with complete or partial recanalization of the portal vein. Treatment with anticoagulants is effective and should be considered the first option. Vigorous hydration has also been shown to be an essential conduct in the postoperative period of these patients, and should always be encouraged.