The effects of bougie caliber on leaks and excess weight loss following laparoscopic sleeve gastrectomy. Is there an ideal bougie size?

Long-Term Outcomes of Patients with Staple Line Leaks Following Sleeve Gastrectomy

PURPOSE

The long-term outcomes of patients with staple line leaks (SLL) after SG are under-reported. The purpose of this study is to evaluate the long-term outcomes of patients with SLL after SG.

MATERIALS AND METHODS

A retrospective analysis of a maintained patient registry of patients undergoing SG between January 2012 and December 2020 in a single bariatric center was analyzed and included patients with SLL. Outcomes were compared to a group without SLL.

RESULTS

During this period, 1985 patients underwent SG of which 61 patients (3.1%) developed leak. 26 patients (1.3%) had overt SLL and the rest had organ space infection around the staple line. The mean age and body mass index (BMI) were 39.8 ± 11.3 and 41.5 ± 4.7, respectively. 7 patients (11.4%) underwent concomitant surgery and 12 patients (19.7%) had intraoperative complications. Leak was complicated by Clavien-Dindo ≥ 3 in 31 patients (50.8%). Reoperation rate was 27.8% (n = 17). ≥ 2 interventions were required in 26% of patients (n = 16). Two patients died during hospitalization due to septic complications. Long-term follow-up of median 121 months was available in 78% of the cohort (n = 48). The median total weight loss and BMI were 27% and 30.1 kg/m2, respectively. Weight loss outcomes were higher in comparison to patients without SLL. Seven patients (14.6%) underwent SG revision. All associated medical problems improved during follow-up except for gastroesophageal reflux which was found in 50% of cohort.

CONCLUSION

Long-term outcomes of SG patients with SLL are satisfactory in terms of weight loss, resolution of comorbidities, and requirement for surgical revision.

Robotic Versus Laparoscopic Sleeve Gastrectomy Outcome Trends Over Time: Are We Improving?

BACKGROUND

Sleeve gastrectomy (SG) is an effective treatment option for patients with obesity. Robotic sleeve gastrectomy (RSG) is reported to have worse short-term patient outcomes compared to laparoscopic SG (LSG), but prior studies may not have accounted for evolving technology, including stapler utilization.

OBJECTIVE

This study compared RSG and LSG outcomes over different time periods.

SETTING

Academic Hospital.

MATERIAL AND METHODS

The 2015 to 2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project (MBSAQIP) databases were used. Matched cohort analyses compared adverse outcomes within 30 days for the 2015-2018 and 2019-2021 cohorts. Bivariate and regression models compared cohorts using Stata/MP 17.0.

RESULTS

Seven hundred sixty-eight thousand and sixty-nine SG were analyzed. Over the 7-year study period, all patient outcomes, operation length (OL), and length of stay (LOS) trended downward for RSG, except surgical site infection (SSI). In the 2015-2018 cohort, leak was significantly higher with RSG (OR 1.53), and OL and LOS longer (p < 0.001). In the 2019-2021 cohort which corelated with a significant increase in robotic cases, leak (OR 1.36), SSI (OR 1.46), and morbidity (OR 1.11) were higher with RSG. While the mean difference in OL and LOS decreased between the two time periods, they remain longer for RSG (p < 0.001).

CONCLUSION

While RSG and LSG are safe with similar mortality, RSG continues to be associated with higher rates of morbidity, leak, and SSI, as well as longer OL, hospital LOS, and higher cost. The study is limited by the ability to account for the impact of surgeon experience and stapler utilization on outcomes.

Effectiveness of sleeve gastrectomy plus fundoplication versus sleeve gastrectomy alone for treatment of patients with severe obesity: a systematic review and meta-analysis

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) is a widely performed bariatric surgery, but it is associated with an increased risk of gastroesophageal reflux (GERD) in the long term. The addition of fundoplication to laparoscopic SG may improve lower oesophageal sphincter function and reduce postoperative GERD.

OBJECTIVES

This systematic review and meta-analysis aims to compare the efficacy and safety of SG plus fundoplication (SG + F) versus SG alone for the treatment of patients with severe obesity (≥35 kg/m2).

SETTING

Meta-analysis.

METHODS

Three electronic databases were searched from inception until January 2023. Studies were included if they compared outcomes of SG + F versus SG in patients with severe obesity (≥35 kg/m2). The primary outcome was remission of GERD postoperatively. Secondary outcomes were the percentage of excess weight loss, percentage of total weight loss, postoperative complication rate, operative time, and length of stay.

RESULTS

A total of 5 studies with 539 subjects (212 SG + F and 327 SG alone) were included. The mean preoperative body mass index was 42.6 kg/m2. SG + F achieved higher remission of GERD compared with laparoscopic SG (odds ratio [OR] = 13.13; 95% CI, 3.54-48.73; I2 = 0%). However, the percentage of total weight loss was lower in the SG + F group (mean difference [MD] = -2.75, 95% CI, -4.28 to -1.23; I2 = 0%), whereas there was no difference in the percentage of excess weight loss (MD = -0.64; 95% CI, -20.62-19.34; I2 = 83%). There were higher postoperative complications in SG + F (OR = 2.56; 95% CI, 1.12-5.87; I2 = 0%) as well. There was no difference in operative time or length of stay between the 2 groups.

CONCLUSION

SG + F achieved better GERD remission but is associated with lesser weight loss and increased postoperative complications compared with SG alone. Further studies are required to ascertain the overall clinical benefit of SG + F for patients with severe obesity.

The impact of the bougie size and the extent of antral resection on weight-loss and postoperative complications following sleeve gastrectomy: results from the Scandinavian Obesity Surgery Registry

BACKGROUND

The optimal sleeve diameter and distance from the pylorus to the edge of the resection line in laparoscopic sleeve gastrectomy (LSG) remain controversial.

OBJECTIVES

To evaluate the influence of bougie size and antral resection distance from the pylorus on postoperative complications and weight-loss results in LSG.

SETTING

Nationwide registry-based study.

METHODS

This study included all LSGs performed in Sweden between 2012 and 2019. Data were obtained from the Scandinavian Obesity Surgery Registry. Reference bougie size of 35-36 Fr and an antral resection distance of 5 cm from the pylorus were compared to narrower bougie size (30-32 Fr), shorter distances (1-4 cm), and extended distances (6-8 cm) from the pylorus in assessing postoperative complications and weight loss as the outcomes of LSG.

RESULTS

The study included 9,360 patients with postoperative follow-up rates of 96%, 79%, and 50% at 30 days, 1 year, and 2 years, respectively. Narrow bougie and short antral resection distance from the pylorus were significantly associated with increased postoperative weight loss. Bougie size was not associated with increased early or late complications. However, short antral resection distance was associated with high risk of overall early complications [odds ratio: 1.46 (1.17-1.82, P = .001)], although no impact on late complications at 1 and 2 years was observed.

CONCLUSIONS

Using a narrow bougie and initiating resection closer to the pylorus were associated with greater maximum weight loss. Although a closer resection to the pylorus was associated with an increased risk of early postoperative complications, no association was observed with the use of narrow bougie for LSG.

Risk Factors and Management Approaches for Staple Line Leaks Following Sleeve Gastrectomy: A Single-Center Retrospective Study of 402 Patients

Sleeve gastrectomy (SG) has gained ever-increasing popularity among laparoscopic surgeons involved in bariatric surgery. This single-institution, retrospective cohort study aims to evaluate the prevalence of postoperative staple line leakage (PSLL) after LSG and identify risk factors for its development. We included patient data that underwent LSG at our institution for a span of 17 years-starting in January 2005 and ending in December 2022. We set the investigation of correlations of patient-related factors (age, weight, BMI, smoking status, presence of diabetes mellitus) with the occurrence of postoperative leaks. A total of 402 patients were included in our study. Of them, 26 (6.46%) developed PSLL. In total, 19 (73%) patients underwent percutaneous drainage and 14 patients (53.8%) were treated with intraluminal endoscopic stenting. Finally, five patients (19.2%) were treated with endoscopic clipping of the defect. Operative management was required in only one patient. There were no statistically significant differences in patient age, mean weight at the time of operation, and mean BMI. Abnormal drain amylase levels were associated with earlier detection of PSLL. More consideration needs to be given to producing a consensus regarding the management of PSLL, prioritizing nonoperative management with the combination of percutaneous drainage and endoscopic stenting as the safest and most efficient approach.

Impact of Gastropexy/Omentopexy on Gastrointestinal Symptoms after Laparoscopic Sleeve Gastrectomy

Background

Laparoscopic sleeve gastrectomy (LSG) has become a single-step operation for the management of severe obesity. A statistically significant number of participants who undergo this procedure experience nausea, vomiting, and reflux symptoms early after the operation. The objectives of this study were to measure the positive or negative effect of gastropexy on reducing distressing postoperative LSG-related gastrointestinal symptoms.

Patients and Methods

This was a comparative randomized study conducted from January 2018 to January 2021. The study was carried out in the general surgery department at Menoufia University Hospital, Menoufia Faculty of Medicine in Egypt. Two hundred participants were included randomly during this trial. The participants were divided into two groups, with 100 patients in each group. Patients in group A underwent gastropexy, and patients in group B underwent LSG without gastropexy.

Results

There was no significant difference between the groups in age or sex (p > 0.05). There was no significant difference in the length of hospital stay (p > 0.05). There was a significant difference between the two groups regarding nausea, vomiting, reflux symptoms, and the amount and frequency of antiemetics used (p < 0.001). There was also a significant difference in hospital readmissions (p < 0.05) and in clinic visits during the postoperative period.

Conclusions

Patients who underwent gastropexy showed a significant reduction in antiemetic consumption and a significantly lower incidence of postoperative nausea, vomiting, gastroesophageal reflux disease symptoms and gastric torsion than those who did not undergo gastropexy.

Graphical abstract

Laparoscopic sleeve gastrectomy for morbid obesity in a Belgian-French prospective multicenter study: outcomes and predictors weight loss failure

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) became the most frequently performed bariatric procedure worldwide, gaining rapidly popularity thanks to its technical simplicity and the relatively good results. The aim of this Belgian-French study was to evaluate postoperative complications, weight loss, and resolution of obesity-related comorbidities after LSG, and identify predictive factors of weight loss failure.

PATIENTS AND METHODS

A prospective multicenter study was conducted on all LSG performed during 2014 in 7 centers. Their demographic, preoperative, and postoperative data were prospectively collected and analyzed statistically.

RESULTS

Overall 529 patients underwent LSG, with a mean preoperative weight and body mass index (BMI) of 118.9 ± 19.9 kg and 42.9 ± 5.5 kg/m², respectively. Postoperative mortality was null and early postoperative morbidity was 6%, including 2.5% of gastric leakage. BMI significantly decreased to 31.1 kg/m² and 30.0 kg/m² at 1 and 3 years, respectively (p < .001). The mean %EWL was 77.2 and 74.6% at 1 and 3 years. A significant reduction in dyslipidemia (28.0-16.8%), obstructive sleep apnea (OSAS) (34.6-23.3%) and arterial hypertension (HTN) (30.4-20.2%) was observed after 3 years, but it does not concern diabetes and gastroesophageal reflux disease (GERD). At multivariate analysis, age > 50 years old, BMI >50 kg/m² and previous laparoscopic adjustable gastric banding (LAGB) remained independent predictors of weight loss failure.

CONCLUSIONS

LSG for morbid obesity is safe and effective. Satisfactory outcome after 3 years can be achieved regarding %EWL and some comorbidities such as dyslipidemia, OSAS, and HTN, but not diabetes and GERD. Age > 50 years old, BMI > 50 kg/m² and previous LAGB were independent predictors of weight loss failure.

Impact of the calibration bougie diametre during laparoscopic sleeve gastrectomy on the rate of postoperative staple-line leak (BOUST): study protocol for a multicentre randomized prospective trial

Background

Laparoscopic sleeve gastrectomy (LSG) has become an increasing bariatric procedure. The basic principle is to create a narrow stomach along the lesser curvature, using a calibration bougie as a template to perform a vertical partial gastrectomy, resecting the greater curvature and fundus of the stomach. The most common postoperative complication is gastric leak from the staple line, observed in approximately 3% of cases, which can result in long and incapacitating treatment. The diametre of the bougie used to calibrate the remnant stomach could impact the rate of postoperative gastric leak, a higher diametre being correlated with a lower risk of leak, without lowering long-term weight loss. This is the first randomized trial to compare the outcomes of LSG regarding the use of two different bougie diametres on postoperative gastric leak and mid-term weight loss.

Methods

Bougie Sleeve Trial (BOUST) is a superiority single-blinded randomized national trial, involving 17 centres. Participants will be randomized into two groups. LSG will be performed using a 48-Fr diametre calibration bougie in the experimental group and a standard care (34 to 38-Fr diametre) calibration bougie in the control group. Both groups will take part in a 2-year postoperative follow-up to assess postoperative gastric leak rate and weight loss and quality of life evolution.

Discussion

This study protocol will allow the investigators to determine if the use of a larger calibration bougie during LSG is associated with lower postoperative gastric leak occurrence without impairing mid-term weight loss and quality of life. The results of this trial will provide important data on patient safety and promote best practice for LSG procedures.

Trial registration

ClinicalTrials.govNCT02937649. Registered on 18 October 2016

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05734-3.

Promising effects of 33 to 36 Fr. bougie calibration for laparoscopic sleeve gastrectomy: a systematic review and network meta-analysis

The standard size of bougie for laparoscopic sleeve gastrectomy (LSG) is not yet established. Therefore, a systematic review and network meta-analysis were conducted to assess the weight loss effects and associated complications of LSG for patients with morbid obesity, based on different bougie sizes. A total of 15 studies were reviewed in this systemic review and network meta-analysis (2,848 participants), including RCTs and retrospective studies in PubMed, and Embase until September 1, 2020. The effectiveness of different bougie calibration sizes was assessed based on excess weight loss (EWL), total complications, and staple line leak. Within this network meta-analysis, S-sized (≤ 32 Fr.) and M-sized (33–36 Fr.) bougies had similar effects and were associated with the highest EWL improvement among all different bougie sizes (S-sized: standardized mean difference [SMD], 10.52; 95% confidence interval [CI] − 5.59 to  − 26.63, surface under the cumulative ranking curve [SUCRA], 0.78; and M-sized: SMD, 10.16; 95% CI − 3.04–23.37; SUCRA, 0.75). M-sized bougie was associated with the lowest incidence of total complications (M-sized: odds ratio, 0.43; 95% CI, 0.16–1.11; SUCRA, 0.92). Based on our network meta-analysis, using M-sized bougie (33–36 Fr.) is an optimal choice to balance the effectiveness and perioperative safety of LSG in the clinical practice.

The True Story on Deficiencies After Sleeve Gastrectomy: Results of a Double-Blind RCT

BACKGROUND

Since a few years, the laparoscopic sleeve gastrectomy (SG) has become the most performed bariatric operation worldwide. However, as with all bariatric procedures, SG also leads to vitamin and mineral deficiencies post-operatively and standard multivitamin supplements are probably not sufficient.

OBJECTIVE

The present study evaluates the effectiveness of a specialized multivitamin supplement for SG patients (WLS Optimum 1.0, FitForMe, Rotterdam, the Netherlands), compared to a standard multivitamin supplement (sMVS).

DESIGN

A double-blind randomized controlled trial was performed. For 12 months, patients in the intervention group received WLS Optimum, containing elevated doses of multiple vitamins and minerals. Patients in the control group were provided with sMVS, containing 100% of the recommended dietary allowance.

RESULTS

In total, 139 patients were available for analysis (WLS Optimum, n = 69; sMVS, n = 70). Intention-to-treat analyses revealed more folic acid deficiencies and higher serum vitamin B1 levels in the WLS Optimum group. Per protocol analyses showed that in patients using WLS Optimum, serum folic acid and vitamin B1 levels were higher, serum PTH levels were lower, and only one patient (2.6%) was anemic compared to 11 patients (17.5%) using a sMVS (p < 0.05 for all). No differences were found in prevalence of deficiencies for iron, vitamin B12, vitamin D, and other vitamins and minerals.

CONCLUSIONS

This optimized multivitamin supplement only affected serum levels of folic acid, PTH and vitamin B1, and anemia rates compared to a sMVS. There is a clear need to further optimize multivitamin supplementation for SG patients. Besides, non-compliance with multivitamin supplements remains an important issue that should be dealt with.

CLINICAL TRIAL REGISTRY

The study protocol was registered at the clinical trials registry of the National Institutes of Health (ClinicalTrials.gov; identifier NCT01609387).

Laparoscopic Vertical Sleeve Gastrectomy

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

Five-year Outcomes of Sleeve Gastrectomy: A Prospective Multicenter study

BACKGROUND

Sleeve gastrectomy (SG) is the most frequently performed bariatric procedure in the world. Our purpose was to evaluate the percentage of excess weight loss (%EWL), resolution of obesity-related comorbidities after SG, and identify predictive factors of weight loss failure.

METHODS

A prospective cohort study of adults who underwent SG during 2014 in 7 Belgian-French centers. Their demographic, preoperative, and postoperative data were prospectively collected and analyzed statistically.

RESULTS

Overall, 529 patients underwent SG, with a mean preoperative weight and body mass index (BMI) of 118.9 ± 19.9 kg and 42.9 ± 5.5 kg/m², respectively. Body mass index significantly decreased to 32.2 kg/m² at 5 years (P < .001). The mean %EWL was 63.6% at 5 years. A significant reduction in dyslipidemia (28.0%-18.2%), obstructive sleep apnea (OSAS) (34.6%-25.1%), and arterial hypertension (HTN) (30.4%-21.5%) was observed after 5 years, but not for diabetes and gastroesophageal reflux disease (GERD). At multivariate analysis, age >50 years old, BMI >50 kg/m², and previous laparoscopic adjustable gastric banding (LAGB) remained independent predictors of weight loss failure.

CONCLUSIONS

Five years after SG, weight loss was satisfactory; the reduction of comorbidities was significant for dyslipidemia, OSAS, and HTN, but not diabetes and GERD. Age >50 years old, BMI >50 kg/m², and previous LAGB were independent predictors of weight loss failure.

Mechanisms of Esophageal and Gastric Transit Following Sleeve Gastrectomy

PURPOSE

Sleeve gastrectomy (SG) patients have substantially altered anatomy. The mechanism of rapid gastric emptying and the role of esophageal contractile function in esophago-gastric transit has not been defined. We aimed to determine the mechanisms of esophago-gastric transit and role of esophageal function following sleeve gastrectomy.

METHODS

Prospective study of twenty-six asymptomatic participants post SG underwent nuclear scintigraphy and high-resolution manometry. Fourteen had semi-solid stress barium to model the emptying process. Concurrent video fluoroscopy and manometry were performed on 7 participants.

RESULTS

Demographic data are as follows: age 45.3 ± 15.0 years, 73.1% female, excess weight loss 62.2 ± 28.1% at 8 months. Scintigraphy showed rapid gastric emptying (24.4 ± 11.4 vs. 75.80 ± 45.19 min in control, p < 0.001) with 35.24 ± 17.12% of bolus transited into small bowel on initial frame. Triggered deglutitive reflux was common (54.4% vs. 18.2%, p = 0.017). Stress barium delineated separate vertical and antral gastric compartments with cyclical emptying of 8 stages, including reflux-induced repeated esophageal peristalsis. During manometry, ramping effects were noted, with sequential swallows producing sustained isobaric pressurizations in proximal stomach (33.6 ± 29.5 mmHg). Video fluoroscopy showed individual esophageal peristalsis generating pressurizations at 5.0 ± 1.4 cm below lower esophageal sphincter (LES), at amplitude of 31.6 ± 13.1 mmHg, associated with intragastric transit. Pressurizations were sustained for 17.3 ± 8.2 s, similar to the prolonged LES contraction (18.5 ± 9.0 s, p = 0.355).

CONCLUSIONS

Repeated esophageal peristaltic contractions induced isobaric pressurization of proximal stomach, thus providing the drive to pressurize and empty the vertical compartment of the gastric sleeve. Transit following SG appeared to be esophageal-mediated and followed a distinct cycle with strong associations with reflux.

Does intensive multidisciplinary intervention for adults who elect bariatric surgery improve post-operative weight loss, co-morbidities, and quality of life? A systematic review and meta-analysis

This systematic review and meta-analysis of intervention studies aims to evaluate the effect of preoperative and/or post-operative support for adults who elect bariatric surgery delivered by a multidisciplinary team (MDT) on post-operative body composition, mental health, co-morbidities, quality of life, and side effects. Six electronic databases were searched. Revman and GRADE were used to assess confidence in pooled effects. Included interventions (N = 1533 participants in total) focused on lifestyle counselling (n = 4 studies), psychology (n = 4 studies), or exercise (n = 10 studies); comparator groups were less intensive usual care. Intensive MDT interventions increased post-operative weight loss (SMD: -0.94; 95% CI: -1.27 to -0.61) if delivered post-operatively. Preoperative and post-operative intensive interventions improved symptoms of depression and anxiety, quality of life, diastolic blood pressure, and resting heart rate but not lipids or glycaemic measures. Whilst usual MDT care is important preoperatively, this review conditionally recommends intensive MDT interventions for enhanced post-operative weight loss if delivered in the post-operative period, led by any health professional, based on moderate evidence. This review also conditionally recommends preoperative and/or post-operative lifestyle, nutrition, or psychology counselling and/or physical activity for improved mental and physical health. Further randomized controlled trials are required, which aim to specifically evaluate the best use of MDT resources.

The Unconventional Role for Gastric Volume in the Response to Bariatric Surgery for Both Weight Loss and Glucose Lowering

OBJECTIVE

To study the relationship between the amount of surgery-induced gastric volume reduction and long-term weight loss and glucose tolerance.

BACKGROUND DATA

Vertical sleeve gastrectomy (VSG) has recently surpassed gastric bypass to become the most popular surgical intervention to induce sustained weight loss. Besides inducing significant weight loss, VSG also improves glucose tolerance. Although no clear correlation has been observed between the size of the residual stomach and sustained weight loss, this begs the question whether less aggressive gastric volume reduction may provide sufficient efficacy when weight loss is not the major goal of the surgical intervention.

METHODS

A series of strategies to reduce gastric volume were developed and tested in Long Evans male rats, namely: VSG, Fundal (F)-Resection, Gastric Sleeve Plication (GSP), Fundal-Plication, and Fundal-Constrained.

RESULTS

All surgical interventions resulted in a reduction of gastric volume relative to sham, but none of the interventions were as effective as the VSG. Gastric volume was linearly correlated to increased gastric emptying rate as well as increased GLP-1 response. Overall, cumulative food intake was the strongest correlate to weight loss and was logarithmically related to gastric volume. Regression modeling revealed a nonlinear inverse relation between body weight reduction and gastric volume, confirming that VSG is the only effective long-term weight loss strategy among the experimental operations tested.

CONCLUSIONS

The data suggest a minimum threshold volume of the residual stomach that is necessary to induce sustained weight loss. Although all gastric volume interventions increased the GLP-1 response, none of the interventions, except VSG, significantly improved glucose tolerance. In conclusion, if weight loss is the primary goal of surgical intervention, significant volume reduction is required, and this most likely requires excising gastric tissue.

Presurgical Predictive Factors of Excess Weight Loss After Laparoscopic Sleeve Gastrectomy

PURPOSE

Conditions associated with surgical technique and postoperative lifestyle changes, as well as the characteristics of patients, may affect weight loss following laparoscopic sleeve gastrectomy. In this study, the effects of age, gender, BMI, and excess weight at the time of surgery on weight loss during follow-up were examined.

MATERIALS AND METHODS

Demographic data (age, gender), preoperative BMI, and weight values of the patients were recorded. TWL% and EWL% values of patients were recorded during follow-up at 1st, 3rd, 6th, 9th, 12th, and 18th months. Patients were grouped according to age (AGE1 < 30, AGE2 30-50, AGE3 ≥ 50 years), BMI at the time of surgery (BMI1 ≤ 50, BMI2 > 50 kg/m²), and EW at the time of surgery (EW1 ≤ 60, EW2 > 60 kg). EWL% values obtained in the follow-up visits were compared among the gender, age, BMI, and EW groups.

RESULTS

A total of 456 patients (371 females, 85 males) were operated. Mean EWL% was lower in AGE3 group (p < 0.001). Patients in AGE1 group had the highest mean EWL%, while those in BMI2 and EW2 groups had lower mean EWL% values throughout the follow-up period (p < 0.001). Regression analysis showed that age and BMI were associated with EWL% at all follow-up visits (p < 0.05).

CONCLUSION

Patients with less than 60 kg of excess weight, those with BMI ≤ 50 kg/m² and younger patients may lose weight more effectively following LSG.

The Impact of Staple Line Reinforcement Utilization on Bleeding and Leak Rates Following Sleeve Gastrectomy for Severe Obesity: a Propensity and Case-Control Matched Analysis

INTRODUCTION

Staple line reinforcement (SLR) is a commonly used technique during laparoscopic sleeve gastrectomy (SG) for severe obesity. There remains controversy over the potential benefit or risk associated with SLR. There are currently no consensus recommendations about SLR use. Its use is surgeon-dependent and remains controversial.

STUDY AIM

To determine the impact of staple line reinforcement on staple line leak and bleeding rates after sleeve gastrectomy.

METHODS

Using the Metabolic and Bariatric Surgery Quality Improvement Program Participant User File (MBSQIP-PUF) database, we identified patients who had a SG in 2015 and 2016. SLR utilization status was used to create two cohorts. An unmatched cohort analysis was performed, and the outcomes were compared. A propensity score and case-control matched cohort analysis were then performed, and the outcomes were compared. Statistical analysis was performed with SPSS and SAS.

RESULTS

Of the 189,173 SG cases identified, SLR utilization was noted in 127,521 (67.4%). In the unmatched analysis, bleeding and reoperation were significantly higher in the cohort without SLR utilization. In both propensity score and case-control matched analysis, bleeding and reoperation remained significantly higher in the cohort without SLR utilization. There was no difference in mortality and staple line leak rates between the cohorts.

CONCLUSIONS

SLR significantly reduces bleeding and reoperation rates following SG and has no deleterious impact on staple line leak rate. While further prospective studies factoring in the SLR method and staple characteristics are needed, this large database analysis supports the use of routine SLR during SG to reduce the risk of perioperative bleeding and reoperation.

Gender-related metabolic outcomes of laparoscopic sleeve gastrectomy in 6-month follow-up

Introduction

Laparoscopic sleeve gastrectomy (LSG) is recently a leading method in surgical treatment of morbid obesity. The metabolic outcome of intervention may be a result of many factors such as age, gender, preoperative weight loss and dietary restrictions.

Aim

To evaluate gender-related differences in the results of LSG in 6-month follow-up.

Material and methods

The study included 101 patients who underwent LSG at the University Clinical Hospital of Bialystok. Patients were divided and analyzed in 2 groups: males (n = 48) and females (n = 53). The primary analysis included the influence of gender on postoperative weight loss calculated using the percentage of excess weight loss (%EWL) and excess BMI loss (%EBMIL). For secondary outcomes the levels of glucose, insulin, glycated hemoglobin, aspartate transaminase, alanine transaminase, total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides and C-reactive protein were analyzed.

Results

A significant influence of patients’ gender was proved for both %EWL (p = 0.026) and %EBMIL (p = 0.001). Females had significantly higher %EWL in 6-month follow-up than males (p = 0.0034). The analysis also showed significantly higher %EBMIL for women at 3 and 6 months observation (p = 0.022 and p < 0.001 respectively).

Conclusions

Laparoscopic sleeve gastrectomy is an effective method of obesity treatment especially in terms of postoperative weight loss. Females seem to benefit more from the procedure when analyzing the parameters of body mass reduction. However, further research is needed to provide strong evidence of an association between gender and the results of LSG.

Laparoscopic vertical sleeve gastrectomy, long and short-term impact on weight loss and associated co-morbidities

The laparoscopic vertical sleeve gastrectomy (LVSG) has become the most popular operation for the treatment of morbid obesity in the United States. Being a purely restrictive procedure, the LVSG works to reduce the caloric intake of patients as well as decrease appetite through removal of ghrelin producing cells. Initially developed as the first part of a combined two step restrictive and malabsorptive procedure, the LVSG developed as a standalone procedure when patients lost significant weight with the restrictive portion of the operation alone. Short term outcomes have been promising in terms of weight loss and resolution of comorbid conditions. Long term outcomes are still evolving, but do demonstrate durable weight loss for a significant number of patients. Concerns with the LVSG in the long term revolve around development or worsening of gastroesophageal reflux disease or weight regain. The LVSG has been demonstrated to be a useful tool in the surgical management of morbid obesity.

Perioperative Outcomes of Robotic Versus Laparoscopic Sleeve Gastrectomy in the Super-obese

BACKGROUND

The robotic platform is often used for bariatric surgery in superobese patients (body mass index ≥ 50 kg/m²) with the assumption that it offers a technical advantage. This study aimed to compare perioperative outcomes of robotic-assisted sleeve gastrectomy (RSG) and laparoscopic sleeve gastrectomy (LSG) in superobese patients.

METHODS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was queried for superobese patients undergoing nonrevisional RSG and LSG from 2015 through 2017. Univariate analysis and multivariable logistic regression were used to compare outcomes in RSG and LSG.

RESULTS

A total of 61,493 patients (4685 RSG and 56,808 LSG) were identified. Patients were similar in terms of age (RSG 42.3 ± 11.8 versus LSG 42.4 ± 11.7 y; P = 0.60) and body mass index (RSG 56.8 ± 6.9 versus LSG 56.9 ± 7.1 kg/m²; P = 0.17). The RSG group had a longer operative time (102.4 ± 46.0 versus 74.7 ± 37.5 min; P < 0.01) and length of stay (1.79 ± 1.78 versus 1.66 ± 1.51 d; P < 0.01). Overall morbidity (RSG 3.5% versus LSG 3.7%; P = 0.54) and mortality (RSG 0.1% versus LSG 0.1%; P = 0.73) were similar between the two groups. After adjustment, RSG represented an independent risk factor for organ-space surgical site infection (adjusted odds ratio 2.70; 95% confidence interval 1.54-4.73; P < 0.01).

CONCLUSIONS

Use of RSG in superobese patients infers higher risk for organ-space surgical site infection and is associated with prolonged operative time and length of stay. This questions the role of robotics in superobese patients undergoing sleeve gastrectomy.

Predictors of weight regain after sleeve gastrectomy: an integrative review

BACKGROUND

Sleeve gastrectomy (SG) is one of the most effective treatments for severe obesity, but weight regain after surgery is a challenging issue. The mechanism of postoperative weight relapse is barely understood because of the lack of long-term data.

OBJECTIVES

To review and synthesize current evidence related to factors that contribute to weight regain after SG.

METHODS

Whittemore and Knafl's integrative method guided the research. The databases PubMed, EMBASE, and CINAHL, as well as 2 selected journals, were searched through October 2018 to gather English-language journal articles on the potential predictors of post-SG weight regain among adult populations. Only articles with sample size ≥10 were included. A narrative synthesis was used to analyze the 17 studies included in the review.

RESULTS

In recent years there has been an upward trend in the published reports of SG on longer-term outcomes. After a review of 6863 records, 17 eligible studies were identified, reporting various definitions of weight regain and 3 main categories of predictors: surgical/anatomic factors, hormonal/metabolic imbalance, and behavioral/mood factors. The 17 studies used quantitative (n = 16) and qualitative methods (n = 1).

CONCLUSION

There is a dearth of available literature addressing predictors of weight regain after SG, and the inconsistency in the definition of regain limited the comparability between studies. Besides the surgical/anatomic factors that have been reported as significant predictors, other modifiable factors such as behavioral and psychosocial determinants need to be further investigated.

Standardised Sleeve Gastrectomy Without Reinforcement

Background and Objectives:

Laparoscopic sleeve gastrectomy (LSG) has some unique complications, the most concerning of which is sleeve leak. Staple line reinforcement (SLR) has been suggested as a means of decreasing the risk of sleeve leak, but it increases the cost. However, there is little in the literature regarding the effect of standardized operative technique in reducing the complications and improving the outcomes in LSG. We sought to demonstrate that standardization of the operative procedure and perioperative care is the key to an excellent 30-day outcome and that SLR is not necessary to ensure a negligible staple line leak and bleeding rate.

Methods:

A prospectively maintained database was analyzed to identify 303 consecutive patients undergoing LSG between July 2010 and November 2017. Data on patient demographics, length of hospital stay, conversion to open surgery, perioperative complications, and mortality were analyzed. Standardized operative technique and postoperative protocol were followed in all cases. SLR was not used in any case.

Results:

Among 303 cases, there were 15 complications (5%), 5 (1.7%) of which were severe (Clavien-Dindo grade ≥3a). There were no conversions to open procedure, no staple line leaks, and no inpatient deaths in the cohort. No patient was readmitted with an early stricture.

Conclusions:

The use of a standardized operative and postoperative protocol led to an excellent early outcome in our LSG cases. Standardization may act to obviate the need for routine SLR techniques which are associated with a significant financial cost to both patient and hospital.

30-day outcomes of robot-assisted versus conventional laparoscopic sleeve gastrectomy: First analysis based on MBSAQIP

BACKGROUND

Sleeve gastrectomy (SG) is the most popular bariatric procedure in the United States. Although standardized, variation exists in how the staple line is managed. Robotic approaches to SG (RSG) are increasing, though benefits compared with the conventional laparoscopic approach (LSG) remain controversial.

OBJECTIVE

Evaluate the safety of RSG versus LSG using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry, controlling for variation in staple-line management.

SETTING

University health network, United States.

METHODS

SG cases from January 1 to December 31, 2016, in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry were included. Demographic characteristics and 30-day outcomes were analyzed with separate Mann-Whitney rank sums tests, χ² tests, or Fisher's exact tests, with P < .05 denoting statistical significance. Multivariate regression analysis was performed to control for method of staple-line treatment.

RESULTS

Of the 107,726 patients who underwent SG, 7385 were RSG. Treatment of the staple line was associated with a significantly lower rate of bleeding, with odds ratios of .69 and .58 for staple-line reinforcement alone and staple-line reinforcement plus oversewing, respectively. Multivariate analysis revealed RSG had a higher rate of organ space infection than LSG (odds ratio 2.07). Otherwise, RSG did not significantly differ from LSG save for a longer median operative time (89 versus 63 min, respectively, P < .0001).

CONCLUSIONS

RSG is a growing alternative to the conventional laparoscopic approach. According to the 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, the RSG carries a higher risk of organ space infection. The reasons behind this finding require further study.

Roux-en-Y gastric bypass, sleeve gastrectomy, or one anastomosis gastric bypass as rescue therapy after failed adjustable gastric banding: a multicenter comparative study

BACKGROUND

To date, laparoscopic adjustable gastric banding remains the third most commonly performed surgical procedure for weight loss. Some patients fail to get acceptable outcomes and undergo revisional surgery at rates ranging from 7% to 60%. Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass (OAGB), and sleeve gastrectomy (SG) are among the most common salvage options for failed laparoscopic adjustable gastric banding.

OBJECTIVE

To compare the outcomes of converting failed laparoscopic adjustable gastric banding to RYGB, OAGB, or SG.

METHODS

Data collected from 7 experienced bariatric centers around the world were retrospectively collected, reviewed, and analyzed. Final body mass index (BMI), change in BMI, percentage excess BMI loss, and major complications with particular attention to leaks, hemorrhage, and mortality were reported.

RESULTS

Of 1219 patients analyzed, 74% underwent RYGB, 16% underwent OAGB, and 10% underwent SG after banding failure. The mean age was 38 years (±10 yr), and 82% of patients were women. The mean follow-up was 33 months. The follow-up rate was 100%, 87%, and 52% at 1, 3, and 5 years, respectively. At the latest follow-up, percentage excess BMI loss >50% was achieved by 75% of RYGB, 85% of OAGB, and 67% of SG patients. Postoperative complications occurred in 13% of patients after RYGB, 5% after OAGB, and 15% after SG.

CONCLUSION

Our data show that it is possible to achieve or maintain significant weight loss with an acceptable complication rate with all 3 surgical options.

The Effects of Bougie Diameters on Tissue Oxygen Levels After Sleeve Gastrectomy: A Randomized Experimental Trial

Background:

Staple-line leak is the most frightening complication of laparoscopic sleeve gastrectomy and several predisposing factors such as using improper staple sizes regardless of gastric wall thickness, narrower bougie diameter and ischemia of the staple line are asserted.

Aims:

To evaluate the effects of different bougie diameters on tissue oxygen partial pressure at the esophagogastric junction after sleeve gastrectomy.

Study Design:

A randomized and controlled animal experiment with 1:1:1:1 allocation ratio.

Methods:

Thirty-two male Wistar Albino rats were randomly divided into 4 groups of 8 each. While 12-Fr bougies were used in groups 1 and 3, 8-Fr bougies were used in groups 2 and 4. Fibrin sealant application was also carried out around the gastrectomy line after sleeve gastrectomy in groups 3 and 4. Burst pressure of gastrectomy line, tissue oxygen partial pressure and hydroxyproline levels at the esophagogastric junction were measured and compared among groups.

Results:

Mortality was detected in 2 out of 32 rats (6.25%) and one of them was in group 2 and the cause of this mortality was gastric leak. Gastric leak was detected in 2 out of 32 rats (6.25%). There was no significant difference in terms of burst pressures, tissue oxygen partial pressure and tissue hydroxyproline levels among the 4 groups.

Conclusion:

The use of narrower bougie along with fibrin sealant has not had a negative effect on tissue perfusion and wound healing.

Clinical and Economic Evaluation of Absorbable Staple Line Buttressing in Sleeve Gastrectomy in High-Risk Patients

BACKGROUND

Gastric leaks and bleeding are the most important complications after laparoscopic sleeve gastrectomy (LSG). The use of absorbable membranes as staple line reinforcement may decrease this risk. On the other hand, these materials bring additional costs and their economic impact is not well known. The purpose of this study was to assess the clinical and economic performance of one of the commercially available buttressing absorbable materials when treating a high-risk population.

METHODS

A retrospective, observational, and comparative study was conducted at Montpellier University Hospital, France, between July 2013 and September 2014. Patients undergoing LSG, who were at a high risk for leaks and bleeding, were included and treated according to two groups: no buttressing (July 2013 to January 2014) and buttressing (February 2014 to September 2014). Clinical and economic outcomes were measured throughout the first 6 months.

RESULTS

Two hundred two patients were included in the study: 116 during the no stapling reinforcement period and 86 during the buttressing period. Baseline characteristics were similar. There was no significant difference between the two groups regarding gastric leaks. However, buttressing reduced hemorrhagic complications (0 vs 8.6 %, p = 0.005) and decreased average total hospital costs for the first hospitalization (5768 vs 6025 €, p < 0.001), as well as 6-month total inpatient cost (5944 vs. 6246 €, p < 0.001).

CONCLUSIONS

Staple line reinforcement with absorbable material reduces bleeding in high-risk population. Therefore, this type of material can also result in cost-savings.

Different surgical approaches in laparoscopic sleeve gastrectomy and their influence on metabolic syndrome: A retrospective study

Obesity is a growing health, social, and economic issue and became an epidemic, according to recent report of World Health Organization.The only method with scientifically proved efficiency of body mass loss is a surgical treatment. Laparoscopic sleeve gastrectomy (LSG) is recently a leading method in metabolic surgery. There are no standards of operative technique for LSG so far. The influence of technique modification on metabolic effect has not been described clearly.The aim of this study was to evaluate metabolic effects in patients with morbid obesity who underwent various surgical approaches of LSG.The study included 120 patients who were randomly divided into 3 groups: Group I, where bougie size was 32 French (Fr), Group II-36 Fr and Group III-40 Fr. Each group was divided into 2 subgroups, based on the distance of resection beginning from the pylorus-2 or 6 cm. Statistical analysis of: body mass index (BMI), the Percentage of Excess Weight Loss (%EWL), the Percentage of Excess BMI Loss (%EBMIL), levels of glucose and insulin on an empty stomach, glycated hemoglobin (HbA1c), insulin resistance (Homeostatic Model Assessment of Insulin Resistance Index-HOMA-IR), aspartate transaminase (AST), alanine transaminase (ALT), total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides (TG), and C-reactive protein (CRP) were under investigation.Statistically significant decrease in body mass, BMI, %EWL, %EBL, glucose, and insulin concentrations has been observed in all studied groups. It was the highest when the smallest calibration tube has been used (32 Fr). Similar results were observed in HOMA-IR and HbA1c levels. Statistically significant decrease of total cholesterol, LDL, and TG concentrations have been observed. Significant increase of HDL in every group has been also noted. Postoperative CRP values were the lowest when the smallest bougie was used.LSG is effective method of obesity treatment. Metabolic effects of LSG are the most noticeable when a small bougie size is used.

The bariatric surgery and weight losing: a meta-analysis in the long- and very long-term effects of laparoscopic adjustable gastric banding, laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy on weight loss in adults

BACKGROUND

Several studies have been investigated to find the long-term effect of bariatric surgery on weight loss; nevertheless, a meta-analysis can detailedly demonstrate the effect of bariatric surgery on weight in morbidly obese patients. This study aimed to assess the long- and very long-term effects of laparoscopic adjustable gastric banding (LAGB), laparoscopic Roux-en-Y gastric bypass (LRYGB), and laparoscopic sleeve gastrectomy (LSG) on weight loss in adults.

METHODS

An electronic search using PubMed, Scopus, and Google scholar databases was performed for all English-language articles up to May 15, 2016 with no publication date restriction. Outcome was long-term (≥5-10 years) and very long-term (≥10 years) weight reduction that reported as the mean %EWL and changes in BMI from baseline.

RESULTS

Eighty articles with 87 arms were included in this meta-analysis. The excess weight loss percentage (%EWL) was 47.94% and 47.43% after LAGB at ≥5 and ≥10 years, respectively. After LRYGB the %EWL was 62.58% at ≥5 years and 63.52% at ≥10 years. It was 53.25% at ≥5 years after LSG. Results of subgroup analyses have indicated that LRYGB leads to higher %EWL in America and Asia compared with Europe. Meta-regression analyses have shown that there is no significant association between %EWL and baseline age, BMI and length of follow-up after three procedures. However, there is a positive association between gender and %EWL after LRYGB (β = 1.24). No publication bias was found.

CONCLUSIONS

These findings suggest that LRYGB is an effective procedure in morbidly obese patients that leads to sustainable weight loss over the long- and very long-term periods in compared with LAGB and LSG.

Prognostic factors of weight loss after sleeve gastrectomy: Multi centre study in Spain and Portugal

INTRODUCTION

Sleeve gastrectomy (SG) has become a technique in its own right although a selective or global indication remains controversial. The weight loss data at 5 years are heterogeneous. The aim of the study is to identify possible prognostic factors of insufficient weight loss after SG.

METHODS

A SG retrospective multicenter study of more than one year follow-up was performed. Failure is considered if EWL>50%. Univariate and multivariate study of Cox regression were performed to identify prognostic factors of failure of weight loss at 1, 2 and 3 years of follow up.

RESULTS

A total of 1,565 patients treated in 29 hospitals are included. PSP per year: 70.58±24.7; 3 years 69.39±29.2; 5 years 68.46±23.1. Patients with EWL<50 (considered failure): 17.1% in the first year, 20.1% at 3 years, 20.8% at 5 years. Variables with influence on the weight loss failure in univariate analysis were: BMI>50kg/m², age>50years, DM2, hypertension, OSA, heart disease, multiple comorbidities, distance to pylorus> 4cm, bougie>40F, treatment with antiplatelet agents. The reinforcement of the suture improved results. In multivariate study DM2 and BMI are independent factors of failure.

CONCLUSION

The SG associates a satisfactory weight loss in 79% of patients in the first 5 years; however, some variables such as BMI>50, age>50, the presence of several comorbidities, more than 5cm section of the pylorus or bougie>40F can increase the risk of weight loss failure.

Excess Body Mass Index Loss at 3 Months: A Predictive Factor of Long-Term Result after Sleeve Gastrectomy

Introduction. Laparoscopic Sleeve Gastrectomy (SG) is considered as successful if the percentage of Excess Body Mass Index Loss (% EBMIL) remains constant over 50% with long-term follow-up. The aim of this study was to evaluate whether early % EBMIL was predictive of success after SG. Methods. This retrospective study included patients who had SG with two years of follow-up. Patients had follow-up appointments at 3 (M3), 6, 12, and 24 months (M24). Data as weight and Body Mass Index (BMI) were collected systematically. We estimated the % EBMIL necessary to establish a correlation between M3 and M24 compared to % EBMIL speeds and calculated a limit value of % EBMIL predictive of success. Results. Data at operative time, M3, and M24 were available for 128 patients. Pearson test showed a correlation between % EBMIL at M3 and that at M24 (r = 0.74; p < 0.0001). % EBMIL speed between surgery and M3 (p = 0.0011) was significant but not between M3 and M24. A linear regression analysis proved that % EBMIL over 20.1% at M3 (p < 0.0001) predicted a final % EBMIL over 50%. Conclusions. % EBMIL at M3 after SG is correlated with % EBMIL in the long term. % EBMIL speed was significant in the first 3 months. % EBMIL over 20.1% at M3 leads to the success of SG.

Evaluating the effect of operative technique on leaks after laparoscopic sleeve gastrectomy: a case-control study

OBJECTIVE

To assess the effect of operative technique on staple line leaks after laparoscopic sleeve gastrectomy (LSG).

BACKGROUND

Staple-line leaks after LSG are a major source of morbidity and mortality. Variations in operative technique exist; however, their effect on leaks is poorly understood.

METHODS

We analyzed data from the Michigan Bariatric Surgery Collaborative (MBSC) to perform a case-control study comparing patients who had a clinically significant leak after undergoing a primary LSG to those who did not. A total of 45 patients with leaks were identified between January 2007 and December 2013. The leak group was matched 1:2 to a control group based on procedure type, age, body mass index, sex, and year the procedure was performed. Technique-specific factors were assessed by reviewing operative notes from all primary bariatric procedures in our study population. Conditional logistic regression was used to identify techniques associated with leaks. To increase the power of our analysis, we used a significance level of .10.

RESULTS

Leak rates with LSG have decreased over the past 5 years (1.18% to .36%) as annual case volume has increased (846 cases/yr to 4435 cases/yr). Surgeons who performed 43 or more cases per year had a leak rate<1%. Leaks were more common among cases requiring a blood transfusion (26.2% versus 1.08%, P = .0031) and when cases were converted to open surgery (7.14% versus 0%, P = .0741). However, there was no significant difference in operative time between cases involving a leak and their matched controls (95.4 min versus 87.1 min, P = .1197). Oversewing of the staple line was the only technique associated with less leaks after controlling for confounding factors (OR .397 CI .174, .909, P = .0665). Notably, surgeons who oversewed routinely were also found to have higher case volume (307 versus 140, P = .0216) and less overall complication rates (4.81% versus 7.95%, P = .0027). Furthermore, oversewing technique varied widely as only 22.6% of cases involved oversewing of the entire staple line.

CONCLUSION

Despite considerable variation in operative technique, leak rates with laparoscopic sleeve gastrectomy have decreased over time as operative volume has increased. Oversewing of the staple line was associated with fewer leaks, but specific suturing technique was not uniform and oversewing was performed routinely by more experienced surgeons with higher case volumes and less complication rates overall. Before standardizing surgical technique one must take into account variations in surgeon skill and experience.

Effect of Resected Gastric Volume on Ghrelin and GLP-1 Plasma Levels: a Prospective Study

BACKGROUND

The correlation between resected gastric volume (RGV) and neuro-humoral changes (ghrelin and GLP-1) after laparoscopic sleeve gastrectomy (LSG) and their effects on type 2 diabetes mellitus (T2DM) has been evaluated.

MATERIALS

Ninety-eight patients were divided in two groups: RGV <1200 mL (group A: 53 pts) and RGV >1200 mL (group B: 45 pts). Insulin secretion (insulin area under the curve (AUC)), insulinogenic index (IGI) and insulin-resistance (homeostasis model assessment, HOMA_IR) were assessed before and after surgery (at the 3rd day and 6, 12 and 24 months after LSG) using the oral glucose tolerance test (OGTT). At the same time, ghrelin and GLP-1 levels were determined.

RESULTS

A significant difference in T2DM resolution rate was observed after 6, 12 and 24 months in favour of RGV >1200 mL. Group B performed better than group A at the 3rd day and at the 6th, 12th and 24th months with regard to AUC, IGI and HOMA_IR. In both groups, OGTT resulted in decreased ghrelin values and a significant increase in GLP-1 values for group B at the 3rd day and at the 6th and 12th months with no difference at the 24th month.

CONCLUSION

Ghrelin and GLP-1 changes play a role in the regulation of glucose metabolism during the 1st year after LSG. RGV influences ghrelin and GLP-1 plasma levels after LSG, with a significant improvement in the T2DM control.

Sleeve Gastrectomy and Roux-en-Y Gastric Bypass Lead to Comparable Changes in Body Composition after Adjustment for Initial Body Mass Index

BACKGROUND

Bariatric surgery is a safe and established treatment option of morbid obesity. Mere percentage of excess weight loss (%EWL) should not be the only goal of treatment.

METHODS

One hundred seventy-three obese patients were included in the study. They underwent either Roux-en-Y gastric bypass (RYGB; n = 127, mean body mass index (BMI) 45.7 ± 5.7 kg/m(2)) or sleeve gastrectomy (SG; n = 46, mean BMI 55.9 ± 7.8 kg/m(2)) for weight reduction. Body weight and body composition were assessed periodically by bioelectrical impedance analysis.

RESULTS

After 1 year of observation, %EWL was 62.9 ± 18.0 % in RYGB and 52.3 ± 15.0 % in SG (p = 0.0024). Body fat was reduced in both procedures with a slight preference for SG, and lean body mass was better preserved in the RYGB group. Due to significant differences in the initial BMI between the two groups, an analysis of covariance was performed, which demonstrated no significant differences in the %EWL as well as in the other parameters of body composition 1 year after surgery. Using percentage of total weight loss to evaluate the outcomes between the two procedures, no significant difference was found (31.7 ± 8.4 % in RYGB and 30.5 ± 7.6 % in SG patients, p > 0.4).

CONCLUSIONS

Excess weight loss is highly influenced by the initial BMI. Total weight loss seems to be a better measurement tool abolishing initial weight differences. SG and RYGB do not differ in terms of body composition and weight loss 1 year after surgery.

MEDIUM-TERM FOLLOW-UP RESULTS WITH LAPAROSCOPIC SLEEVE GASTRECTOMY

Background

: The indications for sleeve gastrectomy in the surgical treatment of morbid obesity have increased worldwide. Despite this, several aspects related to results at medium and long term remain in constant research.

Aim

: To present the experience of sleeve gastrectomy in a center of excellence in bariatric surgery by analyzing clinical outcomes, complications and follow-up in the medium term.

Methods

: The study included 120 morbidly obese patients who underwent sleeve gastrectomy and who were followed for at least 24 months. Aspects related to surgical technique, surgical complications and clinical outcome were analyzed.

Results

: Seventy-five patients were women (62.5%) and the average age was 36 years. The body mass index preoperatively ranged from 35.5 to 58 kg/m²(average of 40.2 kg/m²). The length of stay ranged from 1 to 4 days (mean 2.1 days). Comorbidities observed were hypertension (19%), type 2 diabetes mellitus (6.6%), dyslipidemia (7.5%), sleep apnea (16.6%), reflux esophagitis (10%) and orthopedic diseases (7.5%). The mean body mass index and total weight loss percentage with 3, 12, 18 and 24 months were 32.2 kg/m²-19,9%; 29.5 kg/m²-26,5%; 28.2 kg/m²-30,3% and 26.9 kg/m²-32,7%, respectively. Remission of diabetes and dyslipidemia occurred in all patients. In relation to hypertension, there was improvement or remission in 86%. There were only two complications (bronchial pneumonia and dehydration), with good response to clinical treatment. There was no evidence digestive fistula and mortality was zero. Eleven patients (9.1%) had regained weighing more than 5 kg.

Conclusion

: The sleeve gastrectomy is surgical technique that has proven safe and effective in the surgical treatment of obesity and control of their comorbidities in postoperative follow-up for two years.

Results of More Than 11,800 Sleeve Gastrectomies: Data Analysis of the German Bariatric Surgery Registry

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) is an upcoming procedure in bariatric surgery and is currently performed worldwide. Staple line leakage, as the most frequent and most feared complication, is still a major concern.

METHODS

Since 2005 data from patients undergoing bariatric procedures in Germany have been prospectively registered in an online database and analyzed. All patients who had undergone primary SG within a 7-year period were considered for analysis.

RESULTS

Using the German Bariatric Surgery Registry, data from more than 11,800 SGs were collected between January 1, 2005, and December 31, 2013. Staple line leak rate decreased from 6.5% to 1.4%. Male sex, higher body mass index, concomitant sleep apnea, conversion to laparotomy, longer operation time, a combination of buttresses and oversewing, and the occurrence of intraoperative complications were associated with a significantly higher leakage rate compared with when using either buttresses or oversewing alone. On multivariable analysis, operation time and year of procedure only had a significant impact on staple line leakage rate.

CONCLUSIONS

Owing to the growing experience a constant decrease in the leakage rate after SG has been observed. Staple line disruption may still lead to sepsis, multiorgan dysfunction, and increased mortality. The results of the current study demonstrated that there are factors that increase the risk of leakage and which would enable surgeons to define risk groups, select patients more carefully, and offer closer follow-up during the postoperative course with early recognition and adequate treatment.

[Stenosis and ulceration after bariatric surgery]

INTRODUCTION

The increasing number of morbidly obese patients leads to a rising number of bariatric procedures in Germany. The operative techniques are highly standardized but such a standardization is lacking for the management of postoperative complications such as stenosis and ulceration after Roux-en-Y gastric bypass (RYGB) surgery and sleeve gastrectomy (SG).

METHODS

The current literature is reviewed and a complication management is developed and presented in this article.

RESULTS AND CONCLUSION

Postoperative stenoses occure with a frequency of 0.1-3.9% after SG and 3-27% after RYGB. Stenosis is secondary to inadequate surgical technique or microinsufficiency. Ulcers can be due to reaction to foreign body, local ischemia, peptic lesion, fistula and microinsufficiency.

CONCLUSION

Endoscopic interventions are successful in most cases for stenosis after RYGB and for short stenoses after SG. After SG long stenoses require redo surgery and conversion to RYGB. Ulcers can be managed by medication with the exception of perforation and hemorrhage, which require emergency laparoscopy.

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.

•

Laparoscopic sleeve gastrectomy shows sustainable long-term weight loss.

•

Laparoscopic sleeve gastrectomy shows excellent resolution of comorbidities.

•

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

Weight loss, weight regain, and conversions to Roux-en-Y gastric bypass: 10-year results of laparoscopic sleeve gastrectomy

BACKGROUND

With promising short-term results, laparoscopic sleeve gastrectomy (SG) has become the second most frequently performed bariatric procedure worldwide. Aside from a growing number of reports covering up to 10 years of follow-up, only limited data have been published so far on long-term results.

OBJECTIVES

The aim of the study was to present a 10-year follow-up for SG.

SETTING

University hospital setting, Austria.

METHODS

We present the first complete 10-year follow-up of 53 consecutive patients who underwent SG before 2006. In this multicenter study, weight loss success, weight regain, and revisional surgery were analyzed beside Bariatric Analysis and Reporting Outcome System (BAROS) scores.

RESULTS

A mean maximum percent excess weight loss of 71±25% (percent total weight loss: 28±15%) was reached at a median of 12 (range 12-120) months after SG. At 10 years, a mean percent excess weight loss of 53±25% was achieved by 32 patients, corresponding to a percent total weight loss of 26.3±13.4%. Nineteen of the 53 patients (36%) were converted to Roux-en-Y gastric bypass (n = 18) or duodenal switch (n = 1) due to significant weight regain (n = 11), reflux (n = 6), or acute revision (n = 2) at a median of 36 months. Two patients died at 3 and 101 months postoperatively, unrelated to SG. A total of 31 patients (59%) suffered from weight regain of 10 kg or more, among them 24 patients (45%) with 15 kg or more, 16 patients (30%) with 20 kg or more, and 7 patients (13%) with 25 kg or more weight regain from nadir. Mean BAROS score was 2.4±2.2 at 10 years follow-up, classifying SG as "fairly efficient."

CONCLUSION

Within a long-term follow-up of 10 years or more after SG, a high incidence of both significant weight regain and intractable reflux was observed, leading to conversion, most commonly to Roux-en-Y gastric bypass.

Impact of sleeve gastrectomy volumes on weight loss results: a prospective study

BACKGROUND

Causes of weight loss failure after sleeve gastrectomy (SG) are still controversial. The impact of the size of the sleeve continues to be debated.

OBJECTIVE

The aim of our study was to determine the impact of sleeve volumes assessed at 3 months using gastric computed tomography (CT) on weight loss at 18 months.

SETTING

University Hospital, France.

METHODS

Sixty-seven obese patients eligible for SG were prospectively evaluated. Sleeve volumes were assessed postsurgery using 3-dimensional gastric CT with gas at 3 months and weight loss outcomes recorded up to 18 months. The population was divided into 2 groups: the first tertile (n = 22) with the smallest gastric volume was defined as the "small sleeve" group (SSG) and the rest of the population (n = 45) was defined as the "without small sleeve" group (WSSG).

RESULTS

No patients were lost to follow-up. In the SSG, overall gastric volume was 133±7 mL versus 264±11 mL for the WSSG (P<.0001). Percentage excess body mass index loss (%EBMIL) during the first postoperative 18 months was significantly greater in the SSG compared with the WSSG (P = .04). Although the volume of the gastric tube was not correlated with weight loss (r =-.04, P = .78), there was a negative linear correlation between the volume of the antrum and the %EBMIL at 18 months (r =-.39, P = .005). A narrow gastric tube was also associated with a high digestive intolerance and reflux.

CONCLUSION

Our data suggest that performing the sleeve with a not-too-small bougie size and a radical antrectomy could improve weight loss and digestive tolerance.

Laparoscopic sleeve gastrectomy with 27 versus 39 Fr bougie calibration: a randomized controlled trial

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become a widely used primary bariatric surgery. As this is a restrictive procedure, calibrating bougie size is assumed to impact on both morbidity and weight loss. However, no prospective studies have confirmed this hypothesis. The objective of this trial was to compare LSG outcomes using different calibrating bougie diameters.

MATERIALS AND METHODS

A randomized controlled trial: 126 patients undergoing LSG were randomized to either a 27-Fr (group A) or a 39-Fr (group B) calibrating bougie. Inclusion criteria were BMI 40-50 kg/m(2), aged 20-70 and absence of prior gastric surgery. All surgeries were performed by the same surgeon. Sample size was calculated to detect a six-point difference in percentage of excess weight loss (%EWL) at 1 year after surgery, considering an α error = 0.05 and a β error = 0.2. The volume of resected stomach, morbidity and weight loss at 6 months and at 1 year after surgery were analyzed.

RESULTS

Groups (group A n = 62, group B n = 64) were similar in BMI (44.3 vs. 43.5), aged (41.9 vs. 42.2) and female percentage (87.1 vs. 84.3 %). A 1-year follow-up was achieved in 90.1 and 87.1 %, respectively. Two major complications occurred, one leak in each group (1.6 %). The volume of resected stomach was similar (426 vs. 402 ml, P = 0.71), as well as 6 months %EWL (66.3 vs. 66.6 %; P = 0.91) and 1 year %EWL (75.6 vs. 71.3 %, P = 0.21). A 1-year %EWL higher than 50 was achieved in 96.5 % of patients in group A versus 85.2 % in group B (P = 0.11).

CONCLUSIONS

The use of different bougie diameters had no impact on the volume of resected stomach, morbidity or short-term weight loss after LSG, although a trend was seen toward better weight loss with the smaller bougie. A longer-lasting follow-up will be necessary to further assess differences.