Randomized clinical trial of laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for the management of patients with BMI < 50 kg/m2

Systematic Review and Meta-analysis of the Effects of Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy on Dyslipidemia

The aim of this meta-analysis was to compare the effects of LRYGB and LSG on dyslipidemia. Studies comparing the effects of LRYGB and LSG on dyslipidemia with follow-up of 12 months or more were included. Twenty-four studies comprising seven RCTs and 17 comparative observational studies were included. Meta-analysis of RCTs (n=487) showed that improvement/resolution of dyslipidemia was better after LRYGB (68.5%, n=161/235) compared to LSG (48.4%, n=122/252). Patients undergoing LRYGB were more than twice as likely to experience improvement/resolution in dyslipidemia compared to those undergoing LSG (OR 2.28, 95% CI 1.21-4.29, p=0.010). Both LRGYB and LSG appears effective in improving dyslipidemia at >12 months after surgery; however, this improvement is more than twice higher after LRYGB compared to LSG.

Advances in obesity pharmacotherapy; learning from metabolic surgery and beyond

Currently, metabolic surgery (MS) constitutes the most effective means for durable weight loss of clinically meaningful magnitude, type 2 diabetes remission and resolution of non-alcoholic steatohepatitis, as well as other obesity-related comorbidities. Accumulating evidence on the mechanisms through which MS exerts its actions has highlighted the altered secretion of hormonally active peptides of intestinal origin with biological actions crucial to energy metabolism as key drivers of MS clinical effects. The initial success of glucagon-like peptide-1 (GLP-1) receptor agonists regarding weight loss and metabolic amelioration have been followed by the development of unimolecular dual and triple polyagonists, additionally exploiting the effects of glucagon and/or glucose-dependent insulinotropic polypeptide (GIP) which achieves a magnitude of weight loss approximating that of common MS operations. Through the implementation of such therapies, the feasibility of a "medical bypass", namely the replication of the clinical effects of MS through non-surgical interventions may be foreseeable in the near future. Apart from weight loss, this approach ought to be put to the test also regarding other clinical outcomes, such as liver steatosis and steatohepatitis, cardiovascular disease, and overall prognosis, on which MS has a robustly demonstrated impact. Besides, a medical bypass as an alternative, salvage, or combination strategy to MS may promote precision medicine in obesity therapeutics.

Nutritional Considerations for Patients With Renal Failure Undergoing Sleeve Gastrectomy

Obesity is highly prevalent in patients with renal disease, as it contributes to or accelerates the progression of kidney disease and is frequently a barrier to kidney transplantation. Patients with renal disease have unique dietary needs due to various metabolic disturbances resulting from altered processing and clearance of nutrients. They also frequently present with physical disability, resulting in difficulty achieving adequate weight loss through lifestyle modifications. Therefore, kidney transplant candidates may benefit from bariatric surgery, particularly sleeve gastrectomy (SG), as the safest, most effective, and long-lasting weight loss option to improve comorbidities and access to transplantation. However, concerns regarding nutritional risks prevent broader dissemination of SG in this population. No specific guidelines tailored to the nutritional needs of patients with renal disease undergoing SG have been developed. Moreover, appropriate monitoring strategies and interventions for muscle loss and functional status preservation, a major concern in this at-risk population, are unknown. We aimed to summarize the available literature on the nutritional requirements of patients with renal disease seeking SG as a bridge to transplantation. We also provide insight and guidance into the nutritional management pre and post-SG.

Bariatric Surgery for Patients with Overweight/Obesity. A Comprehensive Grading Methodology and Network Metanalysis of Randomized Controlled Trials on Weight Loss Outcomes and Adverse Events

This study aims to compare different types of metabolic bariatric surgery (MBS) with lifestyle intervention/medical therapy (LSI/MT) for the treatment of overweight/obesity. The present and network meta-analysis (NMA) includes randomized trials. MBS was associated with a reduction of BMI, body weight, and percent weight loss, when compared to LSI/MT, and also with a significant reduction of HbA1c and a higher remission of diabetes. Meta-regression analyses revealed that BMI, a higher proportion of women, and a longer duration of trial were associated with greater effects of MBS. The NMA showed that all surgical procedures included (except greater curvature plication) were associated with a reduction of BMI. MBS is an effective option for the treatment of obesity. The choice of BMI thresholds for eligibility for surgery of patients with different complications should be performed making an evaluation of risks and benefits in each BMI category.

Laparoscopic Sleeve Gastrectomy versus Laparoscopic Roux-en-Y Gastric Bypass: An Analysis of Weight Loss Using a Multilevel Mixed-Effects Linear Model

Background: Regarding weight loss outcomes, the results published after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y (LRYGB) are conflicting. At this time, no clear evidence exists that outcomes from LSG are similar to those for LRYGB. The main objective of this study was to compare the percent of total weight loss (%TWL) between LRYGB and LSG over the first 2 years using a multilevel mixed-effects linear regression. Methods: Data were collected from a prospectively maintained database of patients who underwent primary laparoscopic bariatric surgery from January 2016 to December 2017 at a French accredited bariatric center. The medical records of 435 consecutive patients were analyzed. %TWL was calculated at each follow-up surgical consultation and used as a repeated outcome variable in our models to assess the long-term %TWL. Due to this hierarchical structure of the data (%TWL at each visit = level 1) within patients (level 2), a multilevel linear regression adjusted for age, sex, preoperative BMI and comorbidities was used. Results: Among the medical records of 435 consecutive patients included, 266 patients underwent LRYGB and 169 underwent LSG. The average %TWL at 2 years was 31.7% for the LRYGB group and 25.8% for the LSG group. The final multivariate model showed that, compared with LRYGB, LSG was associated with a decreased %TWL at over 2 years of follow-up (β: −4.01; CI95%: −5.47 à −2.54; p ≤ 0.001). Conclusion: This observational study suggests that compared with LRYGB, LSG was associated with a decreased %TWL at 2 years using a multilevel model. Further studies are required to confirm the results observed with this statistical model.

Proposal and multicentric validation of a laparoscopic Roux-en-Y gastric bypass surgery ontology

BACKGROUND

Phase and step annotation in surgical videos is a prerequisite for surgical scene understanding and for downstream tasks like intraoperative feedback or assistance. However, most ontologies are applied on small monocentric datasets and lack external validation. To overcome these limitations an ontology for phases and steps of laparoscopic Roux-en-Y gastric bypass (LRYGB) is proposed and validated on a multicentric dataset in terms of inter- and intra-rater reliability (inter-/intra-RR).

METHODS

The proposed LRYGB ontology consists of 12 phase and 46 step definitions that are hierarchically structured. Two board certified surgeons (raters) with > 10 years of clinical experience applied the proposed ontology on two datasets: (1) StraBypass40 consists of 40 LRYGB videos from Nouvel Hôpital Civil, Strasbourg, France and (2) BernBypass70 consists of 70 LRYGB videos from Inselspital, Bern University Hospital, Bern, Switzerland. To assess inter-RR the two raters' annotations of ten randomly chosen videos from StraBypass40 and BernBypass70 each, were compared. To assess intra-RR ten randomly chosen videos were annotated twice by the same rater and annotations were compared. Inter-RR was calculated using Cohen's kappa. Additionally, for inter- and intra-RR accuracy, precision, recall, F1-score, and application dependent metrics were applied.

RESULTS

The mean ± SD video duration was 108 ± 33 min and 75 ± 21 min in StraBypass40 and BernBypass70, respectively. The proposed ontology shows an inter-RR of 96.8 ± 2.7% for phases and 85.4 ± 6.0% for steps on StraBypass40 and 94.9 ± 5.8% for phases and 76.1 ± 13.9% for steps on BernBypass70. The overall Cohen's kappa of inter-RR was 95.9 ± 4.3% for phases and 80.8 ± 10.0% for steps. Intra-RR showed an accuracy of 98.4 ± 1.1% for phases and 88.1 ± 8.1% for steps.

CONCLUSION

The proposed ontology shows an excellent inter- and intra-RR and should therefore be implemented routinely in phase and step annotation of LRYGB.

Which nutritional prognosis is better? comparison of the three most commonly performed bariatric surgeries: A systematic review and network meta-analysis

Background

Obesity is one of the most important public health conditions in the world, and surgical intervention is the only medical treatment recognized by the medical community as a complete and permanent cure for morbid obesity and its complications. The choice of surgical modality is also based more on the experience of the physician or the requirements of people with obesity, rather than on scientific data. In this issue, a thorough comparison of the nutritional deficiencies caused by the three most commonly used surgical modalities is needed.

Objectives

We aimed to use the network meta-analysis to compare the nutritional deficiencies caused by the three most common BS procedures in many subjects who underwent BS to help physicians determine the best BS surgical approach to apply to their clinical people with obesity.

Setting

A systematic review and network meta-analysis of world literature.

Methods

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, systematically reviewed the literature, and conducted a network meta-analysis using R Studio.

Results

For the four vitamins calcium, vitamin B12, iron and vitamin D, the micronutrient deficiency caused by RYGB is the most serious.

Conclusions

RYGB causes slightly higher nutritional deficiencies in Bariatric surgery, but RYGB remains the most commonly used modality for Bariatric surgery.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022351956, identifier: CRD42022351956.

Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy effects on obesity comorbidities: A systematic review and meta-analysis

Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the most commonly used bariatric procedures. There is an increasing awareness about a comorbidity-based indication for bariatric surgery regardless of weight (metabolic surgery). The best operation to mitigate obesity-associated comorbidities is a matter of controversy. This review is aimed at comparing LRYGB and LSG for the treatment of diabetes, hypertension, dyslipidemias, obstructive sleep apnea (OSA), and gastroesophageal reflux (GERD). We searched PubMed, MEDLINE, SCOPUS, Web of Science, and Cochrane library for articles comparing these two commonly used bariatric approaches. We identified 2,457 studies, 1,468 of which stood after the removal of duplications; from them, 81 full texts were screened and only 16 studies were included in the final meta-analysis. LRYGB was equal weight to LSG for diabetes (P-value = 0.10, odd ratio, 1.24, 95% CI, 0.96-1.61, I ² for heterogeneity = 30%, P-value for heterogeneity, 0.14), and OSA (P-value = 0.38, odd ratio, 0.79, 95% CI, 0.47-1.33, I ² for heterogeneity = 0.0%, P-value for heterogeneity, 0.98). However, LRYGB was superior to LSG regarding hypertension (P-value = 0.009, odd ratio, 1.55, 95% CI, 1.20-2.0, I ² for heterogeneity = 0.0%, P-value for heterogeneity, 0.59), dyslipidemia (odd ratio, 2.18, 95% CI, 1.15-4.16, P-value for overall effect, 0.02), and GERD (P-value = 0.003, odd ratio, 3.16, 95% CI, 1.48-6.76). LRYGB was superior to LSG for gastroesophageal reflux, hypertension, and dyslipidemia remission. While the two procedures were equal regarding diabetes and obstructive sleep, further reviews comparing LSG, and one anastomosis gastric bypass are recommended.

Complications Rate Variability after Bariatric Surgery and the Importance of Standardization of a Reporting System

BACKGROUND

The rate of early (< 30 days) complications after bariatric surgery has been reported to be 0.4-27.4%. Although the incidence of serious adverse events has decreased with time and experience, controversy regarding how they are reported persists, and the current literature is heterogeneous.

METHODS

Data from patients, who underwent primary bariatric surgery (gastric bypass and sleeve gastrectomy) at a single institution between 2012 and 2018, were retrospectively reviewed. Any deviation from a "normal" postoperative course (< 30 days) was identified, and a comparative analysis of early complications according to five models was performed: modified Clavien-Dindo; Longitudinal Assessment of Bariatric Surgery (LABS); Bariatric Surgery Centers of Excellence (BSCOE); American Society for Metabolic and Bariatric Surgery (ASMBS); and Li (major/minor).

RESULTS

A total of 788 patients (83.7% gastric bypass), of whom 8.8% deviated from a "normal" postoperative course, were included. After applying the five classifications, the results were as follows: Clavien-Dindo, 8.8%; LABS, 2.3%; BSCOE, 0.4%; ASMBS, 9.9%; and Li, 11.2%. The incidence of major/severe/adverse outcomes were as follows: Clavien-Dindo, 2.4%; LABS, 2.3%; BSCOE, 0.4%; ASMBS, 6.9%; and Li 9.2%. Minor complications were as follows: Clavien-Dindo, 6.5%; ASMBS, 3%; and Li, 2%. There was no mortality.

CONCLUSION

Germane heterogeneity was found in reporting of early complications after bariatric surgery. Incidence varied according to classification system applied, and Clavien-Dindo demonstrated accuracy as a reporting model. To avoid bias, standardized reporting should be mandatory, and a more stringent and homogeneous reporting system should be established.

Comparative risk of anemia and related micronutrient deficiencies after Roux-en-Y gastric bypass and sleeve gastrectomy in patients with obesity: An updated meta-analysis of randomized controlled trials

Although Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the most prevalent bariatric surgical procedures, high-level evidence is scarce regarding the assessment of postoperative nutritional risk in RYGB versus SG. Therefore, we performed a systematic review and meta-analysis to compare the risk of anemia and related micronutrient deficiencies after RYGB and SG. We analyzed 10 randomized controlled trials that compared RYGB and SG with reported incidence of postoperative anemia and/or anemia-related micronutrient deficiencies (iron, vitamin B₁₂ , or folate). There were no significant differences in the risk of postoperative anemia (moderate level of evidence), iron deficiency (high level of evidence), or folate deficiency (moderate level of evidence). Patients undergoing RYGB had a higher risk of postoperative vitamin B₁₂ deficiency than those undergoing SG (relative risk, 1.86; 95% confidence interval, 1.15-3.02; p = 0.012; high level of evidence). Our findings imply that patients undergoing RYGB require more stringent vitamin B₁₂ supplementation and surveillance than those undergoing SG. Additionally, our results may aid patients with high concern for anemia and related micronutrient deficiencies in making informed decisions regarding surgical methods based on nutritional risk.

Roux-en-Y gastric bypass, sleeve gastrectomy, or one-anastomosis gastric bypass? A systematic review and meta-analysis of randomized-controlled trials

OBJECTIVE

This study aimed to determine which bariatric procedure allows patients to obtain the best weight-loss outcomes and a remission of type 2 diabetes.

METHODS

Databases were searched for randomized-controlled trials comparing Roux-en-Y gastric bypass (RYGB) with sleeve gastrectomy (SG) or one-anastomosis gastric bypass (OAGB). The mean difference (MD) or the relative risk was determined.

RESULTS

Twenty-five randomized-controlled trials were analyzed. Excess weight loss (EWL, percentage) was greater for RYGB patients at 3 years (MD: 11.93, p < 0.00001) and 5 years (MD: 13.11, p = 0.0004). Higher excess BMI loss (percentage) was found in RYGB at 1 year (MD: 11.66, p = 0.01). Total weight loss (percentage) was greater for RYGB patients after 3 months (MD: 2.41, p = 0.02), 6 months (MD: 3.83, p < 0.00001), 1 year (MD: 6.35, p < 0.00001), and 5 years (MD: 3.90, p = 0.005). No difference in terms of remission of type 2 diabetes was seen between RYGB and SG. EWL was significantly more important after OAGB than after RYGB after 1 year (MD: -10.82, p = 0.003).

CONCLUSIONS

RYGB is more efficient than SG in the midterm. OAGB offers greater EWL than RYGB after 1 year, but further evidence is needed to confirm this result.

Vitamin B Complex Deficiency After Roux-en-Y Gastric Bypass and Sleeve Gastrectomy-a Systematic Review and Meta-Analysis

Bariatric surgery, although an effective method, still has complications, like nutritional deficiencies. Our aim was to summarize the evidence on the frequency of complex B vitamin deficiencies in studies comparing Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). We included 25 studies for qualitative synthesis and 21 studies for quantitative synthesis. Relevant data was extracted, including proportion of patients with deficiency and mean serum vitamin values in 3 different timeframes. B12 and folate were the most prevalent deficiencies. B12 deficiency was more common after RYGB and folate serum mean levels were higher after RYGB. SG causes less nutrient deficiency and is therefore a better technique from this point of view. More studies are needed on B2, B3, and B6 vitamins to draw better conclusions.

Effect of Obesity and Roux-En-Y Gastric Surgery on Omeprazole Pharmacokinetics

INTRODUCTION

The prevalence of obesity is increasing globally. The principal aim was to evaluate whether gastric bypass surgery modifies the bioavailability and pharmacokinetic (PK) parameters of omeprazole.

METHODS

Controlled, open-label, bioavailability clinical trial in patients undergoing Roux-en-Y gastric bypass (RYGB). Healthy patients with obesity (body mass index >35) were included and assessed for omeprazole PKs before and after RYGB (1 and 6 months). PK sampling was done at baseline and several times up to 12 h after drug dosing. Pre- and post-surgery parameters were compared using paired ANOVA or Wilcoxon tests, and control versus cases using ANOVA or Mann-Whitney tests. Given the post-surgery change in body weight, parameters were corrected by dose/body weight.

RESULTS

Fourteen case and 24 control subjects were recruited; 92% were women (N = 35/38). In patients who underwent RYGB, maximum plasma concentration (Cmax) was significantly reduced at 1 and 6 months after surgery compared with presurgery values (p = 0.001). Regarding the AUC, the values are lower at 1 and 6 months after surgery than at baseline (p < 0.001). The drug clearance was also increased in the first month after surgery. No differences were found between patients 6 months after surgery and controls. Cmax and AUC corrected by dose/body weight were significantly different between the baseline surgery subjects and controls. Discusion/Conclusions: Omeprazole bioavailability is reduced in patients with obesity at 1 and 6 months after RYGB. However, omeprazole PK parameters 6 months after RYGB are similar to control subjects, and thus no dose correction is required after RYGB for a given indication.

Efficacy and effects of bariatric surgery in the treatment of obesity: Network meta-analysis of randomized controlled trials

AIMS

Bariatric surgery (BS) is recommended for subjects with a Body Mass Index (BMI) over of 40 kg/m² or with a BMI between 35 and 40 kg/m² with obesity-related comorbidities. Aim of the study was to compare different types of BS with medical therapy (MT) for the treatment of obesity.

DATA SYNTHESIS

We conducted a network-meta-analysis (NMA) including randomized clinical trials comparing different BS techniques versus MT in people with obesity, with a duration ≥24 weeks (PROSPERO, #CRD42020160359). Primary endpoint was BMI. Indirect comparisons of different types of surgery were performed by NMA. Types of BS included: laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass, sleeve gastrectomy (SG), bilio-pancreatic diversion (BPD); greater curvature plication (GCP); one-anastomosis gastric bypass (OAGB); Laparoscopic Vertical Banded Gastroplasty (LVBG) and duodenal switch (DS). 43 trials were retrieved in this metanalysis. BS was associated with a significant reduction in BMI, systolic blood pressure, triglyceride and fasting glucose, and with a significant increase of HDL cholesterol when compared to MT. In direct comparisons, RYGB was more effective than LAGB, LVBG, and GCP, but less effective than DS, whereas LAGB was less effective than LVBG and SG. In the NMA, DS and BPD appeared to be more effective than other procedures.

CONCLUSIONS

BS produces a greater weight loss than MT in morbidly obese patients, inducing a greater improvement of obesity-associated metabolic parameters. Available data are insufficient to assess the effect of BS on mortality. Different surgical procedures are heterogeneous for efficacy and safety.

Network Meta-Analysis of Metabolic Surgery Procedures for the Treatment of Obesity and Diabetes

Background

Metabolic surgery is part of a well-established treatment intensification strategy for obesity and its related comorbidities including type 2 diabetes (T2DM). Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG) and one-anastomosis gastric bypass (OAGB) are the most commonly performed metabolic surgeries worldwide, but comparative efficacy is uncertain. This study employed network meta-analysis to compare weight loss, T2DM remission and perioperative complications in adults between RYGB, SG and OAGB.

Methods

MEDLINE, EMBASE, trial registries were searched for randomised trials comparing RYGB, SG and OAGB. Study outcomes were excess weight loss (at 1, 2 and 3–5 years), trial-defined T2DM remission at any time point and perioperative complications.

Results

Twenty randomised controlled trials were included involving 1803 patients investigating the three metabolic surgical interventions. RYGB was the index for comparison. The excess weight loss (EWL) demonstrated minor differences at 1 and 2 years, but no differences between interventions at 3–5 years. T2DM remission was more likely to occur with either RYGB or OAGB when compared to SG. Perioperative complications were higher with RYGB when compared to either SG or OAGB. Two-way analysis of EWL and T2DM remission against the risk of perioperative complications demonstrated OAGB was the most positive on this assessment at all time points.

Conclusion

OAGB offers comparable metabolic control through weight loss and T2DM remission to RYGB and SG whilst minimising perioperative complications.

Registration number: CRD42020199779 (https:// www.crd.york.ac.uk/PROSPERO)

Graphical abstract

Effect of various weight loss interventions on serum NT-proBNP concentration in severe obese subjects without clinical manifest heart failure

Obesity is associated with a “natriuretic handicap” indicated by reduced N-terminal fragment of proBNP (NT-proBNP) concentration. While gastric bypass surgery improves the natriuretic handicap, it is presently unclear if sleeve gastrectomy exhibits similar effects. We examined NT-proBNP serum concentration in n = 72 obese participants without heart failure before and 6 months after sleeve gastrectomy (n = 28), gastric bypass surgery (n = 19), and 3-month 800 kcal/day very-low calorie diet (n = 25). A significant weight loss was observed in all intervention groups. Within 6 months, NT-proBNP concentration tended to increase by a median of 44.3 pg/mL in the sleeve gastrectomy group (p = 0.07), while it remained unchanged in the other groups (all p ≥ 0.50). To gain insights into potential effectors, we additionally analyzed NT-proBNP serum concentration in n = 387 individuals with different metabolic phenotypes. Here, higher NT-proBNP levels were associated with lower nutritional fat and protein but not with carbohydrate intake. Of interest, NT-proBNP serum concentrations were inversely correlated with fasting glucose concentration in euglycemic individuals but not in individuals with prediabetes or type 2 diabetes. In conclusion, sleeve gastrectomy tended to increase NT-proBNP levels in obese individuals and might improve the obesity-associated “natriuretic handicap”. Thereby, nutritional fat and protein intake and the individual glucose homeostasis might be metabolic determinants of NT-proBNP serum concentration.

Polyneuropathy and Korsakoff syndrome complicating sleeve gastrectomy

We report a case of a 36 year old gentleman presenting with polyneuropathy and Korsakkoff Syndrome complicating Sleeve Gastrectomy.

Laparoscopic sleeve gastrectomy as a primary bariatric procedure: postoperative outcomes

Background and aims

Laparoscopic sleeve gastrectomy is at present the most popular bariatric procedure due to its significant effect on weight loss, resolution of comorbidities and improvement in the quality of life. However, there are not many studies showing its medium and long term efficacy and safety in Eastern Europe. We aim to report the outcomes of laparoscopic sleeve gastrectomy as a primary bariatric procedure from a single surgical department.

Methods

This is a retrospective analysis of obese patients who underwent laparoscopic sleeve gastrectomy between 2009 – 2016 in our department. Outcomes were analyzed in terms of weight loss, comorbidity resolution and quality of life changes.

Results

A number of 70 patients were included in the study, with a mean age of 47.6 ± 9.8 years. Mean initial Body Mass Index was 47.4 ± 6.4 kg/m². The mean percentage of excess weight loss during follow-up was 78.2% at 12 months, 80.2%, 76.7%, 74.7%, 72.8%, 73.3%, 74.1%, 67.2%, 64.07%, 69.7% at 24, 36, 48, 60, 72, 84, 96, 108 and 120 months, respectively. Weight regain occurred in 61 (87.1%) patients during the postoperative period. The mean weight regained was 8.1 ± 4.8 kg at 24 months postoperatively. Regarding the quality of life, 83% of patients declared an increase in self-esteem. Resolution of diabetes, arterial hypertension, and obstructive sleep apnea syndrome occurred in 80%, 42.5% and 70.1% of patients respectively.

Conclusions

Laparoscopic sleeve gastrectomy is an effective procedure, with good outcomes in the medium and long term, although a tendency for weight regain was noted after 2 years. Resolution of comorbidities is comparable with that reported in the literature, namely an improvement of the quality of life.

Assessment of nutritional status, body composition and blood biochemical parameters of patients following sleeve gastrectomy: 6 months follow up

BACKGROUND AND AIMS

Today, Sleeve gastrectomy (SG) has recently become the most common bariatric procedure among various bariatric surgical procedures due to its advantages. The aim of this study is to investigate nutritional status, body composition and biochemical parameters following SG.

METHODS

This was a prospective study, the subjects were patients who underwent SG at a special obesity clinic in İstanbul, Turkey, between 01.05.2017 and 01.11.2017. The mean body mass index (BMI) of the participants was 42.15 ± 4.84 kg/m² for men and 41.44 ± 4.34 kg/m² for women, preoperatively. Nutritional status, some anthropometric measurements and blood sampling were taken at each visit. Data were collected and analyzed for the present study at the following periods: pre-operation (pre-op), 1 month, 3 months and 6 months after surgery.

RESULTS

A total of 47 SG patients (20 men, 27 women) were evaluated. The mean BMI was 30.23 ± 3.56 kg/m² for men and 30.35 ± 4.36 kg/m² for women after 6 months and the amount of excess weight loss (EWL) increased in the 3 months (p < .001). Mean energy, fiber, vitamin A, vitamin C, vitamin B₁, niacin, vitamin B₁₂, folate, calcium, magnesium, iron, zinc, phosphorus and iodine were above the Dietary Reference Intake (DRI) recommendations. A significant association was found between protein intake and fat free mass loss in both genders after SG at 6 months (p < .05).

CONCLUSION

Nutrition deficiencies are common for patients after SG. Therefore, it is important to routinely monitor these patients with a professional team.

Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy: 5-year outcomes of merged data from two randomized clinical trials (SLEEVEPASS and SM-BOSS)

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (LRYGB) are both effective surgical procedures to achieve weight reduction in patients with obesity. The trial objective was to merge individual-patient data from two RCTs to compare outcomes after LSG and LRYGB.

METHODS

Five-year outcomes of the Finnish SLEEVEPASS and Swiss SM-BOSS RCTs comparing LSG with LRYGB were analysed. Both original trials were designed to evaluate weight loss. Additional patient-level data on type 2 diabetes (T2DM), obstructive sleep apnoea, and complications were retrieved. The primary outcome was percentage excess BMI loss (%EBMIL). Secondary predefined outcomes in both trials included total weight loss, remission of co-morbidities, improvement in quality of life (QoL), and overall morbidity.

RESULTS

At baseline, 228 LSG and 229 LRYGB procedures were performed. Five-year follow-up was available for 199 of 228 patients (87.3 per cent) after LSG and 199 of 229 (87.1 per cent) after LRYGB. Model-based mean estimate of %EBMIL was 7.0 (95 per cent c.i. 3.5 to 10.5) percentage points better after LRYGB than after LSG  (62.7 versus 55.5 per cent respectively; P < 0.001). There was no difference in remission of T2DM, obstructive sleep apnoea or QoL improvement; remission for hypertension was better after LRYGB compared with LSG (60.3 versus 44.9 per cent; P = 0.049). The complication rate was higher after LRYGB than LSG (37.2 versus 22.5 per cent; P = 0.001), but there was no difference in mean Comprehensive Complication Index value (30.6 versus 31.0 points; P = 0.859).

CONCLUSION

Although LRYGB induced greater weight loss and better amelioration of hypertension than LSG, there was no difference in remission of T2DM, obstructive sleep apnoea, or QoL at 5 years. There were more complications after LRYGB, but the individual burden for patients with complications was similar after both operations.

Sleeve gastrectomy versus Roux-en-Y gastric bypass in patients Aged ≥65 years: a comparison of short-term outcomes

BACKGROUND

Bariatric surgery in the elderly population has been reported as feasible and safe. Sleeve gastrectomy (SG) seems to have fewer complications than Roux-en-Y gastric bypass (RYGB) even in the 65 years of age population. We analyzed the difference in weight loss between SG and RYGB in patients age 65 years.

OBJECTIVES

To analyze and compare outcomes between SG and RYGB in patients 65 years of age and older.

SETTING

Academic hospital, United States.

METHODS

After internal review board approval, we retrospectively reviewed 2486 patients who underwent either SG or RYGB between 2005 and 2018 at our institution. Basic demographics, preoperative body mass index (BMI), and co-morbidities were described. We identified all patients age ≥65 years and subsequently divided them into 2 groups based on type of bariatric procedure performed. Analysis and comparison of outcomes between these groups were completed. Postoperative BMI was reviewed at 6, 12, and 24 months and percent excess BMI loss (%EBMIL, as defined by the ASMBS clinical committee) was calculated accordingly. The t test and χ² analysis were performed for nominal and categorical variables, respectively.

RESULTS

From 2486 patients reviewed, 22.7% (n = 565) were aged ≥65 years. From these, 43.1% (n = 244) underwent SG and 56.8% (n = 321) underwent RYGB. White and female patients were predominant in both groups. Mean age was similar for both populations (SG: 71.1 ± 4.0, RYGB: 71.7 ± 4.5; P = .12). Pre-procedure mean BMI for both groups was close in value, but the difference was statistically significant (40.5 ± 5.5 for SG versus 43.7 ± 7.2 for RYGB; P < .0001). Postoperative follow-up rates were similar in both groups at 12 and 24 months (SG: 51.2% and 31.6%; RYGB: 48.3% and 34.3%; P = .49 and P = .5). The %EBMIL at 6, 12, and 24 months was higher for the RYGB group than the SG group (59.3 ± 27.9, 72.1 ± 29.5, 77.4 ± 26.1 versus 50.2 ± 21.9, 55.2 ± 25.6, 43.9 ± 32.2; P < .01, P < .01, and P < .01, respectively). Complication rates were significantly higher in RYGB versus SG (27.7% versus 9.4%; P < .01). We observed significantly higher anastomotic ulcer and stricture rates for RYGB versus SG (7.2% and 5.9 versus 0% and 0%; P < .01 and P < .01, respectively). RYGB had a higher rate for gastrointestinal obstruction requiring intervention (2.2% versus .4%; P = .07). A similar de novo gastroesophageal reflux disease rate was noted in both procedures (3.7% versus 3.7%; P = .98). No leaks were reported in either group.

CONCLUSIONS

Both SG and RYGB are effective weight loss procedures for patients aged ≥65 years. RYGB seems to have higher %EBMIL at 1 and 2 years; however, when compared with SG, complication rates appear to be almost 3 times higher.

In Terms of Nutrition, the Most Suitable Method for Bariatric Surgery: Laparoscopic Sleeve Gastrectomy or Roux-en-Y Gastric Bypass? A Systematic Review and Meta-analysis

This study assesses the differences in postoperative nutritional status between laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). We searched the literature from PubMed, Web of Science, Embase, and the Cochrane Library database. Twenty-nine articles were included, with a total of 5437 obese patients. After bariatric surgery, the LSG group had less anemia and iron deficiency anemia than the LRYGB group. The serum iron, ferritin deficiency, and vitamin B₁₂ rates after LSG were lower than patients receiving LRYGB. And PTH and serum phosphorus concentration of patients after LSG were both lower than those after LRYGB. The postoperative results of LSG were better than that of LRYGB. Therefore, we recommend LSG for a better postoperative nutrition, but only for reference.

Iron Deficiency - Not Only a Premenopausal Topic After Bariatric Surgery?

Purpose

In our centre, specialized high dose multivitamin supplementation designed to meet the needs of patients after gastric bypass surgery is routinely recommended in the early postoperative period. The aim of the present study was to analyse whether iron supplementation prescribed in clinical practice is sufficient in both sexes and whether multivitamin supplementation standardized for women might potentially lead to iron overload in men.

Materials/Methods

This was a retrospective study covering the period up to 36 months after bariatric surgery. Three groups were compared (men, premenopausal and postmenopausal women). The iron status was evaluated employing serum ferritin concentrations.

Results

A total of 283 patients who had at least one follow-up visit between January 2015 and April 2018 at a specialized academic outpatient centre were included (71 men, 130 premenopausal women, 82 postmenopausal women). Thirty-six months after surgery, 33.3%, 68.4% and 54.5% of the men, pre- and postmenopausal women, respectively, were iron deficient. The preoperative prevalence of excess ferritin levels was 13.7% in premenopausal, 3.0% in postmenopausal women, 5.7% in men and declined in the following months.

Conclusion

Iron deficiency is very common after gastric bypass surgery, and even high dosages of multivitamin and mineral supplements might not be sufficient to prevent the development of iron deficiency. Men, pre- and postmenopausal women differ in their prevalence of iron deficiency which demands adapted iron dosage regimens based on the sex and the age. Iron overload is rare in all observed groups and highest in premenopausal women.

Graphical abstract

A Comprehensive Comparison of LRYGB and LSG in Obese Patients Including the Effects on QoL, Comorbidities, Weight Loss, and Complications: a Systematic Review and Meta-Analysis

Purpose

To systematically and comprehensively evaluate the differences between laparoscopic Roux-en-Y gastric bypass (LRYGB) versus sleeve gastrectomy (LSG) in obese patients.

Methods

A systematic literature search was performed in PubMed, EMBASE, Web of Science, and the Cochrane Library from inception to December 2018. The meta-analysis was performed by the RevMan 5.3 software.

Results

Twenty-three articles with 7443 patients were included. In short term (< 3 years), LRYGB was superior to LSG in terms of improving comorbidities (T2D, odds ratio (OR) 1.93, 1.06–3.52, P < 0.05, hypertension, OR 1.59, 1.08–2.34, P < 0.05, dyslipidemia, OR 1.61, 1.05–2.46, P < 0.05), but there were no differences in the midterm and long term. Quality of life (QoL) after bariatric surgery was included, but no differences were observed in the QoL after LRYGB or LSG (gastrointestinal quality of life index (GIQLI) and Moorehead–Ardelt quality of life questionnaire (M-A-Q), P > 0.05). LRYGB achieved a higher EWL% than LSG (after 3 years, WMD 5.48, 0.13–10.84. P < 0.05; after 5 years, WMD 4.55, 1.04–8.05, P < 0.05) in long term, but no significant differences were found during 0.25- to 2.0-year follow-up. The rate of early and late complications was much higher in LRYGB than in LSG (early complications, OR = 2.11, 95% CI = 1.53–2.91, P < 0.001; late complications, OR = 2.60, 95% CI = 1.93–3.49, P < 0.001).

Conclusions

This meta-analysis showed that LRYGB was more effective than LSG in comorbidities’ resolution or improvement in short term. For weight loss, LRYGB had better long-term effects than LSG. In addition, no differences were observed in the quality of life after LRYGB or LSG. LRYGB was associated with more complications than LSG.

Electronic supplementary material

The online version of this article (10.1007/s11695-019-04306-4) contains supplementary material, which is available to authorized users.

Systematic Review and Meta-Analysis of Randomised Controlled Trials Comparing Long-Term Outcomes of Roux-En-Y Gastric Bypass and Sleeve Gastrectomy

INTRODUCTION

Sleeve gastrectomy (SG) has overtaken Roux-En-Y gastric bypass (RYGB) as the most common bariatric procedure worldwide. However, there is little long-term data comparing the two procedures.

OBJECTIVES

We perform a systematic review and meta-analysis comparing 5-year outcomes of randomised controlled trials (RCTs) comparing RYGB and SG.

METHODS

Medline, Embase, The Cochrane Library, and NHS Evidence were searched for English language RCTs comparing RYGB with SG and assessed weight loss and/or comorbidity resolution at 5 years.

RESULTS

Five studies were included in the final analysis. Meta-analysis demonstrates a significantly greater percentage excess weight loss in patients undergoing RYGB compared with SG (65.7% vs 57.3%, p < 0.0001). Resolution of diabetes was seen in 37.4% and 27.5% after RYGB and SG respectively. There was no significant difference between RYGB and SG in rates of resolution or improvement of diabetes. Similarly, HbA1C levels were not significantly different between the two procedures. Resolution of dyslipidaemia was more common after RYGB (68.6% vs 55.2%, p = 0.0443). Remission of gastro-oesophageal reflux occurred in 60.4% in the RYGB group in contrast to 25.0% in the SG group (p = 0.002).

CONCLUSIONS

Both RYGB and SG result in sustained weight loss and comorbidity control at 5 years. RYGB resulted in greater %EWL, improved dyslipidaemia outcomes and a lower incidence of postoperative gastro-oesophageal reflux disease (GORD).

Roux-en-Y Gastric Bypass vs Sleeve Gastrectomy for Remission of Type 2 Diabetes

CONTEXT

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the bariatric procedures most commonly used for the management of obesity. Whether one or the other is associated with a higher chance of remission of type 2 diabetes (T2D) is unclear.

OBJECTIVE

This work aims to compare the efficacy of RYGB and SG for T2D remission at 1, 3, and 5 years after surgery.

DATA SOURCES

Four databases were searched until January 2020.

STUDY SELECTION

Randomized controlled studies with at least 12 months of follow-up of patients with T2D allocated to RYGB or SG were selected.

DATA EXTRACTION

To ensure uniformity, broad and narrow criteria for T2D remission were defined. The number of patients achieving remission of T2D at each assessment was extracted. Data were pooled using a random-effects model.

DATA SYNTHESIS

Ten studies were included, evaluating 778 patients. The overall prevalence of achievement of broad and narrow criteria for T2D remission was 73% and 53% at the 1-year, 60% and 48% at the 3-year, and 51% and 43% at the 5-year assessment. Compared to SG, RYGB was associated with a higher chance of achieving broad and narrow criteria for remission at 1 year after surgery (risk ratio [RR] = 1.34 vs RR = 1.22) and broad criteria for remission at 5 years (RR = 1.18). No other differences were found.

CONCLUSIONS

The present meta-analysis suggests a more favorable effect of RYGB than SG on achieving T2D remission in the short-term only, although the evidence currently available does not clarify whether differences in this outcome are confirmed long term or fade thereafter.

Prevention and treatment of nutritional complications after bariatric surgery

Obesity and the corresponding burden of related diseases is a major public health issue worldwide that is reaching pandemic proportions. Bariatric surgery is the only intervention that has been shown to result in substantial and lasting weight loss, and a decrease in overall mortality for patients with severe obesity. Consequently, the population of patients having undergone this procedure is increasing. Multifactorial weight-dependent and independent mechanisms underlying metabolic diseases could also drive preventable, but potentially life-threatening, long-term nutritional complications. However, given post-bariatric patients are prone to functional gastrointestinal symptoms and substantial weight loss, nutritional complications might be challenging. This Review is focused on the prevention and treatment of nutritional complications after bariatric surgery in the clinical setting.

Propensity Score-Matching Sleeve Gastrectomy (SG) vs. Gastric Bypass (RYGB) in Patients ≥ 60 Years

BACKGROUND

Since 1 January 2005, the practice of bariatric surgery has been examined with the help of the German Bariatric Surgery Registry (GBSR) in Germany. The focus of the study was to evaluate if sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) has the best benefit in terms of perioperative risk in patients over 60 years of age.

METHODS

Data collection includes patients over the age of 60 years who underwent SG or RYGB between 2005 and 2017. The bougie is limited to 33-40 French for SG. Furthermore, the RYGB is determined to be 120-180 cm alimentary and 40-60 cm biliopancreatic length. Outcome criteria are perioperative morbidity, postoperative complications, 30-day mortality, and postoperative length of stay.

RESULTS

The study analyzes data from 3561 patients beyond the age of 60 years who underwent SG (1970 patients) and RYGB (1591 patients). Mean age of the patients was 63.4 ± 3.2 in the RYGB group and 63.8 ± 3.5 in the SG group. Mean BMI was 46.4 ± 6.8 in the RYGB group and 49.1 ± 8.0 in the SG group. The average number of comorbidities was 4.5 ± 2.4 for RYGB and 4.5 ± 2.3 for SG. For the 30-day mortality, identical results were found SG vs. RYGB (0.31 vs. 0.38, p = 1.000).

CONCLUSION

Based on the results of this study, it can be concluded that both SG and RYGB in patients ≥ 60 years can be considered safe surgical procedures.

Clinical Features and Short-Term Outcomes of Bariatric Surgery in Morbidly Obese Patients: Institutional Experience at a Rural Hospital

Objective: To prospectively evaluate the postoperative morbidity, mortality, and weight loss evolution of patients who underwent a bariatric procedure during 1 year of follow-up. Methods: Since July 2016, a total of 101 patients' data have been prospectively registered in a database. Comorbidities, operating time, hospital stay, early and late complications rate, and weight loss evolution after 1 year of follow-up were recorded. Results: The mean age was 38.41 ± 11.05 years with a mean body mass index (BMI) of 49.02 ± 5.89 kg/m2 (range 38-67). Laparoscopic sleeve gastrectomy (LSG) was performed in 93 patients (92.07%) and Roux-en-Y gastric bypass (RNYGB) in 8 patients (7.92%). Thirty-day morbidity rate was 7.92% (8/101). Within a mean 9.32 ± 2.25 (range 1-19) months follow-up time, mean percent of the excess of weight loss of 1st, 6th, and 12th months were 22.7 ± 6.1, 67.2 ± 11.2, and 81.4 ± 10.5, respectively. Diabetes (n = 38, 37.6%), hypertension (n = 13, 12.9%), and obstructive sleep apnea (n = 5, 4.9%) were resolved in 76%, 68.4%, and 100% of the patients, respectively (p < 0.001). Conclusions: LSG and RNYGB are safe and highly effective, particularly in patients with a BMI >50 kg/m2. Both techniques have been presented with better clinical outcomes regarding significant comorbidity resolution in the early evolution of weight loss.

Laparoscopic Sleeve Gastrectomy Versus Laparoscopic Roux-en-Y Gastric Bypass: A Systematic Review and Meta-analysis of Weight Loss, Comorbidities, and Biochemical Outcomes From Randomized Controlled Trials

OBJECTIVE

The aim of this study was to compare weight loss, obesity-related comorbidities, and biochemical outcomes of LSG versus LRYGB through a meta-analysis of randomized controlled trials (RCTs).

SUMMARY OF BACKGROUND DATA

LSG and LRYGB are the 2 most commonly performed bariatric surgeries for the treatment of obesity. The comparative outcomes of the 2 surgeries is a topic of ongoing debate and medium-term outcomes remain uncertain.

METHODS

A search for RCTs comparing LRYGB versus LSG was conducted. Pooled outcomes between 2 procedures were compared using pairwise random-effects meta-analysis at 1, 3, and 5-year follow-up time points. Grading of recommendations, assessment, development, and evaluation was used to assess certainty of evidence.

RESULTS

Thirty-three studies involving 2475 patients were included. LRYGB resulted in greater loss of body mass index compared to LSG at 1 year [mean difference -1.25 kg/m2, 95% confidence interval (CI) -2.01 to -0.49, P = 0.001; moderate certainty of evidence] which persisted at 3 years, but there was insufficient evidence at 5 years. Resolution of dyslipidemia was higher for LRYGB than LSG at 1 year (risk ratio 0.58, 95% CI 0.46-0.73, P < 0.001; moderate certainty of evidence) and 5 years (risk ratio 0.68, 95%CI 0.46-0.99, P = 0.04; low certainty of evidence). There was no difference between LRYGB and LSG for remission of type 2 diabetes, hypertension, and hemoglobin A1c, fasting insulin, homeostatic model assessment of insulin resistance, high-density lipoprotein, and the rate of 30-day major and minor complications.

CONCLUSIONS

There are insufficient data from RCTs to draw any conclusions regarding the long-term comparative effectiveness beyond 3 years between LRYGB and LSG.

Primary laparoscopic sleeve gastrectomy versus gastric bypass: a propensity-matched comparison of 30-day outcomes

BACKGROUND

Bariatric surgery is the most effective treatment for obesity. There is uncertainty regarding rates of adverse outcomes between the most common methods: laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG).

OBJECTIVES

To compare rates of readmission, reoperation, intervention, unplanned intensive care unit (ICU) admission, all-cause and procedure-related mortality, and postoperative complications at 30 days between LRYGB and LSG.

SETTING

Retrospective, observational, multicenter registry.

METHODS

We identified 611,619 patients from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry between January 1, 2015, and December 31, 2018 (447,326 [73.1%] LSG; 164,293 [26.9%] LRYGB).

RESULTS

Adverse events were more common after LRYGB (readmission: 3% with LSG versus 5.9% with LRYGB [P < .001; odds ratio {OR}, LSG/LRYGB = .489]; intervention: .9% with LSG versus 2.4% with LRYGB [P < .001; OR, LSG/LRYGB = .357]; reoperation: .8% with LSG versus 2.3% with LRYGB [P < .001; OR, LSG/LRYGB = .363]; unplanned ICU admission: .52% with LSG versus 1.1% with LRYGB [P < .001; OR, LSG/LRYGB = .454]; all-cause mortality: .07% with LSG versus .15% with LRYGB [P < .001; OR, LSG/LRYGB = .489]; procedure-related mortality: .04% with LSG versus .08% with LRYGB [P < .001; OR, LSG/LRYGB = .446]; Clavien-Dindo I: .20% with LSG versus .63% with LRYGB [P < .001; OR, LSG/LRYGB = .317]; Clavien-Dindo II: .70% with LSG versus 1.3% with LRYGB [P < .001; OR, LSG/LRYGB = .527]; Clavien-Dindo III: 3.3% with LSG versus 6.6% with LRYGB [P < .001; OR, LSG/LRYGB = .481]; Clavien-Dindo IV: .36% with LSG versus .76% with LRYGB [P < .001; OR, LSG/LRYGB = .466]; and Clavien-Dindo V: .07% with LSG versus .15% with LRYGB [P < .001; OR, LSG/LRYGB = .488]). Surgery type was among the strongest independent predictors of adverse events, and LRYGB conferred higher adjusted odds of all adverse outcomes (all-cause mortality: OR, LRYGB/LSG = 1.791 [P < .001]; procedure-related mortality: OR, LRYGB/LSG = 1.979 [P < .001]; readmission: OR, LRYGB/LSG = 1.921 [P < .001]; unplanned ICU admission: OR, LRYGB/LSG = 1.870 [P < .001]; intervention: OR, LRYGB/LSG = 2.662 [P < .001]; reoperation: OR, LRYGB/LSG = 2.646 [P < .001]; and Clavien-Dindo grade: OR, LRYGB/LSG = 2.007 [P < .001]).

CONCLUSION

The rates of 30-day adverse outcomes are lower after LSG compared with after LRYGB. LRYGB independently conferred increased odds of adverse outcomes compared with LSG, and surgery type was among the strongest predictors of adverse outcomes.

Recommendations for nutritional care after bariatric surgery: Recommendations for best practice and SOFFCO-MM/AFERO/SFNCM/expert consensus

Nutritional care after bariatric surgery is an issue of major importance, especially insofar as risk of deficiency has been extensively described in the literature. Subsequent to the deliberations carried out by a multidisciplinary working group, we are proposing a series of recommendations elaborated using the Delphi-HAS (official French health authority) method, which facilitates the drawing up of best practice and consensus recommendations based on the data of the literature and on expert opinion. The recommendations in this paper pertain to dietary management and physical activity, multivitamin and trace element supplementation and the prevention and treatment of specific deficiencies in vitamins B1, B9, B12, D and calcium, iron, zinc, vitamins A, E and K, dumping syndrome and reactive hypoglycemia.

Laparoscopic sleeve gastrectomy versus endoscopic sleeve gastroplasty: a systematic review and meta-analysis

Background and study aims  Laparoscopic sleeve gastrectomy (LSG) is the current standard for bariatric surgery, but it is affected by several postoperative complications. Endoscopic sleeve gastroplasty (ESG) was created as a less invasive alternative to LSG. However, its efficacy and safety compared with LSG is unclear. Materials and methods  Relevant publications were identified in MEDLINE/Cochrane/EMBASE/OVID/ PROSPERO and NIH up to January 2020. Studies were selected that included obese patients with a baseline body mass index (BMI) between 30 and 40 kg/m² with a minimum of 12 months of follow-up and with reported incidence of complications. The mean difference in percentage of excess weight loss (%EWL) at 12 months between LSG and ESG represented the primary endpoint. We also assessed the difference in pooled rate of adverse events. The quality of the studies and heterogeneity among them was analyzed. Results  Sixteen studies were selected for a total of 2188 patients (LSG: 1429; ESG: 759) with a mean BMI 34.34 and 34.72 kg/m² for LSG and ESG, respectively. Mean %EWL was 80.32 % (± 12.20; 95 % CI; P  = 0.001; I² = 98.88) and 62.20 % (± 4.38; 95 % CI; P  = 0.005; I² = 65.52) for the LSG and ESG groups, respectively, corresponding to an absolute difference of 18.12 % (± 0.89; 95 % CI, P  = 0.0001). The difference in terms of mean rate of adverse events was 0.19 % (± 0.37; 95 %CI; χ ²  = 1.602; P  = 0.2056). Conclusions  Our analysis showed a moderate superiority of LSG versus ESG. No difference in terms of safety was shown between the two groups. ESG is a less-invasive, repeatable and reversable and acceptable option for mild-moderate obese patients.

Comparative Safety of Sleeve Gastrectomy and Gastric Bypass: An Instrumental Variables Approach

OBJECTIVE

To compare the safety of sleeve gastrectomy and gastric bypass in a large cohort of commercially insured bariatric surgery patients from the IBM MarketScan claims database, while accounting for measurable and unmeasurable sources of selection bias in who is chosen for each operation.

SUMMARY OF BACKGROUND DATA

Sleeve gastrectomy has rapidly become the most common bariatric operation performed in the United States, but its longer-term safety is poorly described, and the risk of worsening gastroesophageal reflux requiring revision may be higher than previously thought. Prior studies comparing sleeve gastrectomy to gastric bypass are limited by low sample size (in randomized trials) and selection bias (in observational studies).

METHODS

Instrumental variables analysis of commercially insured patients in the IBM MarketScan claims database from 2011 to 2018. We studied patients undergoing bariatric surgery from 2012 to 2016. We identified re-interventions and complications at 30 days and 2 years from surgery using Comprehensive Procedural Terminology and International Classification of Disease (ICD)-9/10 codes. To overcome unmeasured confounding, we use the prior year's sleeve gastrectomy utilization within each state as an instrumental variable-exploiting variation in the timing of payers' decisions to cover sleeve gastrectomy as a natural experiment.

RESULTS

Among 38,153 patients who underwent bariatric surgery between 2012 and 2016, the share of sleeve gastrectomy rose from 52.6% (2012) to 75% (2016). At 2 years from surgery, patients undergoing sleeve gastrectomy had fewer re-interventions (sleeve 9.9%, bypass 15.6%, P < 0.001) and complications (sleeve 6.6%, bypass 9.6%, P = 0.001), and lower overall healthcare spending ($47,891 vs $55,213, P = 0.003), than patients undergoing gastric bypass. However, at the 2-year mark, revisions were slightly more common in sleeve gastrectomy than in gastric bypass (sleeve 0.6%, bypass 0.4%, P = 0.009).

CONCLUSIONS AND RELEVANCE

In a large cohort of commercially insured patients, sleeve gastrectomy had a superior safety profile to gastric bypass up to 2 years from surgery, even when accounting for selection bias. However, the higher risk of revisions in sleeve gastrectomy merits further exploration.

Micronutrient Deficiencies in Laparoscopic Sleeve Gastrectomy

The purpose of this study was to conduct a literature review to examine micronutrient deficiencies in laparoscopic sleeve gastrectomy. We conducted a literature review using PubMed and Cochrane databases to examine micronutrient deficiencies in SG patients in order to identify trends and find consistency in recommendations. Seventeen articles were identified that met the defined criteria. Iron, vitamin B12 and vitamin D were the primary micronutrients evaluated. Results demonstrate the need for consistent iron and B12 supplementation, in addition to a multivitamin, while vitamin D supplementation may not be necessary. Additional prospective studies to establish a clearer picture of micronutrient deficiencies post-SG are needed.

Do we understand the pathophysiology of GERD after sleeve gastrectomy?

Gastroesophageal reflux disease (GERD), a prevalent problem among obese individuals, is strongly associated with obesity and weight loss. Hence, bariatric surgery effectively improves GERD for many patients. Depending on the type of bariatric procedure, however, surgery can also worsen or even cause a new onset of GERD. As a consequence, GERD remains a relevant problem for many bariatric patients, and especially those who have undergone sleeve gastrectomy (SG). Affected patients report not only a decrease in physical functioning but also suffer from mental and emotional problems, resulting in poorer social functioning. The pathomechanism of GERD after SG is most likely multifactorial and triggered by the interaction of anatomical, physiological, and physical factors. Contributing factors include the shape of the sleeve, the extent of injury to the lower esophageal sphincter, and the presence of hiatal hernia. In order to successfully treat post-sleeve gastrectomy GERD, the cause of the problem must first be identified. Therapeutic approaches include lifestyle changes, medication, interventional treatment, and/or revisional surgery.

Laparoscopic sleeve gastrectomy versus Roux-en-Y gastric bypass for quality of life: a systematic review and meta-analysis

Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the mainstays of bariatric surgery in recent years. In addition, there has been an increased interest in the quality of life (QoL) of obese patients after surgery. This study examined the QoL of patients who had undergone either LSG or LRYGB. We retrieved the literature from PubMed, Web of Science, Embase, and the Cochrane Library database before November 2019. A total of 10 articles and 2327 obese patients were included in our meta-analysis. The QoL scoring tools included in the statistical analysis are the following: the gastrointestinal quality of life index, 36-items short-form health survey, bariatric analysis and reporting outcome system, and the Moorehead-Ardelt quality of life questionnaire II. Although the QoL score of the LRYGB group was higher than that of the LSG group in the bariatric analysis and reporting outcome system subgroup, statistical analysis showed no difference in the postoperative QoL of LSG and LRYGB. In our study, no difference was found in the QoL between LSG and LRYGB. Therefore, in terms of postoperative QoL, surgical methods should be selected on the basis of the patients' condition and level of understanding of the surgeries.

Metabolic surgery for the treatment of type 2 diabetes: A network meta-analysis of randomized controlled trials

AIM

To compare different types of metabolic surgery (MS) with medical therapy (MT) for the treatment of type 2 diabetes (T2D).

MATERIALS AND METHODS

We conducted a network-meta-analysis (NMA) including randomized clinical trials comparing different MS techniques versus MT in people with T2D, with a duration of ≥24 weeks. Primary endpoints were glycated haemoglobin (HbA1c), fasting plasma glucose (FPG) and diabetes remission. Indirect comparisons of different types of surgery were performed by NMA. Mean and 95% confidence intervals for continuous variables, and Mantel-Haenzel odds ratios for categorial variables, were calculated using random effect models. Types of MS included: laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass, sleeve gastrectomy (SG), bilio-pancreatic diversion (BPD); greater curvature plication (GCP); one-anastomosis gastric bypass (OAGB); and duodenojejunal bypass.

RESULTS

The 24 retrieved trials included 1351 patients (1014 with MS and 337 with MT). The mean baseline BMI was 36.8 kg/m² . MS was associated with significantly greater reductions in HbA1c and FPG and greater diabetes remission when compared to MT. In the NMA, a significant reduction in HbA1c was observed with OAGB and SG. All surgical procedures were associated with a significant increase in diabetes remission, except GCP and LAGB. All procedures were associated with a reduction of body mass index (BMI).

CONCLUSIONS

Metabolic surgery is an interesting option for the treatment of T2D, although further data are needed to demonstrate its long-term efficacy and safety. Present data are not sufficient to modify current recommendations, which consider MS a possible treatment for T2D in those with a BMI >35 kg/m² .

Micronutrient Deficiencies After Roux-en-Y Gastric Bypass: Long-Term Results

BACKGROUND

Patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) are under risk of micronutrient deficiencies. We aimed to assess the preoperative and postoperative micronutrient deficiencies in a sample of patients with obesity who underwent LRYGB.

METHODS

We evaluated 169 patients-satisfying the National Institute of Health criteria for bariatric surgery-who underwent a LRYGB from January 2014 to July 2017. Before surgery, we recorded a detailed medical history for every patient, and after surgery, we instructed them to return at 1, 6, 12, 24, 36, and 48 months after surgery.

RESULTS

Preoperatively, anemia was present in 4.24% of patients, iron deficiency in 5.33%, vitamin B12 deficiency in 12.3%, and vitamin D deficiency in 74.35%. Postoperatively, the deficiency rates of calcium, magnesium, folate, and vitamins A, B1, and B6 were markedly low at 1, 2, and 3 years after surgery. In regard to anemia, iron, and vitamin B12, rates of deficiency were higher at 2 and 3 years postoperatively versus preoperatively, but only anemia (4% vs 14% and 4% vs 27%, at 2 and 3 years) and iron (5% vs 23% at 3 years) reached statistical significance. Compared with the preoperative assessment, the rates of vitamin D deficiency decreased over time (74% vs 50% at 1 year [p < 0.001], 74% vs 45% at 2 years [p < 0.002] and 74% vs 41% at 3 years [p < 0.04]).

CONCLUSIONS

Vitamin D deficiency remains the most common preoperative deficiency. Anemia and deficiencies of iron and vitamin B12 are common before and after surgery. Deficiencies of calcium, magnesium, folate, and vitamins A, B1, and B6 are markedly low in the postoperative period.

The hundred most frequently cited studies on sleeve gastrectomy

INTRODUCTION

Sleeve gastrectomy (SG) is one of the most popular bariatric operations and one of the most frequently studied areas in bariatric surgery.

AIM

To summarise the characteristics of the most frequently cited studies focusing on SG.

MATERIAL AND METHODS

We used the Web of Science database to identify all studies focused on SG published from 2000 to 2018. The term "sleeve gastrectomy" and synonyms were used to reveal the 100 most cited records.

RESULTS

The most frequently cited publication had 493 citations. The highest mean number of citations per year was 73.00. Studies were most frequently published in the years 2010 and 2012. Articles were most commonly published in bariatric surgery-oriented journals.

CONCLUSIONS

Our study indicates an increase in medical researchers' interest in the subject of SG and underlines the need to perform studies with a higher level of evidence to further analyse the outcomes and basic science behind SG.

Comparison of the effect of Roux-en-Y gastric bypass and sleeve gastrectomy on remission of type 2 diabetes: A systematic review and meta-analysis of randomized controlled trials

Bariatric surgery is an effective treatment option for patients with type 2 diabetes mellitus (T2DM) and obesity. This study aims to compare the effects of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) on remission of T2DM. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for studies published between database inception and 21 November 2019. A meta-analysis, using a random effects model, was performed to calculate relative risk (RR) of T2DM remission between the groups in randomized controlled trials (RCTs). Of 2650 records identified, 12 records from 10 different RCTs were finally included. The studies comprised 705 patients with follow-up from 1 to 5 years. The remission rate of T2DM at 1 year was higher among those undergoing RYGB (156/276, 57%) compared with those undergoing SG (128/275, 47%), RR (95% CI) 1.20 (1.00-1.45), P = .047, I² = 24.9%, moderate-quality evidence. Among studies with 2- to 5-year follow-up, there was no difference in remission rates between the RYGB (132/263, 50%) and SG (121/266, 46%) groups, RR 1.06 (0.94-1.20), P = .34, I² = 0.0%, low-quality evidence. RYGB resulted in a higher rate of T2DM remission compared with SG after 1 year. The T2DM remission rates did not differ in studies with 2- to 5-year follow-up.

Relationship Between Bariatric Surgery and Gastroesophageal Reflux Disease: a Systematic Review and Meta-analysis

The purpose of this study was to investigate the relationship between bariatric surgery (laparoscopic sleeve gastrectomy [LSG] and laparoscopic Roux-en-Y gastric bypass [LRYGB]) and gastroesophageal reflux disease (GERD). The number of obese patients with newly onset, worsened, or improved GERD after bariatric surgery in each article were extracted. In the pooled analysis, LSG was associated with a higher risk of GERD than LRYGB (odds ratio [OR] = 5.10, 95% confidence interval [CI] 3.60-7.23, p < 0.001). Compared with LSG, LRYGB had a better effect on GERD (OR = 0.19, 95% CI 0.12-0.30, p < 0.001). LRYGB was more effective for treating GERD in obese patients than LSG and the incidence of newly onset GERD after LRYGB was lower.

Impact of obesity on dialysis and transplant and its management

Obesity is increasing to unprecedented levels, including in the end-stage kidney disease population, where upwards of 60% of kidney transplant patients are overweight or obese. Obesity poses additional challenges to the care of the dialysis patient, including difficulties in creating vascular access and inserting Tenckhoff catheters, higher rates of catheter malfunction and peritonitis, the need for longer and/or more frequent dialysis (or peritoneal dialysis [PD] exchanges) to achieve adequate clearance, increased metabolic complications particularly with PD, and obesity is a barrier to kidney transplantation. In this article, we review special considerations in performing PD, hemodialysis and transplant in the obese patient, as well as the evidence behind medical and surgical management of obesity in dialysis patients.