A nationwide survey on bariatric surgery in Germany--results 2005-2007

Laparoscopic sleeve gastrectomy: A role of inflammatory markers in the early detection of gastric leak

Setting:

Laparoscopic sleeve gastrectomy (LSG) is gaining popularity as a bariatric option. Gastric leak (GL) is the most dreaded septic complication of LSG. Early detection and treatment of this complication may improve outcomes.

Objectives:

This study investigates biomarkers that might be useful to predict GL before its clinical presentation in patients who underwent LSG.

Patients and Methods:

This study, prospective observational, was carried out in 151 patients, who underwent LSG for morbid obesity between February 2014 and October 2019. Blood samples were collected before the operation and on post-operative days one, three and five to dose serum C-reactive protein (CRP), pro-calcitonin (PCT), fibrinogen, white blood cells (WBCs) count and neutrophil-to-lymphocyte ratio (NLR).

Results:

GL occurred in 6 patients (3.97%). According to the receiver operating characteristics curve, NLR detected leak with remarkably higher sensitivity (100%) and specificity (100%) than CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5. Moreover, the area under the curve (AUC) of NLR (AUC = 1) was higher than the AUC of CRP, fibrinogen, WBC on all the days and higher than PCT in post-operative days 3 and 5, suggesting important statistical significance.

Conclusions:

Because NLR and PCT detected GL with remarkably higher sensitivity and specificity than CRP, fibrinogen and WBC, these two markers seem to be more accurate for the early detection of this complication.

Publication Trends in Bariatric Surgery: a Bibliometric Study

BACKGROUND

The interest in bariatric surgery has considerably increased in the scientific community in the last two decades. We present a bibliometric analysis of scientific publications in bariatric surgery focusing on the period 2010-2014.

METHODS

We used the Web of Science database as source of data. The main bibliometric indicators were applied in order to assess the increase of scientific production, the productivity of journals, authors, and countries.

RESULTS

Bibliographic research retrieved 7860 papers for the period 2010-2014. The scientific production in bariatric surgery has an exponential distribution (r = 97.9 %). A total of 76.8 % (21,893/28,505) of authors signed one paper and 307 (1.1 %) signed ten or more. The two most prolific journals are Obesity Surgery and SOARD, responsible for 22 % of the publication. The largest contributors in absolute number of articles are the USA, the UK, and Italy, while Sweden, Norway, and Switzerland are the most prolific nations after adjustment for the number of inhabitants and prevalence of obesity.

CONCLUSION

Bariatric surgery has been a field of intense research in the last 20 years. We observed a growing interest of non-surgical journals and an increasing participation of new countries. Nevertheless, latest trends suggest a saturation of scientific production in this field.

Cost-utility analysis of bariatric surgery compared with conventional medical management in Germany: a decision analytic modeling

Background

The objective was to evaluate cost-utility of bariatric surgery in Germany for a lifetime and 10-year horizon from a health care payer perspective.

Methods

State-transition Markov model provided absolute and incremental clinical and monetary results. In the model, obese patients could undergo surgery, develop post-surgery complications, experience diabetes type II, cardiovascular diseases or die. German Quality Assurance in Bariatric Surgery Registry and literature sources provided data on clinical effectiveness and safety. The model considered three types of surgeries: gastric bypass, sleeve gastrectomy, and adjustable gastric banding. The model was extensively validated, and deterministic and probabilistic sensitivity analyses were performed to evaluate uncertainty. Cost data were obtained from German sources and presented in 2012 euros (€).

Results

Over 10 years, bariatric surgery led to the incremental cost of €2909, generated additional 0.03 years of life and 1.2 quality-adjusted life years (QALYs). Bariatric surgery was cost-effective at 10 years with an incremental cost-effectiveness ratio of €2457 per QALY. Over a lifetime, surgery led to savings of €8522 and generated an increment of 0.7 years of life or 3.2 QALYs. The analysis also depicted an association between surgery and a reduction of obesity-related adverse events (diabetes, cardiovascular disorders). Delaying surgery for up to 3 years, resulted in a reduction of life years and QALYs gained, in addition to a moderate reduction in associated healthcare costs.

Conclusions

Bariatric surgery is cost-effective at 10 years post-surgery and may result in a substantial reduction in the financial burden on the healthcare system over the lifetime of the treated individuals. It is also observed that delays in the provision of surgery may lead to a significant loss of clinical benefits.

Dysphagia after vertical sleeve gastrectomy: Evaluation of risk factors and assessment of endoscopic intervention

AIM

To evaluate the risks of medical conditions, evaluate gastric sleeve narrowing, and assess hydrostatic balloon dilatation to treat dysphagia after vertical sleeve gastrectomy (VSG).

METHODS

VSG is being performed more frequently worldwide as a treatment for medically-complicated obesity, and dysphagia is common post-operatively. We hypothesize that post-operative dysphagia is related to underlying medical conditions or narrowing of the gastric sleeve. This is a retrospective, single institution study of consecutive patients who underwent sleeve gastrectomy from 2013 to 2015. Patients with previous bariatric procedures were excluded. Narrowing of a gastric sleeve includes: inability to pass a 9.6 mm gastroscope due to stenosis or sharp angulation or spiral hindering its passage.

RESULTS

Of 400 consecutive patients, 352 are included; the prevalence of dysphagia is 22.7%; 33 patients (9.3%) have narrowing of the sleeve with 25 (7.1%) having sharp angulation or a spiral while 8 (2.3%) have a stenosis. All 33 patients underwent balloon dilatation of the gastric sleeve and dysphagia resolved in 13 patients (39%); 10 patients (30%) noted resolution of dysphagia after two additional dilatations. In a multivariate model, medical conditions associated with post-operative dysphagia include diabetes mellitus, symptoms of esophageal reflux, a low whole blood thiamine level, hypothyroidism, use of non-steroidal anti-inflammatory drugs, and use of opioids.

CONCLUSION

Narrowing of the gastric sleeve and gastric sleeve stenosis are common after VSG. Endoscopic balloon dilatations of the gastric sleeve resolves dysphagia in 69% of patients.

Nationwide Survey on Bariatric and Metabolic Surgery in Korea: 2003-2013 Results

A survey to evaluate the current status of bariatric and metabolic operations in Korea was conducted. Data from 5467 cases (32 hospitals) were collected. The annual numbers of bariatric and metabolic operations increased each year, from 139 in 2003 to 1686 in 2013. Adjustable gastric band (AGB, 67.2 %) was the most common operation, followed by sleeve gastrectomy (SG, 14.2 %), and Roux-en-Y gastric bypass (RYGB, 12.7 %). Mean patient age and body mass index (BMI) were 35.4 years and 35.9 kg/m2, respectively. In-hospital morbidity and mortality rates were 6 % (114/2305) and 0.25 % (5/2176), respectively. In Korea, AGB was the most common operation because of the availability and activity of specialized bariatric clinics. These national survey results established a baseline for future data collection.

Laparoscopic sleeve gastrectomy using a synthetic bioabsorbable staple line reinforcement material: Post-operative complications and 6 year outcomes

Background

Gastric leak after laparoscopic sleeve gastrectomy (LSG) is a serious complication. Currently, the literature lacks long-term outcomes in LSG and leak rates after reinforcement of the staple line. The aims are two-fold: to present leak rates from using staple line reinforcement and six year outcomes of LSG in relation to resolution of obesity-related comorbidities and long-term weight loss.

Materials and methods

This is a single-institution, retrospectively reviewed study of 204 patient case files. Data from all patients undergoing LSG between December 2007 and May 2013 was collected.

Results

The total complication rate was 6.9% (14/204), with no recorded staple line leaks. The mean postoperative Body Mass Index (BMI) at 1 year, 2 years, 3 years, 4 years, 5 years, and 6 years was 39.3 ± 8, 38.7 ± 8, 40.4 ± 9, 40.5 ± 10, 43.0 ± 10, and 42.4 ± 7, respectively. The mean % excess weight loss at 1 year, 3 years, and 6 years was 48.4 ± 19, 51.7 ± 28, and 41.0 ± 21, respectively. There were no significant differences between follow-ups at year 1 and 3 (p > 0.05), and between year 3 and 6 (p > 0.05) for the mean % excess weight loss. The resolution rates for all patients were 74%, 61%, 79%, and 90% for hypertension, hypercholesterolemia, diabetes mellitus type 2 and obstructive sleep apnea, respectively.

Conclusion

The synthetic bioabsorbable reinforcement material shows no staple line leaks making it safe to use. LSG as a procedure had a high resolution of obesity-related comorbidities as well as sustainable long-term weight loss.

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Laparoscopic sleeve gastrectomy shows sustainable long-term weight loss.

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Laparoscopic sleeve gastrectomy shows excellent resolution of comorbidities.

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The use of a bioabsorbable staple line reinforcement material is safe.

Fifth International Consensus Conference: current status of sleeve gastrectomy

BACKGROUND

For the purpose of building best practice guidelines, an international expert panel was surveyed in 2014 and compared with the 2011 Sleeve Gastrectomy Consensus and with survey data culled from a general surgeon audience.

OBJECTIVES

To measure advancement on aspects of laparoscopic sleeve gastrectomy and identify current best practices.

SETTING

International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) 2014, Fifth International Summit for Laparoscopic Sleeve Gastrectomy, Montréal, Canada.

METHODS

In August 2014, expert surgeons (based on having performed>1000 cases) completed an online anonymous survey. Identical survey questions were then administered to general surgeon attendees.

RESULTS

One hundred twenty bariatric surgeons completed the expert survey, along with 103 bariatric surgeons from IFSO 2014 general surgeon audience. The following indications were endorsed: as a stand-alone procedure (97.5%); in high-risk patients (92.4%); in kidney and liver transplant candidates (91.6%); in patients with metabolic syndrome (83.8%); body mass index 30-35 with associated co-morbidities (79.8%); in patients with inflammatory bowel disease (87.4%); and in the elderly (89.1%). Significant differences existed between the expert and general surgeons groups in endorsing several contraindications: Barrett's esophagus (80.0% versus 31.3% [P<.001]), gastroesophageal reflux disease (23.3% versus 52.5% [P<.001]), hiatal hernias (11.7% versus 54.0% [P<.001]), and body mass index>60 kg/m(2) (5.0% versus 28.0% [P<.001]). Average reported weight loss outcomes 5 years postoperative were significantly higher for the expert surgeons group (P = .005), as were reported stricture (P = .001) and leakage (P = .005) rates. The following significant differences exist between 2014 and 2011 expert surgeons: Patients with gastroesophageal reflux disease should have pH and manometry study pre-laparoscopic sleeve gastrectomy (32.8% versus 50.0%; P = .033); it is important to take down the vessels before resection (88.1% versus 81.8%; P = .025); it is acceptable to buttress (81.4% versus 77.3%; P<.001); the smaller the bougie size and tighter the sleeve, the higher the incidence of leaks (78.8% versus 65.2%; P = .006).

CONCLUSION

This study highlights areas of new and improved best practices on various aspects of laparoscopic sleeve gastrectomy performance among experts from 2011 and 2014 and among the current general surgeon population.

Bariatric surgery and liver transplantation: a systematic review a new frontier for bariatric surgery

This study aims to conduct a systematic review on bariatric surgery (BS) for patients in the setting of liver transplantation (LT). A literature review was conducted on the PubMed, Embase, and Cochrane Library databases. Studies in the English language on adults reporting on BS prior to, during, or after LT were included. Eleven studies with 56 patients were retrieved. Two studies reported on BS before, two during, and seven after LT. Sleeve gastrectomy was the most common procedure, followed by Roux-en-Y gastric bypass, biliopancreatic diversion, and gastric banding. The overall mortality rate was nil in the early postoperative period and 5.3 % in the first postoperative year. The reoperation rate was 12.2 %. Obesity surgery seems feasible in this population, but mortality and morbidity are higher.

Laparoscopic Adjustable Gastric Banding Revisions in Singapore: a 10-Year Experience

BACKGROUND

Bariatric surgery is increasingly being carried out and revisional procedures have also risen in concert. A review of the complications and revisions might elucidate technical and patient factors that influence the outcomes of bariatric surgeries in Asian patients. The objective of this study is to review the safety and efficacy of revisional bariatric surgery in a single center in Singapore over a 10-year period.

METHODS

The setting of this study is a single public hospital with a multidisciplinary bariatric service including a weight management center, specialized endocrinology services, and bariatric surgical team. Participants were selected for surgery based on body mass index (BMI) and comorbidities. All patients underwent primary laparoscopic adjustable gastric banding (LAGB). Patients were then analyzed according to the types of revisional surgeries. The primary outcome was the type of complications and revisional surgeries. Secondary outcomes include short-term excess weight loss and further complications.

RESULTS

A total of 365 patients were analyzed. 9.6% had a secondary procedure. In particular, two groups of complications required revisional surgery: failure of sustained weight loss and complications related to the LAGB insertion and use. Revisional surgeries had equivalent major complication rates (5.7%) compared to primary bariatric surgeries (6.8%). Revisional surgeries such as revisional LAGB (4.9 ± 9.8 kg), laparoscopic sleeve gastrectomy (LSG; 6.9 ± 21.0 kg), Roux-en-Y gastric bypass (RYGB; 4.6 ± 13.0 kg), and bilio-pancreatic diversion (BPD; 3.5 ± 6.3 kg) had modest weight loss compared to primary weight loss (12.7 ± 9.5 kg). Primary LAGB had a greater percentage excess weight loss in the first and second years post-surgery compared to revisional surgeries. There was one mortality post-primary surgery and no post-revisional surgical mortalities.

CONCLUSIONS

Revisional bariatric surgery for complications related to the primary surgery is safe but had reduced excess weight loss compared to the initial surgery.

Are There Gender-Specific Aspects in Obesity and Metabolic Surgery? Data Analysis from the German Bariatric Surgery Registry

Background

Since January 2005, the status of bariatric surgery in Germany has been examined in conjunction with a quality assurance study of the German Bariatric Surgery Registry (GBSR). All data are registered prospectively in cooperation with the Institute for Quality Assurance in Surgical Medicine at the Otto-von-Guericke University Magdeburg, Germany.

Methods

Data are registered in an online database. Data collection on obesity and metabolic surgery is voluntary, and was started in 2005. In addition, follow-up data are collected once a year.

Results

Since 2005, 8,293 sleeve gastrectomies, 10,330 Roux-en-Y gastric bypass procedures, and 3,741 gastric banding procedures have been performed in Germany, according to the data of the GBSR. Mean age and mean body mass index of female patients with gastric banding, sleeve gastrectomy, or Roux-en-Y gastric bypass were significantly lower than those of male patients. The incidence of relevant comorbidities was significantly higher in male than in female patients.

Conclusion

Metabolic and obesity surgery is becoming more and more popular in Germany. Data from the GBSR study show significant differences in preoperative comorbidities and postoperative complication and mortality rates between male and female patients. There is a need for further evaluation of gender-specific aspects to optimize patient selection and reduce specific postoperative complications.

Outcome reporting in bariatric surgery: an in-depth analysis to inform the development of a core outcome set, the BARIACT Study

Outcome reporting in bariatric surgery needs a core outcome set (COS), an agreed minimum set of outcomes reported in all studies of a particular condition. The aim of this study was to summarize outcome reporting in bariatric surgery to inform the development of a COS. Outcomes reported in randomized controlled trials (RCTs) and large non-randomized studies identified by a systematic review were listed verbatim and categorized into domains, scrutinizing the frequency of outcome reporting and uniformity of definitions. Ninety studies (39 RCTs) identified 1,088 separate outcomes, grouped into nine domains with most (n = 920, 85%) reported only once. The largest outcome domain was 'surgical complications', and overall, 42% of outcomes corresponded to a theme of 'adverse events'. Only a quarter of outcomes were defined, and where provided definitions, which were often contradictory. Percentage of excess weight loss was the main study outcome in 49 studies, but nearly 40% of weight loss outcomes were heterogeneous, thus not comparable. Outcomes of diverse bariatric operations focus largely on adverse events. Reporting is inconsistent and ill-defined, limiting interpretation and comparison of published studies. Thus, we propose and are developing a COS for the surgical treatment of severe and complex obesity.

Endospanin 1 silencing in the hypothalamic arcuate nucleus contributes to sustained weight loss of high fat diet obese mice

Leptin targets specific receptors (OB-R) expressed in the hypothalamus to regulate energy balance. Leptin decreases food intake in normal weight individuals, but this effect is blunted in obese subjects who are characterized by a state of leptin resistance. The prevention of leptin resistance is one of the major goals of obesity research. Recently, we identified endospanin 1 as a negative regulator of OB-R, which by interacting with OB-R retains the receptor inside the cell. We show here that in obese mice endospanin 1 is upregulated in the hypothalamic arcuate nucleus (ARC), the major brain structure involved in body weight regulation, suggesting that endospanin 1 is implicated in obesity development and/or the installation of leptin resistance. In contrast, silencing of endospanin 1 with lentiviral vectors in the ARC of obese mice fully restores leptin responsiveness when combined with a switch to ad libitum fed chow diet. The recovery of central leptin sensitivity is accompanied by sustained body weight loss and amelioration of blood lipid parameters and steatosis. Collectively, our results define endospanin 1 as a novel therapeutic target against obesity.

Long term predictors of success after laparoscopic sleeve gastrectomy

BACKGROUND

To evaluate early, mid and long term efficacy of laparoscopic sleeve gastrectomy as a definitive management of morbid obesity and to study factors that may predict its success.

MATERIALS AND METHODS

A retrospective study was conducted by reviewing the database of patients who underwent LSG as a definitive bariatric procedure, from April 2005 to March 2013. Univariate and multivariate analysis were performed.

RESULTS

1395 patients were included in this study. Mean age was 33 years and women:men ratio was 74:26. The mean preoperative BMI was 46 kg/m(2). Operative time was 113 ± 29 min. Reinforcement of staple line was done only in 447 (32%) cases. 11 (0.79%) cases developed postoperative leak, with total number of complications 72 (5.1%) and 0% mortality. Percentage of excess weight loss (%EWL) was 42%, 53%, 61%, 73%, 67%, 61%, 59% and 57% at 6 months, 1-7 years. Remission of diabetes (DM), hypertension (HTN) and hyperlipidaemia (HLP) occurred 69%, 54% and 43% respectively. 56 (4%) patients underwent revision surgery, for insufficient weight loss (n = 37) and severe reflux symptoms (n = 19). Mean follow up was 76 ± 19 (range: 6-103) months. Smaller bougie size and leaving smaller antrum were associated with significant %EWL. Bougie ≤36F remained significant in multivariate analysis.

CONCLUSION

This study supports safety, effectiveness and durability of LSG as a sole definitive bariatric procedure. Smaller bougie size and shorter distance from pylorus were associated with significant %EWL.

Early and long-term clinical outcomes of bilio-intestinal diversion in morbidly obese patients

PURPOSE

To evaluate the early and long-term postoperative results of malabsorptive surgery in morbidly obese patients.

METHODS

Between 2000 and 2007, 102 morbidly obese patients were referred to the Department of Surgery "Pietro Valdoni", "Sapienza" University of Rome, Policlinico "Umberto I°", Rome, Italy for malabsorptive surgery. All patients underwent derivative biliodigestive surgery after they had been reviewed by a team of surgeons, physicians, dieticians, and psychologists.

RESULTS

There were no intra-operative complications, but two patients suffered postoperative pulmonary embolisms, which resolved with medical treatment. The mean postoperative hospital stay was 7 days, with no early or late mortality. Maximum weight loss was reached 12-24 months after surgery, while the mean percentage excess weight loss at 3-5 years ranged from 45 to 64 %. Specific postoperative complications in the first 2 years after surgery were abdominal abscess (n = 2), gastroduodenal reflux (n = 4), and incisional hernia (n = 6). Diabetes resolved in 98 % of the diabetic patients within a few weeks after surgery and blood pressure normalised in 86.4 % of those who had had hypertension preoperatively. Obstructive sleep apnoea and obesity hypoventilation syndrome also improved significantly in 92 % of the patients.

CONCLUSIONS

Morbidly obese patients can undergo biliodigestive surgery safely with good long-term weight loss and quality of life expectancy.

Attitudes towards bariatric surgery in the general public

BACKGROUND

Prevalence rates of obesity are still rising. Weight loss surgery (WLS) is the most invasive but also most effective treatment option when behavioral modification has failed. Research indicates that health care professionals hold ambivalent views on bariatric surgery, while views of the general public have not yet been investigated.

METHODS

In a German representative sample of n = 3,003 respondents in a computer-assisted telephone interview, n = 1,008 persons were interviewed on their views of the effectiveness of bariatric surgery and other interventions for obesity. Also, willingness to recommend a treatment was assessed.

RESULTS

Lifestyle-based interventions were viewed as most effective in terms of weight loss. About 50 % of the population stated that WLS is "very effective" while still a quarter of respondents did not ascribe effectiveness to WLS. Higher age was associated with lower expectations of effectiveness while higher stigmatizing attitudes and genetic attributes for obesity were associated with higher expectations of effectiveness. Seventy-two percent would not recommend WLS or undergo it, if applicable, themselves. Higher educated respondents and those that viewed WLS as effective were more likely to recommend WLS.

CONCLUSIONS

The German general public seems to be rather cautious regarding bariatric surgery. It may be assumed that false beliefs on the effectiveness and risk patterns of bariatric surgery are still very common, despite rising surgery numbers. Our results further emphasize the need for providing evidence-based information on bariatric surgery to the general public.

Bariatric surgery trends in France: 2005-2011

BACKGROUND

Bariatric surgery underwent a dramatic change in the past decade in France. The objective of this study was to examine elective bariatric surgical procedures from 2005 to 2011 in France and to determine trends in the use of the procedure.

METHODS

Data were extracted from the National Hospital Database. All admissions involving a bariatric surgery procedure were included. Procedures authorized by the Public Health Authority for the treatment of morbid obesity, including the adjustable gastric banding (AGB), vertical banded gastroplasty (VBG), gastric bypass (GB), sleeve gastrectomy (SG), and biliopancreatic diversion (BPD), either by laparotomic or laparoscopic approach, were retrieved. Revisional procedures, such as band removal or repositioning, band changing, and access device revisions, were also evaluated.

RESULTS

We observed a 2.5-fold increase in bariatric procedures, from 12,800 in 2005 to 31,000 in 2011. Sleeve gastrectomy and gastric bypass became the most common bariatric procedures in France in 2011, whereas adjustable gastric banding has been decreasing since 2007. During the analysis period, about 50,000 revisional procedures were performed. The number of hospitals (private or public) providing bariatric surgery has considerably increased. However, most of the activity remains confined to a small number of centers, as 50% of all bariatric surgeries are carried out in 12% of hospitals. Bariatric procedures are predominantly performed in private hospitals.

CONCLUSIONS

In France the number of bariatric procedures increased considerably between 2005 and 2011. The type of procedures changed, with a constant decrease of AGB and an important increase of SG and GB. Most bariatric procedures are still performed in low volume activity hospitals and in private hospitals.

3-year real-world outcomes with the Swedish adjustable gastric band™ in France

The study objective was to ascertain outcomes with the Swedish adjustable gastric band (SAGB) on an intention-to-treat basis in multiple centers across the French social health insurance system. SAGB results at 3-year follow-up are reported. The noncomparative, observational, prospective, consecutive cohort study design sought a 500-patient minimum recruitment geographically representative of continental France. Safety (adverse events [AEs], device-related morbidity, and mortality) and effectiveness (change in body mass index [BMI, kilograms per square meter], percentage excess weight loss, comorbidities, quality of life [QoL]) were assessed. Adjustable gastric band survival was calculated. Thirty-one surgeons in 28 multidisciplinary teams/sites enrolled patients between September 2, 2007 and April 30, 2008. SAGB was successfully implanted in 517 patients: 88.0 % female; mean age, 37.5 years; obesity duration, 15.3 years (baseline: mean BMI, 41.0; comorbidities, 773 in 74.3 % of patients; Bariatric Analysis and Reporting Outcome System (BAROS), 1.4; EuroQoL 5-Dimensions (EQ-5D), 0.61; EuroQoL-visual analog scale (EQ-VAS), 52.3). At 3 years: BMI, 32.2 (mean change, -9.0; p < 0.0001); excess weight loss, 47.4 %; comorbidities, 161 in 27.2 %; BAROS, 3.6 (+2.2, p < 0.0001); EQ-5D, 0.84 (+0.22, p < 0.0001); EQ-VAS, 73.4 (+21.4, p < 0.0001). SAGB-induced weight loss was associated with substantially improved QoL. One death occurred and was unrelated to the treatment. No AE was reported in 68.3 % of patients, and no confirmed device-related AE in 77.0 %. Overall AE rate was 0.19 per patient year. Device retention was 87.0 %. Analysis of patients lost to follow-up showed a nonsignificant effect on overall study results. In a prospective, consecutive cohort, "real-world", nationwide study, the Swedish Adjustable Gastric Band was found safe and effective at 3-year follow-up.

Are there gender-specific aspects of sleeve gastrectomy-data analysis from the quality assurance study of surgical treatment of obesity in Germany

Since 1 January 2005, the situation of bariatric surgery has been examined in Germany. All data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University Magdeburg. Data are registered in an internet online database. Data collection on the results of sleeve gastrectomy was started in 2006. Follow-up data were collected once a year. Participation in the quality assurance study is voluntary. Since 2005, 3,125 sleeve gastrectomies have been performed in 80 hospitals. The number of procedures has increased from 1 in 2005 to 1,564 in 2010. Initially, the leakage rate was 7 % in 2007. The leakage rate dropped to 1.7 in 2010. The mean age of patients was 43.5 years and mean body mass index (BMI) was 52.03 kg/m(2). BMI and comorbidities are significantly higher in male than in female patients. The leakage rate in female patients was, at 1.60 %, significantly lower than in male patients, at 3.28 %. Sleeve gastrectomy is becoming more and more popular in Germany. But the postoperative complication rate is still high. Data from the nationwide survey of bariatric surgery in Germany show significant differences in preoperative comorbidities and complication rates between male and female patients. There is a need for further evaluation of gender-specific aspects to optimize patient selection and reduce specific postoperative complications.

Excessive weight loss after sleeve gastrectomy: a systematic review

BACKGROUND

The clinical significance of sleeve gastrectomy (SG) as a primary bariatric intervention is still under debate. This article aims to systematically analyze excessive weight loss (EWL) in patients after SG.

METHODS

A systematic literature search on SG from the period January 2003 to December 2010 was performed. Data described from systematic reviews dealing with gastric bypass procedures was used as comparator.

RESULTS

The final study included 123 papers describing 12,129 patients. Most of the papers describe EWL at 12 months (43.9% of all papers). For SG, the maximum EWL occurred 24 and 36 months postoperatively with a mean EWL of 64.3% (minimum 46.1%, maximum 75.0%) and 66.0% (minimum 60.0%, maximum 77.5%), respectively. At 12 months, the mean EWL in patients receiving SG was significantly lower when compared to patients who underwent gastric bypass (SG 56.1%, gastric bypass 68.3%; p < 0.01, two-sided Wilcoxon test). Although patients with gastric bypass still had higher EWL rates at 24 months compared to patients after SG, these differences were not significant (SG 61.3%, gastric bypass 69.6%; p = 0.09, two-sided Wilcoxon rank-sum test). Reoperations after SG are necessary in 6.8% (range 0.7-25%) of cases with patients receiving SG as a stand alone procedure and in 9.6-28.5% of cases with patients undergoing SG as a planned first stage procedure.

CONCLUSIONS

SG is an effective bariatric procedure with a lasting effect on EWL. Compared with gastric bypasses, there is no difference in EWL at the time point of 24 months.

International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is an emerging surgical approach, but 1 that has seen a surge in popularity because of its perceived technical simplicity, feasibility, and good outcomes. An international expert panel was convened in Coral Gables, Florida on March 25 and 26, 2011, with the purpose of providing best practice guidelines through consensus regarding the performance of LSG. The panel comprised 24 centers and represented 11 countries, spanning all major regions of the world and all 6 populated continents, with a collective experience of >12,000 cases. It was thought prudent to hold an expert consensus meeting of some of the surgeons across the globe who have performed the largest volume of cases to discuss and provide consensus on the indications, contraindications, and procedural aspects of LSG. The panel undertook this consensus effort to help the surgical community improve the efficacy, lower the complication rates, and move toward adoption of standardized techniques and measures. The meeting took place at on-site meeting facilities, Biltmore Hotel, Coral Gables, Florida.

METHODS

Expert panelists were invited to participate according to their publications, knowledge and experience, and identification as surgeons who had performed >500 cases. The topics for consensus encompassed patient selection, contraindications, surgical technique, and the prevention and management of complications. The responses were calculated and defined as achieving consensus (≥70% agreement) or no consensus (<70% agreement).

RESULTS

Full consensus was obtained for the essential aspects of the indications and contraindications, surgical technique, management, and prevention of complications. Consensus was achieved for 69 key questions.

CONCLUSION

The present consensus report represents the best practice guidelines for the performance of LSG, with recommendations in the 3 aforementioned areas. This report and its findings support a first effort toward the standardization of techniques and adoption of working recommendations formulated according to expert experience.

The Endocrine Society's Clinical Practice Guideline on endocrine and nutritional management of the post-bariatric surgery patient: commentary from a European Perspective

Bariatric and metabolic surgery is experiencing a noteworthy increase worldwide in recent years, but protocols and consensus published in the past decade have not yet established clear evidence-based clinical recommendations. The Endocrine Society, with the participation of the European Society of Endocrinology, has promoted the creation of an expert panel to propose a clinical practice guideline for postoperative management of patients, candidates to bariatric surgery, that places a particular emphasis on evidence-based medical aspects. The main arguments reflected in those recommendations are set out in this article and are subject to analysis and discussion from the specific viewpoint of the current European experience.

Fourteen-year long-term results after gastric banding

Background. Gastric banding (GB) is a common bariatric procedure that is performed worldwide. Weight loss can be substantial after this procedure, but it is not sufficient in a significant portion of patients. Long-term rates for associated complications increase with every year of follow up, and only a few long-term studies have been published that examine these rates. We present our results after 14 years of postoperative follow up. Methods. Two hundred patients were operated upon form 01.02.1995 to 31.01.2009. Data collection was performed prospectively. In retrospective analysis, we analyzed weight loss, short- and long-term complications, amelioration of comorbidities and long-term outcome. Results. The mean postoperative follow up time was 94.4 months (range 2-144). The follow up rate was 83.5%. The incidence of postoperative complications for slippage was 2.5%, for pouch dilatation was 9.5%, for band migration was 5.5% and 12.0% for overall band removal. After 14 years, the reoperation rate was 30.5% with a reoperation rate of 2.2% for every year of follow up. Excess weight loss was 40.2% after 1 year, 46.3% after 2 years, 45.9% after 3 years, 41.9% after five years, 33.3% after 8 years, 30.8% after 10 years, 33.3% after 12 years and 15.6% after 14 years of follow up. Conclusion. The complication and reoperation rate after GB is high. Nevertheless, GB is still a therapeutic option in morbid obese patients, but the criteria for patient selection should be carefully evaluated.

[Complications of gastric banding versus gastric bypass]

Das Magenband (Gastric Banding, GB) und der Magenbypass (Roux-en-Y-Gastric Bypass, RYGBP) sind die derzeit am häufigsten durchgeführten bariatrischen Operationsverfahren weltweit. Während in den USA das GB die Häufigkeit an RYGBP-Operationen überstiegen hat, zeigt sich in Europa seit mehreren Jahren eine gegenläufige Tendenz. Dies ergibt sich insbesondere aus der Rate an Langzeitkomplikationen nach GB. Früh- und Spätkomplikationen beeinflussen das Outcome der Patienten wesentlich. Daher werden zur Analyse der Komplikationsrate von GB und RYGBP die Daten der Qualitätssicherungsstudie für die operative Therapie der Adipositas ausgewertet und mit Daten der Literatur verglichen. Complications of Gastric Banding versus Gastric Bypass Gastric banding (GB) and Roux-en-Y gastric bypass (RYGBP) are currently the most-performed bariatric procedures worldwide. GB has become more and more popular in the USA since 2000. In Europe, RYGBP is the procedure of first choice, due to the rate of long-term complications after GB. Early and late postoperative complication rates have a major influence on the patient outcome. Therefore, data of the Nationwide Survey on Bariatric Surgery in Germany were evaluated for complication rate after GB and RYGBP, in comparison with the literature.

[Surgery in morbid obesity: quality assurance--state of the art and prospects]

Seit 2005 führen wir mit Unterstützung unserer wissenschaftlichen Fachgesellschaften eine Qualitätssicherung für die chirurgische Therapie der Adipositas durch. Wichtige Zielparameter sind unter anderem das Ausmaß der Gewichtsreduktion und die Beeinflussung der Komorbiditäten im Langzeitverlauf. Wir berichten darüber anhand von 8716 Patientenverläufen aus 54 deutschen Kliniken. Surgery in Morbid Obesity: Quality Assurance - State of the Art and Prospects Since 2005 we have been performing quality assurance for surgical therapy of obesity, in close collaboration with our scientific associations. Important target parameters are, among others, the range of weight loss and the influence on comorbidities in the long-term process. We report on these by means of 8,716 patient processes from 54 German clinics.

Abordagem multidisciplinar de pacientes obesos mórbidos submetidos a tratamento cirúrgico pelo método da banda gástrica ajustável

OBJETIVO: Avaliar o resultado do tratamento cirúrgico de pacientes obesos mórbidos pelo método da BGA, acompanhados em ambulatório multidisciplinar. MÉTODOS: Foram estudados 20 pacientes com IMC que variou de 36,6 a 72 kg/m2 (X=47,51 +/- 6,1) e idade entre 36 a 60 anos, submetidos à colocação de BGA. As comorbidades encontradas no pré-operatório foram hipertensão arterial (nove), diabetes tipo II (quatro), apneia do sono grave (um), hipertrigliceridemia (quatro) e problemas ortopédicos graves (três). No seguimento pós-operatório os pacientes foram atendidos em ambulatório multidisciplinar (cirurgião, endocrinologista, psiquiatra e nutricionista). Nos primeiros seis meses, a orientação foi de visitas mensais para ajustes da banda e orientação nutricional. Após, as visitas ocorreram a cada dois ou três meses, conforme a necessidade. RESULTADOS: O tempo cirúrgico variou de 40 a 180 minutos; o de internação de 1 a 10 dias (X = 36 horas). Duas pacientes necessitaram reintervenção cirúrgica por complicações tardias: uma rotação do portal e um deslizamento superior da banda . O tempo de seguimento variou de 28 a 36 meses. A perda de peso média foi de 29,26 kg +/- 8,8, ou 24,37% +/- 6,1 do peso inicial e 49,16% +/- 11,3 do excesso de peso. O IMC médio variou de 47,51 para 34,88. Houve melhora global das comorbidades, mais acentuada nos pacientes com maior perda de peso. CONCLUSÃO: Os resultados obtidos foram satisfatórios para a maioria dos pacientes nos quesitos perda de peso e melhora das comorbidades.

Experience in laparoscopic sleeve gastrectomy for morbidly obese Taiwanese: staple-line reinforcement is important for preventing leakage

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a promising procedure for the surgical treatment of morbid obesity. We report our 2-year experience with LSG and specifically evaluate the importance of staple-line protection to prevent leakage after the laparoscopic procedure.

METHODS

One hundred eighteen consecutive patients with BMI > 30 who underwent LSG from January 2006 to February 2009 were included in our study. There were 88 women and 30 men with a mean age of 33.2 ± 9.6 years and a mean BMI of 38.0 ± 6.4 kg/m(2). The first 40 patients (group 1) underwent the operation without any reinforcement procedure and the other 78 patients received reinforcement of the staple-line (group 2). Data including demographics, hospital stay, blood loss, operative time, complications, excess weight loss percentage (EWL%), and gastrointestinal quality of life index (GIQLI) were collected prospectively for evaluation.

RESULTS

The overall mean operative time was 118.5 ± 37.0 min, mean blood loss was 56.8 ± 56.7 ml, mean hospital stay was 5 ± 3 days. The mean EWL% at 12 and 24 months was 81.5 and 76.0%, respectively. The overall leakage rate was 3.39% (4/118). All leakage occurred in group 1 patients, with a leakage rate of 10% (4/40). Mean preoperative GIQLI was 98.7, and the postoperative GIQLI were 116.4, 115, 112.4, and 97.6 at 3, 6, 12, and 24 months, respectively.

CONCLUSIONS

LSG is an effective obesity treatment to achieve significant weight loss after 24 months. Staple-line reinforcement is strongly recommended for laparoscopic sleeve gastrectomy to decrease complications.

Sleeve gastrectomy: a new surgical approach for morbid obesity

While obesity and morbid obesity have reached epidemic proportions worldwide, bariatric surgeons continue to develop safer and more efficacious procedures to battle this lethal disease. Sleeve gastrectomy, a relative new surgical approach, was initially conceived as a restrictive component of the biliopancreatic diversion and duodenal switch in the era of open bariatric surgery. With the advent of minimally invasive surgery in the late 1980s, laparoscopic sleeve gastrectomy (LSG) has been proposed as a step procedure in high-risk patients, followed by a second step Roux-en-Y gastric bypass or biliopancreatic diversion and duodenal switch and, recently, as a standalone bariatric approach. This article reviews the literature and reports the results achieved with LSG performed either as the initial operation for high-risk, high body mass index patients followed by a definitive weight loss operation, or used as a final viable alternative to other well-established bariatric procedures. An extensive literature review was conducted and the information currently available surrounding LSG, such as history, indications and contraindications, mechanism of weight loss, technique and outcomes and controversial issues are discussed. LSG is an accepted procedure for the surgical management of morbid obesity. It is gaining popularity as a primary, staged and revisional operation for its proven safety and simplicity, as well as short-term and mid-term efficacy. Excess weight loss and remission of comorbidities have been reported to take place in a frequency comparable with other well-established procedures. Despite all of the above-mentioned factors, long-term results and larger series are pending.

Vitamin A deficiency (VAD) after a duodenal switch procedure: a case report

Vitamin A deficiency (VAD) after bariatric surgery is a well-documented complication. Clinical signs of VAD deficiency are significant if the vitamin A level is below 100 mug/L (4 mumol/L). Main symptom of VAD is nyctalopia. It has been described in several reports after malabsorptive bariatric procedures. We report a 52-year-old man with VAD complained of night blindness and optic neuropathy after undergoing a duodenal switch procedure. The case illustrates the necessity of lifelong vitamin supplementation after malabsorptive bariatric operations.

Evidence of thromboembolism prophylaxis in bariatric surgery-results of a quality assurance trial in bariatric surgery in Germany from 2005 to 2007 and review of the literature

BACKGROUND

Since January 1st, 2005, the current situation for bariatric surgery has been examined by means of a voluntary quality assurance study in Germany with a multicenter design in which 38 hospitals and surgical departments participated. The data are registered in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany).

METHODS

Data describing peri-interventional characteristics were prospectively documented in an internet online data registry. All primary bariatric procedures performed since January 1st, 2005, were registered. In addition, reoperations in patients who had previously undergone primary surgical intervention were included. As a representative excerpt from the overall prospective multicenter observational study on obesity surgery, data on the type, regimen, and time course of deep venous thrombosis (DVT) prophylaxis were documented. From the number and spectrum of complications, the incidences of clinically manifest DVT or pulmonary embolism (PE) were derived during the in-hospital course and follow-up in conjunction with the type of surgical procedure and body mass index (BMI).

RESULTS

Overall, 3,122 bariatric procedures were performed at 38 German hospitals between January 2005 and December 2007. These procedures were subdivided into 2,869 primary operations and 253 revisions (sex ratio, male to female = 25.6:74.4%). The average BMI of all patients was 48.5 kg/m(2) in 2005, 48.4 kg/m(2) in 2006, and 48.0 kg/m(2) in 2007. In 2005 and 2006, gastric banding (GB) was the most commonly performed operation, followed by Roux-en-Y gastric bypass (RYGBP). In 2007, RYGBP was carried out in 42.1% of all bariatric procedures. Interestingly, the incidence of deep venous thrombosis (DVT) was only 0.06%, whereas PE occurred in 0.06% of patients only after hospital discharge. The DVT prophylaxis protocol used has been changed for the last 2 years: the majority of patients with a BMI above 50 kg/m(2) received low-molecular-weight heparin twice a day.

CONCLUSION

In Germany, a trend from GB to sleeve gastrectomy (SG) and malabsorptive approach has been evaluated. This trend is associated with differences of the DVT prophylaxis regimen in the profile of bariatric surgical patients depending on BMI and the type of bariatric procedure. Despite the low incidence of DVT and pulmonary embolism (PE) detected, there is a lack of evidence on a reasonable regimen for sufficient DVT prophylaxis in bariatric surgery; instead, there are only recommendations from the guidelines and statements of a specific medical society. Therefore, prospective studies are necessary to determine the optimal DVT prophylaxis for bariatric surgical patients as well as obese patients undergoing surgery.

Status of bariatric surgery in Germany--results of the nationwide survey on bariatric surgery 2005-2007

BACKGROUND

Most studies on bariatric surgery outcomes are performed as clinical trials or reflect the clinical experience in single centers. The status of bariatric surgery in Germany has been examined with the cooperation of clinics and hospitals at the Institute of Quality Assurance in Surgery at the Ottovon-Guericke University of Magdeburg (Germany) since January 1, 2005.

METHODS

In this prospective multicenter observational study, the data obtained for all primary bariatric procedures, including all repeated operations, performed on consecutive patients with morbid obesity at participating hospitals from 2005 to 2007 were prospectively collected using an internet online data registry. Perioperative characteristics such as the spectrum of diagnostic measurements, type of surgical procedures, and short- and long-term outcomes were investigated.

RESULTS

During the study period 3,123 surgical procedures were performed. In 2005 and 2006, gastric banding (GB) was the operation performed most frequently, followed by the Roux-en-Y gastric bypass (RYGBP). In 2007, a RYGBP was carried out in 42.1% of all bariatric procedures. Among all patients, 74.4% were female. The mean BMI ranged from 48.5 kg/m2 in 2005 to 48.0 kg/m2 in 2007. Follow-up data after 12 months were available for 63.8% of the patients operated in 2005 and 2006. The mortality was 0.1% (30 days) and 0.16% (overall).

CONCLUSION

As indicated by the worldwide trend, there is an ongoing change from GB to sleeve gastrectomy (SG) and malabsorptive procedures. The BMI of German bariatric surgical patients is substantially higher than that of patients from most other countries. There were no differences in overall outcomes during follow-up as compared to published studies.

Sleeve gastrectomy as a single-stage bariatric operation: indications and limitations

Sleeve gastrectomy (SG) was initially described as a first-step procedure followed by either biliopancreatic diversion with duodenal switch or Roux-en-Y gastric bypass in super-super obese patients. Multiple recent reports have documented SG as single therapy in the treatment of morbid obesity. However,the indications for this procedure are still under evaluation.Accumulating data demonstrate that SG can be an effective and safe procedure for super-super-obese or high-risk patients either as a single operation or as a bridge to more definitive surgery. SG can also be performed in patients who require anti-inflammatory medication or in patients with conditions such as Crohn's disease, cirrhosis, anemia, or severe osteoporosis which preclude intestinal bypass. Furthermore,SG represents not only a safe alternative for morbidly obese patients on anticoagulant medication or immunosuppressive agents but also for those with multiple intra-abdominal adhesions or after failed gastric banding. In addition, SG can be performed safely in morbid obese adolescents. The main limitation of this novel bariatric procedure is the lack of longterm data on sustained weight loss and resolution of obesity related comorbidities. Moreover, the fact that SG is an irreversible operation adds to its weakness as a bariatric procedure, at least until definitive results concerning its efficacy are obtained. SG is effective and safe as a single-stage procedure for certain cohorts of patients. However, the broad application of SG as a single-stage procedure in the bariatric field can be established only if the procedure is standardized and longterm results are available.

Sarcoidosis after adjustable silicone gastric banding - a report of two cases in Germany

We report 2 patients who developed sarcoidosis after the implantation of adjustable silicone gastric banding (GB) in Germany. Before implantation, no pulmonary diseases were evident in the medical history of either patient. The 1st patient suffered sarcoidosis 12 months after GB. He has been treated at a hospital specialising in pulmonary diseases. Because of the treatment with corticoids, the patient has regained weight after the initial weight reduction. The 2nd patient developed signs of pulmonary infection on the 7th postoperative day (after GB). Pulmonary sarcoidosis was diagnosed 4 months later after consultation with a pulmonologist.