Duodenal Switch Is Superior to Gastric Bypass in Patients with Super Obesity when Evaluated with the Bariatric Analysis and Reporting Outcome System (BAROS)

Roux-en-Y gastric bypass versus duodenal switch in patients with body mass index ≥50 kg/m2: a systematic review and meta-analysis

Currently, there is no consensus on the best bariatric surgery type for patients with body mass index (BMI) ≥50 kg/m2. This systematic review and meta-analysis aimed to compare outcomes of duodenal switch (DS) and Roux-en-Y gastric bypass (RYGB) in terms of weight loss, resolution of obesity-related comorbidities, and complications among patients with a BMI ≥50 kg/m2. A systematic search was conducted across databases including PubMed, Embase, Scopus, and Web of Science to include studies that compared outcomes of DS and RYGB in patients with BMI ≥50 kg/m2. A meta-analysis was carried out, alongside subgroup analyses based on the type of study and duration of follow-up. Twelve articles were included in this study (2678 patients, follow-up: 1-15 years). Patients with DS had 7.31 kg/m2 higher BMI loss (95% CI: 5.59-9.03, P < .001) and 9.9% more total weight loss (95% CI: 4.47-15.28%, P < .001) compared with RYGB. The rate of complications, reoperation, mortality, and remission of comorbidities including diabetes, hypertension, dyslipidemia, and obstructive sleep apnea was not significantly different between DS and RYGB. Rate of malnutrition was 8.3% in the DS group compared with 1.2% in RYGB (OR: 5.53, 95% CI: 1.35-22.44, P = .02). In addition, 5.4% DS patients needed revisional surgery for malnutrition versus none in RYGB (OR: 6.1, 95% CI: 1.03-36.33, P = .05), and 24.6% of DS patients developed gallbladder disease needed cholecystectomy versus 4.5% after RYGB (OR: 6.36, 95% CI: 1.70-23.82, P = .01). DS leads to significantly higher BMI and total weight loss in patients with BMI ≥50 kg/m2 but may be associated with a higher rate of major malnutrition and needed revisional surgery. These should be considered in surgical planning.

Is single anastomosis duodenoileal bypass (SADI) an effective option for conversional surgery following sleeve gastrectomy? A comprehensive review and revised scope of current literature

BACKGROUND

Conversional surgery following sleeve gastrectomy (SG) is required in about 20 % of patients due to suboptimal outcomes. Single anastomosis duodenoileal bypass (SADI) has emerged as an option for such cases, though long-term outcomes remain unclear. This review analyzed available data on SADI as a conversional or second-stage procedure after SG.

METHODS

A systematic search across PubMed, Web of Science, and Scopus included studies on adult patients who underwent SADI as a conversional or second-stage surgery following SG, with a minimum of 12 months' follow-up up to July 2024.

RESULTS

Nineteen studies involving 867 patients examined weight loss, comorbidity resolution, postoperative complications, and nutritional deficiencies. Results showed a total weight loss (TWL) of 24 % in the first year post-revision, with a trend toward weight stabilization or regain over two years. Maximum TWL (27 %) occurred at 24 months, decreasing to 24 % at 60 months. Average follow-up of 27 months showed remission rates for type 2 diabetes, hypertension, and dyslipidemia at 68 %, 53 %, and 37 %, respectively. Short-term morbidity within 30 days was 8 %, including a 5 % rate of anastomotic leaks or fistulas and a 5 % reoperation rate. Overall mortality was 2 %.

CONCLUSION

In conclusion, SADI shows promise as a safe and effective mid-term conversional surgery after SG with suboptimal results. However, further studies are needed to confirm its long-term safety and effectiveness.

Effectiveness of robotic metabolic and bariatric surgery in patients with BMI ≥ 50-59.9 and BMI ≥ 60 for the treatment of severe obesity in a national medical center in Mexico

INTRODUCTION

Obesity is a global health issue that significantly increases morbidity and mortality when the Body Mass Index (BMI) reaches values ≥ 50. While metabolic and bariatric surgery (MBS) is the most effective treatment for severe obesity, it carries risks. Robotic surgery is promising but not extensively studied in Mexico, which presents an opportunity for research at a National Hospital with an academic program.

METHODS

This retrospective study reviewed 44 patients who underwent robotic MBS using the da Vinci surgical system from January 2018 to August 2023 at Centro Médico Nacional 20 de Noviembre, ISSSTE. Data collected included surgery type, duration, complications, and weight loss metrics over 54 months post-operatively.

RESULTS

The study involved 44 patients with severe obesity including BMI ≥ 50-59.9 kg/m2 for group 1 and BMI ≥ 60 kg/m2 for group 2. The average initial BMI was 54.7 kg/m2 for group 1 and 68 kg/m2 for group 2. The average operative times for group 1 were 10.09 min for docking, 86.23 min for robotic console time, and 95.73 min for total intraoperative time. Group 2 had average times of 9.80 min for docking, 82.4 min for robotic console time, and 92.2 min for total intraoperative time. Follow-up showed significant weight loss initially, with weight recurrence after 24 months due to different factors. No serious complications or mortality were observed.

CONCLUSION

Robotic MBS at a national academic medical center in Mexico shows promising outcomes for patients with BMI ≥ 50-59.9 and BMI ≥ 60, with significant weight and BMI improvements at 54 month follow-up. Further studies with larger cohorts and longer follow-up are needed to strengthen these findings.

One-Stage Vs. Two-Step One Anastomosis Duodenal Switch (OADS/SADI-S): A Safety and Efficacy Single-Center Propensity-Score Matched Analysis

INTRODUCTION

One Anastomosis Duodenal Switch (OADS/SADI-S) is used both as a one stage and a second-step procedure, either planned or revisional after a failed sleeve gastrectomy. However, there is lack of adjusted comparative evidence validating its use.

MATERIAL AND METHODS

Propensity-score matched comparison between patients submitted to one-stage vs. two-step OADS, adjusted by age, gender, and initial body mass index (BMI).

RESULTS

One hundred ninety-five patients (130 one-stage and 65 two-step OADS) were included, with mean initial BMI 52.4 kg/m2. Overall complication rate was 6.6% in the short-term (3.3% Clavien-Dindo ≥ III), and 7.3% in the long-term, with no differences between groups. Follow-up at 1 and 3 years was 83.6% and 61.5%. After one-stage OADS, total weight loss was 36.6 ± 8.2% at 1 year and 30.4 ± 10.3% at 3 years, vs. 30.2 ± 9.4% and 25.6 ± 10.2% after two-steps OADS (p = 0.021). Resolution rates of diabetes mellitus, hypertension, dyslipidemia, and obstructive sleep apnea were 86.4%, 80.4%, 78.0%, and 73.3%, with no differences between groups.

CONCLUSION

One-stage OADS is a safe and effective bariatric technique for patients with grade III and IV obesity. The two-step strategy does not reduce postoperative risks and may compromise weight loss results at mid-term.

Ten-Year Outcomes Following Roux-en-Y Gastric Bypass vs Duodenal Switch for High Body Mass Index: A Randomized Clinical Trial

Importance

Results from long-term follow-up after biliopancreatic diversion with duodenal switch (DS) are scarce.

Objective

To compare weight loss, health outcomes, and quality of life 10 years or more after Roux-en-Y-gastric bypass (RYGB) and DS surgery in patients with severe obesity-that is, a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 50 to 60.

Design, Setting, and Participants

This open-label randomized clinical trial was conducted at 2 academic bariatric centers in Sweden and Norway. Sixty patients with a BMI of 50 to 60 were included from March 1, 2006, to August 31, 2007. Data were analyzed from August 12, 2022, to January 25, 2023.

Interventions

Laparoscopic RYGB or laparoscopic DS.

Main Outcomes and Measures

The main outcome was change in BMI after 10 or more years. Secondary outcomes included anthropometric measures, lipid and glycemic profiles, bone mass density, adverse events, gastrointestinal tract symptoms, and health-related quality of life.

Results

Forty-eight of the original 60 patients (80%) were assessed after a median of 12 (range, 9-13) years (mean [SD] age, 48.0 [6.0] years; 35 women [73%]). At follow-up, the mean BMI reductions were 11.0 (95% CI, 8.3-13.7) for RYGB and 20.3 (95% CI, 17.6-23.0) for DS, with a mean between-group difference of 9.3 (95% CI, 5.4-13.1; P < .001). Total weight loss was 20.0% (95% CI, 15.3%-24.7%) for RYGB and 33.9% (95% CI, 27.8%-40.0%) for DS (P = .001). Mean serum lipid levels, except high-density lipoprotein cholesterol and hemoglobin A1c, improved more in the DS group during follow-up. Bone mass was reduced for both groups from 5 to 10 years, with lower bone mass after DS at 10 years. Quality-of-life scores (Obesity-Related Problem Scale and the 36-Item Short Form Health Survey) were comparable across groups at 10 years. The total number of adverse events was higher after DS (135 vs 97 for RYGB; P = .02). More patients in the DS group developed vitamin deficiencies (21 vs 11 for RYGB; P = .008) including 25-hydroxyvitamin D deficiency (19 for DS vs 9 for RYGB; P = .005). Four of 29 patients in the DS group (14%) developed severe protein-caloric malnutrition, of whom 3 (10%) underwent revisional surgery.

Conclusions and Relevance

In this randomized clinical trial, BMI reduction was greater after DS, but RYGB had a better risk profile over 10 years. Biliopancreatic diversion with DS may not be a better surgical strategy than RYGB for patients with a BMI of 50 to 60.

Trial Registration

ClinicalTrials.gov Identifier: NCT00327912.

Beyond Restrictive: Sleeve Gastrectomy to Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy as a Spectrum of One Single Procedure

INTRODUCTION

Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a restrictive/hypoabsorptive procedure recommended for patients with obesity class 3. For safety reasons, SADI-S can be split into a two-step procedure by performing a sleeve gastrectomy (SG) first. This stepwise approach also provides an unprecedented opportunity to disentangle the weight loss mechanisms triggered by each component. The objective was to compare weight trajectories and post-prandial endocrine and metabolic responses of patients with obesity class 3 submitted to SADI-S or SG as the first step of SADI-S.

METHODS

Subjects submitted to SADI-S (n = 7) or SG (n = 7) at a tertiary referral public academic hospital underwent anthropometric evaluation and a liquid mixed meal tolerance test (MMTT) pre-operatively and at 3, 6, and 12 months post-operatively.

RESULTS

Anthropometric parameters, as well as metabolic and micronutrient profiles, were not significantly different between groups, neither before nor after surgery. There were no significant differences in fasting or post-prandial glucose, insulin, C-peptide, ghrelin, insulin secretion rate, and insulin clearance during the MMTT between subjects submitted to SADI-S and SG. There was no lost to follow-up.

CONCLUSIONS

The restrictive component seems to be the main driver for weight loss and metabolic adaptations observed during the first 12 months after SADI-S, given that the weight trajectories and metabolic profiles do not differ from SG. These data provide support for surgeons' choice of a two-step SADI-S without jeopardizing the weight loss outcomes.

Analysis of the 1-year efficacy of four different surgical methods for treating Chinese super obese (BMI ≥ 50 kg/m2) patients

This study aimed to retrospectively analyze the perioperative and postoperative follow-up data of patients with super obesity who had undergone RYGB, SG, BPD/DS, and SADI-S. A retrospective observational study was conducted to analyze the perioperative and postoperative follow-up data of 60 patients with super obesity who had undergone bariatric surgery. A total of 34 men and 26 women were included in this study. The participants had an average preoperative BMI of 53.81 ± 3.25 kg/m2. The body weight and BMI of all four patient groups decreased significantly at 3, 6, and 12 months postoperatively compared with the preoperative values. Additionally, the TWL (%) and EWL (%) of all four groups increased gradually over the same period. Compared with the preoperative values, the systolic and diastolic blood pressure, glycosylated hemoglobin, uric acid, triglycerides, and total cholesterol decreased to varying degrees in the four groups 1 year postoperatively. RYGB, SG, BPD/DS, and SADI-S are all safe and effective in treating super obese patients and improving their metabolic diseases to a certain extent.

Long-term Follow-up 15 Years After Duodenal Switch or Gastric Bypass for Super Obesity: a Randomized Controlled Trial

BACKGROUND

In super obesity, Roux-en-Y gastric bypass (RYGB) may be insufficient why some surgeons advocate biliopancreatic diversion with duodenal switch (BPD/DS), a more malabsorptive procedure. There is a paucity of evidence regarding results beyond 10 years, especially after BPD/DS. The aim of this randomized controlled trial was to compare the long-term outcome of BPD/DS, and RYGB in patients with super obesity, i.e., body mass index (BMI) > 50 kg/m2.

METHODS

This is a 13- to 17-year follow-up study of a single-center, single-blinded randomized trial in which 47 patients (BMI > 48 and eligible for bariatric surgery) were randomized 1:1 to BPD/DS and RYGB (25 men, 24 BPD/DS, 39.1 ± 9.9 years, BMI 54.5 ± 6.1 kg/m2). The primary outcome was weight loss. The study was financed by Swedish governmental funding of clinical research (ALF).

TRIAL REGISTRATION NUMBER

ISRCTN10940791.

RESULTS

Thirty-four (18 BPD/DS) of the living 42 patients (81.0%) participated. BPD/DS resulted in higher BMI loss (20.4 ± 7.9 vs. 12.4 ± 8.6, p = .008) and higher percent of total body weight loss (37.5% ± 12.2 vs. 22.8% ± 14.8, p = .004). BPD/DS was associated with lower fasting glucose, glycated hemoglobin (HbA1c), and low-density lipoprotein (LDL) as well as lower hemoglobin. Adverse events were more common after BPD/DS (2.7 vs. 0.9 per patient, p = .004). The global assessment tool BAROS (Bariatric Analysis and Reporting Outcome System) demonstrated superior scores for BPD/DS (p = .047).

CONCLUSION

When compared to RYGB, BPD/DS results in superior weight loss and metabolic control as well as superior BAROS score, however, at the cost of more adverse events.

Analysis of the Impact of the Learning Curve on the Safety Outcome of the Totally Robotic-Assisted Biliopancreatic Diversion with Duodenal Switch: a Single-Institution Observational Study

INTRODUCTION

Totally robotic-assisted biliopancreatic diversion with duodenal switch (BPD/DS) learning curve has been described to be longer at approximately 50 cases, at which point operative time and complications rate decrease and tend to stabilize. This study aimed to form an analysis of the impact of the learning curve on the safety outcomes of the totally robotic-assisted BPD/DS.

METHODS

A retrospective review of patients who underwent primary totally robotic-assisted BPD/DS by one of our certified bariatric and metabolic surgeon member of our institution was performed. The patients were classified into two groups, the learning stage group (first 50 cases) and the mastery stage group. Differences in operative time in minutes and postoperative outcomes were analyzed.

RESULTS

Two hundred seventy-six patients were included. The operative time and the postoperative length of stay were significantly higher in the learning stage group (173.8 ± 35.8 min vs. 139.2 ± 30.2 min, p= 0.0001; 3.4 ± 1.4 days vs. 2.6 ± 0.9 days, p= 0.0002). The overall leakage rate was significantly higher in the learning stage group (8% vs. 0.4%, p= 0.0001). The global rate of complications for the learning stage group was 14%, and for the mastery stage group was 6.6% (p= 0.08).

CONCLUSIONS

After the first 50 cases, the operative time, the length of stay, and the overall rate of complications decreased, being especially significant the decrease in the duodeno-ileal anastomosis leakage rate after reaching the learning curve.

Dumping syndrome after bariatric surgery: prevalence, pathophysiology and role in weight reduction - a systematic review

Background

Dumping syndrome is a frequent and wellknown adverse event after bariatric surgery and covers a dynamic spectrum of early and late dumping. Accelerated gastric emptying is generally considered to be the cause of gastrointestinal and vasomotor complaints. However, there is much uncertainty regarding the exact pathophysiology of dumping. It has been speculated that the syndrome is a desired consequence of bariatric surgery and contributes to more efficient weight loss, but supporting data are scarce.

Methods

A systematic search was conducted in PubMed in July-August 2021. The prevalence of dumping after the most frequently performed bariatric procedures was analyzed, as well as underlying pathophysiology and its role in weight reduction.

Results

Roux-en-Y gastric bypass (RYGB) is associated with the highest postoperative prevalence of dumping. The fast transit induces neurohumoral changes which contribute to an imbalance between postprandial glucose and insulin levels, resulting in hypoglycemia which is the hallmark of late dumping. Early dumping can, when received in a positive way, become a tool to maintain a strict dietary pattern, but no significant relationship to the degree of weight loss has been shown. However, late dumping is detrimental and promotes overall higher caloric intake.

Conclusion

Dumping syndrome is common after bariatric surgery, especially after RYGB. The pathophysiology is complex and ambiguous. Currently available data do not support dumping as a necessary condition to induce weight loss after bariatric surgery.

WEIGHT LOSS AND BEYOND, ASSESSMENT OF QUALITY OF LIFE AFTER LAPAROSCOPIC SLEEVE GASTRECTOMY USING BAROS IN PATIENTS WITH OBESITY IN TURKEY

Context

Sleeve gastrectomy is an effective method for management of obesity. The Bariatric Analysis and Reporting Outcome System (BAROS) is a comprehensive and standard system for the assessment of outcomes of weight loss surgery. It is consisted of weight loss, changes in obesity-related comorbidities and quality of life measurements. We investigated results of the sleeve gastrectomy based on the BAROS.

Material and Methods

Outcomes of laparoscopic sleeve gastrectomy surgery was studied in 45 patients with obesity (11 male, 34 female), after 45 months in Turkey.

Results

Total weight loss was 26.4±0.1% of body weight at 45 months. Weight regain was seen in 97.8% of the patients with an average 14.5 kg and 13.7% body mass index points. The surgery caused 76% decrease in incidence of obstructive sleep apnea, 73% decrease in type 2 diabetes, 63% decrease in hyperlipidemia and 62% decrease in hypertension. Significant improvement is observed in all quality-of-life parameters. The final score of the BAROS was 4.23±1.02.

Conclusion

Based on BAROS, sleeve gastrectomy provides significant improvements in weight loss, incidence of medical comorbidities and quality of life after surgery. Future studies should address prevention of weight regain after the surgery.

Evolution of Bariatric Surgery in Italy in the Last 11 Years: Data from the SICOB Yearly National Survey

BACKGROUND

Bariatric surgery (BS) is a relatively novel surgical field and is in continuous expansion and evolution.

PURPOSE

Aim of this study was to report changes in Italian surgical practice in the last decade.

METHODS

The Società Italiana di Chirurgia dell'Obesità (SICOB) conducted annual surveys to cense activity of SICOB centers between 2011 and 2021. Primary outcome was to detect differences in frequency of performance of adjustable gastric banding (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass (OAGB), bilio-pancreatic diversion (BPD), and gastric plication (GP). Secondary outcome was to detect differences in performance of main non-malabsorptive procedures (AGB + SG) and overall bypass procedures (RYGB + OAGB). Geographical differences were also investigated.

RESULTS

Median response rate was 92%. AGB declined from 36% of procedures in 2011 to 5% in 2021 (p < 0.0001). SG increased from 30% in 2011 to 55% in 2021 (p < 0.0001). RYGB declined from 25 to 12% of procedures (p < 0.0001). OAGB rose from 0% of procedures in 2011 to 15% in 2021 (p < 0.0001). BPD underwent decrease from 6.2 to 0.2% in 2011 and 2021, respectively (p < 0.0001). Main non-malabsorptive procedures significantly decreased while overall bypass procedures remained stable. There were significant differences among regions in performance of SG, RYGB, and OAGB.

CONCLUSIONS

BS in Italy evolved significantly during the past 10 years. AGB underwent a decline, as did BPD and GP which are disappearing and RYGB which is giving way to OAGB. The latter is rising and is the second most-performed procedure after SG which has been confirmed as the preferred procedure by Italian bariatric surgeons.

Impact of gastrointestinal symptoms and psychological disturbances on patients' quality of life after restrictive or malabsorptive bariatric surgery

AIM

The aim of this study was to evaluate and compare the presence and impact of Gastrointestinal (GI) symptoms, physical and psychological disturbances on patients' QoL after sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch (BPD/DS).

METHODS

A prospective, observational, cross-sectional, comparative study was carried-out. GI symptoms and patients' QoL were evaluated by the SF-36 questionnaire and the GI quality of life index (GIQLI). Correlation between GI symptoms, psychological disturbances and QoL scores was analysed.

RESULTS

95 patients were included (mean age 50.5 years, range 22-70; 76 females). Presence of GI symptoms was a consistent finding in all patients, and postprandial fullness, abdominal distention and flatulence had a negative impact on patients' QoL. Patients after SG showed a worsening of their initial psychological condition and the lowest QoL scores. Patients after RYGB showed the best GI symptoms-related QoL.

CONCLUSIONS

Both restrictive and malabsorptive bariatric surgical procedures are associated with GI symptoms negatively affecting patients' QoL. Compared to SG and BPD/DS, patients after RYGB showed the best GI symptoms-related QoL, which can be used as additional information to help in the clinical decision making of the bariatric procedure to be performed.

Safety of biliopancreatic diversion with duodenal switch in patients with body mass index less than 50 kg/m2

INTRODUCTION

Biliopancreatic diversion with duodenal switch (BPD-DS) has often been reserved for patients with BMI > 50 kg/m². We aim to assess the safety of BPD-DS in patients with morbid obesity (BMI ³35 kg/m² and < 50 kg/m²) using a 150-cm common channel (CC), 150-cm Roux limb, and 60-fr bougie.

METHODS

A retrospective review was performed on patients with a BMI < 50 mg/k² who underwent a BPD-DS in 2016-2019 at a single institution. Limb lengths were measured with a laparoscopic instrument with minimal tension. Sleeve gastrectomy was created with 60-fr bougie. Variables were compared using paired t test, Chi-square analysis or repeated measures ANOVA where appropriate.

RESULTS

Forty-five patients underwent BPD-DS. CC lengths and Roux limb lengths were 158 ± 20 cm and 154 ± 18 cm, respectively. Preoperative BMI was 44.9 ± 2.3 kg/m² and follow-up was 2.7 ± 1.4 years. One patient required reoperation for bleeding and died from multiorgan failure and delayed sleeve leak. There was 1 (2.2%) readmission for contained anastomotic leak and 2 ED visits (4.5%) within 30 days. There were no marginal ulcers, limb length revisions, or need for parental nutrition. Percent excess weight loss was 67.2 ± 19.7%. 88.9% (N = 8), 86.6% (N = 13), and 55.5% (N = 5) of patients had resolution or improvement of their diabetes mellitus type II, hypertension, and hyperlipidemia, respectively. 40% (N = 4) of patients had resolution of their gastroesophageal reflux disease (GERD) and 11.4% (N = 5) developed de novo GERD. 32% (N = 14) of patients had vitamin D deficiency and 25% (N = 11) experienced zinc deficiency.

CONCLUSION

BPD-DS may be considered in patients with BMI < 50 kg/m² with 150-cm CC, 150-cm Roux limb, and a 60-fr bougie sleeve gastrectomy. There was sustained weight loss and no protein calorie malnutrition, but Vitamin D and zinc deficiency remained a challenge. Careful patient selection and proper counseling of the risks and benefits are necessary.

Molecular remodeling of adipose tissue is associated with metabolic recovery after weight loss surgery

BACKGROUND

Bariatric surgery is an effective therapy for individuals with severe obesity to achieve sustainable weight loss and to reduce comorbidities. Examining the molecular signature of subcutaneous adipose tissue (SAT) following different types of bariatric surgery may help in gaining further insight into their distinct metabolic impact.

RESULTS

Subjects undergoing biliopancreatic diversion with duodenal switch (BPD-DS) showed a significantly higher percentage of total weight loss than those undergoing gastric bypass or sleeve gastrectomy (RYGB + SG) (41.7 ± 4.6 vs 28.2 ± 6.8%; p = 0.00005). Individuals losing more weight were also significantly more prone to achieve both type 2 diabetes and dyslipidemia remission (OR = 0.75; 95%CI = 0.51-0.91; p = 0.03). Whole transcriptome and methylome profiling showed that bariatric surgery induced a profound molecular remodeling of SAT at 12 months postoperative, mainly through gene down-regulation and hypermethylation. The extent of changes observed was greater following BPD-DS, with 61.1% and 49.8% of up- and down-regulated genes, as well as 85.7% and 70.4% of hyper- and hypomethylated genes being exclusive to this procedure, and mostly associated with a marked decrease of immune and inflammatory responses. Weight loss was strongly associated with genes being simultaneously differentially expressed and methylated in BPD-DS, with the strongest association being observed for GPD1L (r2 = 0.83; p = 1.4 × 10-6).

CONCLUSIONS

Present findings point to the greater SAT molecular remodeling following BPD-DS as potentially linked with higher metabolic remission rates. These results will contribute to a better understanding of the metabolic pathways involved in the response to bariatric surgery and will eventually lead to the development of gene targets for the treatment of obesity. Trial registration ClinicalTrials.gov NCT02390973.

One anastomosis gastric bypass as a one-stage bariatric surgical procedure in patients with BMI ≥ 50 kg/m2

In patients with BMI ≥ 50 kg/m2, it is difficult to select an appropriate procedure that can lead to optimum results. This study aims to evaluate mid-term weight loss outcomes in patients with BMI ≥ 50 kg/m2 following one anastomosis gastric bypass (OAGB) as a one-stage procedure. A prospective study was conducted on patients with BMI ≥ 50 kg/m2, aged 18 years and above who had undergone primary OAGB from January 2016 to February 2019 with at least two years follow-ups. A total of 197 patients with BMI ≥ 50 kg/m2 had underwent OAGB. The mean age was 38 years and the mean pre-operative BMI was 53.7 kg/m2. Mean EWL% were 63.7%, 67.8% and 66.2% at one, two and five years after OAGB respectively. The highest level of EWL% was 68.4%, which was achieved in the 18th month following OAGB. OAGB can be performed safely in patients with BMI ≥ 50 kg/m2 as a one-stage procedure with acceptable weight loss outcomes and remission of obesity associated medical problems.

Bariatric Surgery and Osteoporosis

It has been increasingly acknowledged that bariatric surgery adversely affects skeletal health. After bariatric surgery, the extent of high-turnover bone loss is much greater than what would be expected in the absence of a severe skeletal insult. Patients also experience a significant deterioration in bone microarchitecture and strength. There is now a growing body of evidence that suggests an association between bariatric surgery and higher fracture risk. Although the mechanisms underlying the high-turnover bone loss and increase in fracture risk after bariatric surgery are not fully understood, many factors seem to be involved. The usual suspects are nutritional factors and mechanical unloading, and the roles of gut hormones, adipokines, and bone marrow adiposity should be investigated further. Roux-en-Y gastric bypass (RYGB) was once the most commonly performed bariatric procedure worldwide, but sleeve gastrectomy (SG) has now become the predominant bariatric procedure. Accumulating evidence suggests that RYGB is associated with a greater reduction in BMD, a greater increase in markers of bone turnover, and a higher risk of fracture than SG. These findings should be taken into consideration in determining the most appropriate bariatric procedure for patients, especially those at higher fracture risk. Before and after all bariatric procedures, sufficient calcium, vitamin D and protein intake, and adequate physical activity, are needed to counteract negative impacts on bone. There are no studies to date that have evaluated the effect of osteoporosis treatment on high-turnover bone loss after bariatric surgery. However, in patients with a diagnosis of osteoporosis, anti-resorptive agents may be considered.

Safety of Primary Versus Revisional Biliopancreatic Diversion with Duodenal Switch in Patients with Super Obesity Using the MBSAQIP database

INTRODUCTION

For patients with super obesity (BMI > 50 kg/m²), biliopancreatic diversion/duodenal switch (BPD/DS) can be an effective bariatric operation. Technical challenges and patient safety concerns, however, have limited its use as a primary procedure. This study sought to assess the safety of primary versus revisional BPD/DS.

MATERIALS AND METHODS

The MBSAQIP database was queried for primary and revisional BPD/DS (2015-2018). Inclusion criteria were patients ≥ 18 years of age, BMI > 50 kg/m², and with no concurrent procedures. Preoperative variables were compared using a chi-square test or Wilcoxon two-sample tests. Multivariate logistic or robust linear regression models were used to compare outcomes.

RESULTS

There were 3,378 primary BPD/DS and 487 revisional BPD/DS patients. Primary BPD/DS patients had higher BMI (56.5 [IQR4.4] versus 54.8 [IQR4] kg/m², p < 0.0001) and had more diabetes mellitus type II (29.1% versus 17.2%, p < 0.0001). Intraoperatively, revisional BPD/DS had longer operative time (165 [IQR47] min versus 139 [IQR100] min, p < 0.0001). After adjusting for preoperative characteristics, there was no difference in 30-day readmission or ED visits (primary 12.9% versus revisional 14.6%), reoperation or reintervention (primary 5.7% versus revisional 7.8%), or mortality (primary 0.4% versus revisional 0.6%). In contrast, the revisional BPD/DS patients had higher odds of major morbidity (primary 3.4% versus revisional 5.3%, OR 1.9, CI 1.1-3.2, p = 0.019).

CONCLUSIONS

Revisional BPD/DS is associated with higher morbidity than primary BPD/DS in patients with super obesity. These patients should thus be counselled appropriately when choosing a primary or revisional bariatric procedure.

The first survey addressing patients with BMI over 50: a survey of 789 bariatric surgeons

Background

Bariatric surgery in patients with BMI over 50 kg/m² is a challenging task. The aim of this study was to address main issues regarding perioperative management of these patients by using a worldwide survey.

Methods

An online 48-item questionnaire-based survey on perioperative management of patients with a BMI superior to 50 kg/m² was ideated by 15 bariatric surgeons from 9 different countries. The questionnaire was emailed to all members of the International Federation of Surgery for Obesity (IFSO). Responses were collected and analyzed by the authors.

Results

789 bariatric surgeons from 73 countries participated in the survey. Most surgeons (89.9%) believed that metabolic/bariatric surgery (MBS) on patients with BMI over 50 kg/m² should only be performed by expert bariatric surgeons. Half of the participants (55.3%) believed that weight loss must be encouraged before surgery and 42.6% of surgeons recommended an excess weight loss of at least 10%. However, only 3.6% of surgeons recommended the insertion of an Intragastric Balloon as bridge therapy before surgery. Sleeve Gastrectomy (SG) was considered the best choice for patients younger than 18 or older than 65 years old. SG and One Anastomosis Gastric Bypass were the most common procedures for individuals between 18 and 65 years. Half of the surgeons believed that a 2-stage approach should be offered to patients with BMI > 50 kg/m², with SG being the first step. Postoperative thromboprophylaxis was recommended for 2 and 4 weeks by 37.8% and 37.7% of participants, respectively.

Conclusion

This survey demonstrated worldwide variations in bariatric surgery practice regarding patients with a BMI superior to 50 kg/m². Careful analysis of these results is useful for identifying several areas for future research and consensus building.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08979-w.

Roux-en-Y Gastric Bypass in Patients with Super Obesity: Primary Response Criteria and Their Relationship with Comorbidities Remission

BACKGROUND

The prevalence of super obesity has increased considerably in recent years, representing up to the 0.5% of the population. Even though bariatric surgery induces significant weight loss in these patients, it has been reported that up to 50% of the patients with super obesity will fail according to the current primary response criteria.

OBJECTIVE

To evaluate and compare different primary response criteria and their impact regarding comorbidities remission.

PATIENTS AND METHODS

A total of 104 patients with super obesity who underwent Roux-en-Y gastric bypass (RYGB) were identified in our institution from March 2004 to February 2019. An evaluation of the primary response at a 2-year follow-up was made using different criteria. A multivariate analysis was made to evaluate related variables to comorbidities remission.

RESULTS

Two years later, the rate of patients who achieved an EWL > 50%, %EWL > 70%, and BMI < 35 kg/m² were 84.5%, 52.1%, and 62%, respectively. Regarding the comorbidities, 85%, 84.8%, and 81.1% of the patients improved or remitted T2D, HBP, and hyperlipidemia, respectively. An EWL > 50% 2 years later was related to complete remission of hyperlipidemia (p = 0.047), whereas weight regain above 10% is a risk factor for failure of complete remission of HBP in 3 years.

CONCLUSIONS

More than 75% of patients with super obesity yield an EWL > 50% 2 years later. In terms of hyperlipidemia, it is desirable to achieve an EWL of at least 50%. Whereas for T2D and HBP, a minimum of 25% TWL yields 72% and 60.5% of complete remission.

Direct and two-step single anastomosis duodenal switch (SADI-S): Unicentric comparative analysis of 232 cases

INTRODUCTION

The "Single Anastomosis Duodeno-Ileal bypass with Sleeve gastrectomy" (SADI-S) is a bariatric surgery conceived to simplify the duodenal switch in order to reduce its postoperative complications. The objective of this study is to assess the safety and efficacy of SADI-S, comparing its results in both direct and two-step procedure.

METHODS

Unicentric cohort study that includes patients submitted to SADI-S, both direct or in two-step, between 2014 and 2019.

RESULTS

Two hundred thirty-two patients were included, 192 were submitted to direct SADI-S and 40 had previously undergone a sleeve gastrectomy. The severe complications rate (Clavien-Dindo ≥ IIIA) was 7.8%, being hemoperitoneum and duodenal stump leak the most frequent ones. One patient was exitus between the first 90 days after surgery (0.4%). Patients submitted to direct SADI-S had an initial body mass index (BMI) of 49.6 kg/m² in comparison of 56.2 kg/m² in the two-step SADI-S (P < .001). The mean excess weight loss (EWL) at two years was higher in direct SADI-S (77.3 vs. 59.3%, P < .05). Rate of comorbidities resolution was 88.5% for diabetes, 73.0% for hypertension, 77.0% for dyslipidemia and 85.7% for sleep apnea, with no differences between both techniques.

CONCLUSION

In medium term, SADI-S is a safe and effective technique that offers a satisfactory weight loss and remission of comorbidities. Patients submitted to two-step SADI-S had a higher initial BMI and presented a lower EWL than direct SADI-S.

Is One Anastomosis Gastric Bypass with a Biliopancreatic Limb of 150 cm Effective in the Treatment of People with Severe Obesity with BMI > 50?

Purpose

The treatment of people with severe obesity and BMI > 50 kg/m² is challenging. The present study aims to evaluate the short and mid-term outcomes of one anastomosis gastric bypass (OAGB) with a biliopancreatic limb of 150 cm as a primary bariatric procedure to treat those people in a referral center for bariatric surgery.

Material and Methods

Data of patients who underwent OAGB for severe obesity with BMI > 50 kg/m² between 2010 and 2017 were collected prospectively and analyzed retrospectively. Follow-up comprised clinical and biochemical assessment at 1, 3, 6, 12, 18, and 24 months postoperatively, and once a year thereafter.

Results

Overall, 245 patients underwent OAGB. Postoperative mortality was null, and early morbidity was observed in 14 (5.7%) patients. At 24 months, the percentage total weight loss (%TWL) was 43.2 ± 9, and percentage excess weight loss (%EWL) was 80 ± 15.7 (184 patients). At 60 months, %TWL was 41.9 ± 10.2, and %EWL was 78.1 ± 18.3 (79 patients). Conversion to Roux-en-Y gastric bypass was needed in three (1.2%) patients for reflux resistant to medical treatment. Six patients (2.4%) had reoperation for an internal hernia during follow-up. Anastomotic ulcers occurred in three (1.2%) patients. Only two patients (0.8%) underwent a second bariatric surgery for insufficient weight loss.

Conclusion

OAGB with a biliopancreatic limb of 150 cm is feasible and associated with sustained weight loss in the treatment of severe obesity with BMI > 50 kg/m². Further randomized studies are needed to compare OAGB with other bariatric procedures in this setting.

Graphical abstract

Long-Term Efficacy of Bariatric Surgery for the Treatment of Super-Obesity: Comparison of SG, RYGB, and OAGB

BACKGROUND

The most appropriate procedure for the treatment of super obesity (BMI > 50 kg/m²) is unknown. We aimed to evaluate the safety, long-term (> 5 years) weight loss, and adverse events between three commonly performed procedures, sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and one anastomosis gastric bypass (OAGB) in super-obese patients.

METHODS

Between January 2002 and December 2015, 498 successive patients with super morbid obesity (BMI > 50), who underwent SG or RYGB or OAGB, were recruited. Surgical outcome, weight loss, resolution of co-morbidities, and late complications were followed and compared between the 3 groups. All data derived from a prospective bariatric database and a retrospective analysis was conducted.

RESULTS

The average patient age was 32.1 ± 10.4 years, with a mean body mass index (BMI) of 56.0 ± 6.7 kg/m². Of them, 190 (38.9%) underwent SG, 62 (12.4%) RYGB, and 246 (49.4%) OAGB. There was no difference in basic characters between the 3 groups except SG had fewer diabetic patients. RYGB group had higher intraoperative blood loss, longer operating time, and hospital stay than the other 2 groups. RYGB had a higher 30-days post-operative major complication rate (4.8%) than SG (0.5%) and OAGB (0.8%). The follow-up rate at 1 and 5 years was 89.4% and 52.0%. At post-operative 5 years, OAGB had a higher total weight loss (40.8%) than SG (35.1%), but not RYGB (37.2%). SG had a lower remission rate in dyslipidemia comparing to OAGB and RYGB, but T2DM remission rate was no different between the groups. The overall revision rate is 5.4% (27/498) of the whole group, and SG had a lower revision rate (2.6%) than RYGB (8.1%) and OAGB (6.9%).

CONCLUSION

SG is an effective and durable primary bariatric procedure for the treatment of super obesity and metabolic disorders. OAGB had a similar operation risk to SG but resulted in a better weight loss than SG.

Gastrointestinal Physiology Before and After Duodenal Switch with Comparisons to Unoperated Lean Controls: Novel Use of the SmartPill Wireless Motility Capsule

Purpose

Bariatric surgery alters gastrointestinal anatomy. In this exploratory study, the SmartPill® wireless motility capsule (WMC) was used to study changes in gastrointestinal physiology following biliopancreatic diversion with duodenal switch (BPD/DS).

Material and Methods

Twenty-eight BPD/DS patients (35 ± 11 years, 50% females, body mass index [BMI] 56 ± 5) were to be examined preoperatively and postoperatively. In addition to transit time, appetite control and gastrointestinal symptoms were studied by patient-scored questionnaires (visual analogue scale and Gastrointestinal Symptom Rating Scale (GSRS)). Data was compared to 41 lean unoperated controls.

Results

About 1.8 years postoperatively, 18 patients (BMI 35.8 ± 8.3) returned for a second WMC test. As expected, small bowel transit time was reduced, from 3.9 ± 1.6 h to 2.8 ± 2.0, p = 0.02, and at both these time points, it was shorter than in lean controls (5.4 ± 1.9 h, p = 0.001). Postoperatively, a trend towards reduced colon and whole gut transit times was seen in BPD/DS-patients, thus approaching those of lean controls. Surprisingly, BPD/DS patients scored higher satiety than controls preoperatively as well as increased hunger and desire to eat postoperatively. Compared to lean, BPD/DS patients reported a higher total GSRS score at both time points (1.2 ± 0.2 vs 1.7 ± 0.6 and 2.3 ± 0.5, p < 0.001). Postoperatively, the scores for diarrhea and indigestion increased.

Conclusions

The novel use of the SmartPill system in BPD/DS patients gave the expected readouts. Although small bowel transit time was further shortened after BPD/DS, whole gut transit time did not differ from controls. Typical gastrointestinal symptoms were reported postoperatively.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-021-05452-4.

Diabetes Risk Reduction and Metabolic Surgery

Type 2 diabetes mellitus (T2D) and associated comorbid medical conditions are leading causes of strain on the American health care system. There has been a synchronous rise of obesity to epidemic proportions. If poorly treated, T2D is a scourge for patients, leading to end-organ damage and early mortality. Although T2D is considered best managed with lifestyle modification, medical management, and pharmacotherapy, recent studies have confirmed the superiority of metabolic surgery to conventional treatment algorithms as a path to remission. Increasing access to metabolic surgery will continue to yield benefits to patient health and improve the macroeconomic health of the world.

Laparoscopic Duodenal Switch Versus Roux-en-Y Gastric Bypass at a High-Volume Community Hospital: a Retrospective Cohort Study from a Rural Setting

BACKGROUND

The classic duodenal switch (DS) represents a minority of bariatric procedures due to its high complexity and potential for complications.

METHODS

A retrospective chart review was conducted on 100 laparoscopic DS cases from 2014 to 2018 at an accredited program in a rural community hospital and compared to 100 laparoscopic Roux-en-Y gastric bypasses (RYGB). Primary outcomes were 30-day morbidity and mortality. Secondary outcomes included anastomotic leak and remission of type 2 diabetes.

RESULTS

There were more demographic risk factors for DS. The 30-day morbidity was higher for DS compared to RYGB (31% vs 13%, respectively; p = 0.0037). There was one mortality for DS and none for RYGB. There were statistically significant longer intraoperative times, greater EBL, and greater decrease in BMI for DS. The DS had a lower incidence of anastomotic ulcers (4% vs 13%, respectively; p = 0.0289), with a higher incidence of subsequent surgery beyond 30 days (21% vs 8%, respectively; p = 0.0160). There were 3 anastomotic leaks for DS and none for RYGB, although not statistically significant (p = 0.2463). The DS was more likely to eradicate hypertension, but the RYGB was more likely to eradicate GERD. There were no statistically significant differences for type 2 diabetes remission (92.1% vs 89.5%, respectively; p = 0.7239).

CONCLUSION

Laparoscopic DS offers greater weight loss and hypertension remission, with lower incidence of anastomotic ulcers, but at the expense of greater morbidity and need for subsequent surgery, with no significant differences in type 2 diabetes remission when compared to RYGB in a rural community hospital program.

The Risks of Stone Diagnosis and Stone Removal Procedure After Different Bariatric Surgeries

Introduction: Nephrolithiasis is common after malabsorptive bariatric surgery; however, the comparative risk of stone formation after different bariatric surgeries remains unclear. We seek to compare the risk of stone diagnosis and stone procedure after gastric banding (GB), sleeve gastrectomy (SG), short-limb Roux-en-Y (SLRY), long-limb Roux-en-Y (LLRY), and biliopancreatic diversion with duodenal switch (BPDDS). Patients and Methods: Using an administrative database, we retrospectively identified 116,304 patients in the United States, who received bariatric surgery between 2007 and 2014, did not have a known kidney stone diagnosis before surgery, and were enrolled in the database for at least 1 year before and after their bariatric surgery. We used diagnosis and procedural codes to identify comorbidities and events of interest. Our primary analysis was performed with extended Cox proportional hazards models using time to stone diagnosis and time to stone procedure as outcomes. Results: The adjusted hazard ratio of new stone diagnosis from 1 to 36 months, compared to GB, was 4.54 for BPDDS (95% confidence interval [CI] 3.66-5.62), 2.12 for LLRY (95% CI 1.74-2.58), 2.15 for SLRY (95% CI 2.02-2.29), and 1.35 for SG (95% CI 1.25-1.46). Similar results were observed for risk of stone diagnosis from 36 to 60 months, and for risk of stone removal procedure. Male sex was associated with an overall 1.63-fold increased risk of new stone diagnosis (95% CI 1.55-1.72). Conclusions: BPDDS was associated with a greater risk of stone diagnosis and stone procedures than SLRY and LLRY, which were associated with a greater risk than restrictive procedures. Nephrolithiasis is more common after more malabsorptive bariatric surgeries, with a much greater risk observed after BPDDS and for male patients.

Metabolite Changes After Metabolic Surgery - Associations to Parameters Reflecting Glucose Homeostasis and Lipid Levels

AIMS

To test the hypothesis that adipose tissue gene expression patterns would be affected by metabolic surgery and we aimed to identify genes and metabolic pathways as well as metabolites correlating with metabolic changes following metabolic surgery.

MATERIALS AND METHODS

This observational study was conducted at the Obesity Unit at the Catholic University Hospital of the Sacred Heart in Rome, Italy. Fifteen patients, of which six patients underwent Roux-en-Y gastric bypass and nine patients underwent biliopancreatic diversion, were included. The participants underwent an oral glucose tolerance test and a hyperinsulinemic euglycemic clamp. Small polar metabolites were analyzed with a two-dimensional gas chromatography coupled to time-of-flight mass spectrometry (GC×GC-TOFMS). Gene expression analysis of genes related to metabolism of amino acids and fatty acids were analyzed in subcutaneous adipose tissue. All procedures were performed at study start and at follow-up (after 185.3 ± 72.9 days).

RESULTS

Twelve metabolites were significantly changed after metabolic surgery. Six metabolites were identified as 3-indoleacetic acid, 2-hydroxybutyric acid, valine, glutamic acid, 4-hydroxybenzeneacetic acid and alpha-tocopherol. The branched chain amino acids displayed a significant decrease together with a decrease in BCAT1 adipose tissue mRNA levels. Changes in the identified metabolites were associated to changes in lipid, insulin and glucose levels.

CONCLUSIONS

Our study has identified metabolites and metabolic pathways that are altered by metabolic surgery and may be used as biomarkers for metabolic improvement.

Direct and two-step single anastomosis duoenal switch (SADI-S): Unicentric comparative analysis of 232 cases

INTRODUCTION

The «Single Anastomosis Duodeno-Ileal bypass with Sleeve gastrectomy» (SADI-S) is a bariatric surgery conceived to simplify the duodenal switch in order to reduce its postoperative complications. The objective of this study is to assess the safety and efficacy of SADI-S, comparing its results in both direct and two-step procedure.

METHODS

Unicentric cohort study that includes patients submitted to SADI-S, both direct or in two-step, between 2014 and 2019.

RESULTS

Two hundred thirty-two patients were included, 192 were submitted to direct SADI-S and 40 had previously undergone a sleeve gastrectomy. The severe complications rate (Clavien-Dindo ≥ IIIA) was 7.8%, being hemoperitoneum and duodenal stump leak the most frequent ones. One patient was exitus between the first 90 days after surgery (0.4%). Patients submitted to direct SADI-S had an initial body mass index (BMI) of 49.6 kg/m² in comparison of 56.2 kg/m² in the two-step SADI-S (p < 0.001). The mean excess weight loss (EWL) at two years was higher in direct SADI-S (77.3 vs. 59.3%, p < 0.05). Rate of comorbidities resolution was 88.5% for diabetes, 73.0% for hypertension, 77.0% for dyslipidemia and 85.7% for sleep apnea, with no differences between both techniques.

CONCLUSION

In medium term, SADI-S is a safe and effective technique that offers a satisfactory weight loss and remission of comorbidities. Patients submitted to two-step SADI-S had a higher initial BMI and presented a lower EWL than direct SADI-S.

Long-term BAROS scores and independent obesity-related co-morbidity predictors of failure after laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Long-term (>5 yr) studies assessing outcomes after laparoscopic Roux-en-Y gastric bypass (LRYGB) using the Bariatric Analysis and Reporting Outcome System (BAROS) are limited. Evidence of predictors of failure long-term after LRYGB is also lacking.

OBJECTIVES

To compare BAROS scores at 5 and 10 years post LRYGB and to establish whether individual obesity-related co-morbidities are associated with suboptimal outcomes at these time points.

SETTING

Single bariatric unit.

METHODS

BAROS scores were analyzed in patients who were 5 years (group A) and 10 years (group B) post LRYGB. Obesity-related co-morbidities as predictors of failure of surgery (defined by % excess weight loss [%EWL] <50% or BAROS total score ≤1) were examined. Intergroup comparative analysis of outcomes and logistic regression modeling to determine predictors of weight loss failure were conducted.

RESULTS

A total of 88 patients were 5 years post LRYGB (group A), and 91 patients were 10 years post LRYGB (group B). A total of 52.3% (46/88) in group A and 54.9% (50/91) in group B had failure of weight loss defined by %EWL <50%. There were no significant differences in percentage of total weight loss, %EWL, or BAROS scores between the 2 groups (21.8% versus 22.0%, P = .897; 48.5% versus 47.1%, P = .993; and 3.7 versus 3.3, P = .332, respectively). No individual obesity-related co-morbidity at time of surgery was associated with suboptimal outcomes (%EWL <50% or BAROS total score ≤1) at 5 years or 10 years after LRYGB.

CONCLUSIONS

Long-term outcomes assessed by the BAROS score appear sustainable between 5 and 10 years after LRYGB surgery, and weight loss achieved at 5 years is maintained at 10 years. Preoperative presence of specific obesity-related co-morbidities was not associated with failure of surgery long-term.

Prospective multicentre randomised trial comparing the efficacy and safety of single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) versus Roux-en-Y gastric bypass (RYGB): SADISLEEVE study protocol

INTRODUCTION

Despite the non-negligible weight loss failure rate at midterm, Roux-en-Y gastric bypass (RYGB) remains the reference procedure in the treatment of morbid obesity with metabolic comorbidities. A recently emerged procedure, the single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S), could be more effective on weight loss with similar morbidity and lower weight loss failure rate than RYGB. We propose the first randomised, open, multicentre superiority trial comparing the SADI-S to RYGB (SADISLEEVE).

METHODS AND ANALYSIS

The main objective is to demonstrate the superiority at 2 years after surgery of the SADI-S compared with RYGB in term of excess weight loss percentage. The secondary objectives are the evaluation of nutritional status, metabolic outcomes, overall complication rates and quality of life, within 2 years after surgery. Key inclusion criteria are obese patients with body mass index (BMI) ≥40 kg/m² or ≥35 kg/m² with at least one comorbid condition and candidate to a first bariatric procedure or after failure of sleeve gastrectomy. Patients randomised by minimisation in two arms, based on centre, surgery as a revisional procedure, presence of type 2 diabetes and BMI >50 kg/m² will be included over 2 years.A sample size of 166 patients in each group will have a power of 90% to detect a probability of 0.603 that excess weight loss in the RYGB arm is less than excess weight loss in the SADI-S arm with a 5% two-sided significance level. With a drop-out rate of 10%, it will be necessary to include 183 patients per group.

ETHICS AND DISSEMINATION

The study was approved by Institutional Review Board of Centre Hospitalier Universitaire Morvan (CPP1089-HPS1). Study was also approved by the French national agency for drug safety (2018061500148). Results will be reported in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT03610256.

Different Malabsorptive Obesity Surgery Interventions Result in Distinct Postprandial Amino Acid Metabolomic Signatures

PURPOSE

Biliopancreatic diversion with duodenal switch (BPD-DS) is an effective weight loss surgical procedure. Yet, BPD-DS is technically difficult to perform and carries a higher risk of nutrient deficiencies as compared with other surgical interventions. Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a modified BPD-DS procedure conceived with the aim of decreasing the technical complexity, while retaining the weight loss efficiency. Whether the two surgical procedures diverge in nutrient absorption rates and malnutrition risk is still matter of debate. Our aim was to determine if postprandial nutrient absorption rates are different in patients subjected to BPD-DS or SADI-S for weight loss.

MATERIALS AND METHODS

Plasma amino acid metabolomic profiling during mixed-meal tolerance test (MMTT) was performed in subjects (N = 18) submitted to BPD-DS (n = 9) or SADI-S (n = 9) 1.6 ± 0.1 years earlier.

RESULTS

Patients submitted to SADI-S or BPD-DS presented distinct postprandial metabolomic profiles. Postprandial excursions of total and essential amino acids-leucine, isoleucine, and valine-were higher after SADI-S as compared with BPD-DS.

CONCLUSION

Our study demonstrates that a simplified malabsorptive bariatric surgery procedure SADI-S results in greater essential branched-chain amino acid absorption when compared with the classical BPD-DS intervention. These findings suggest that SADI-S can potentially lower lifetime risk of postoperative protein malnutrition, as well as have a positive impact on systemic metabolism and glucose homeostasis.

Does Reconstruction Type After Gastric Resection Matters for Type 2 Diabetes Improvement?

BACKGROUND

Gastrointestinal (GI) surgery involving gastric resection and bypass of intestinal segments was reported to facilitate glucose control in obese patients with type 2 diabetes (T2D).

AIM

Our aim was to assess whether the type of post-gastrectomy GI reconstruction also influences glucose control in T2D patients with BMI below 35 kg/m² submitted to gastrointestinal surgery without bariatric intention.

METHODS

A cohort of T2D Caucasian patients (n = 40) with upper GI malignancy (n = 33) or complicated reflux disease (n = 7) were submitted to either a gastrectomy plus Billroth II (BII) gastrojejunal anastomosis (n = 17), a gastrectomy plus Roux-en-Y gastrojejunostomy (RY) reconstruction (n = 18; subtotal gastrectomy n = 7 and total gastrectomy n = 11), or atypical gastrectomy without reconstruction (no-R) (n = 5). Patients were evaluated before and 2 years after surgery for body weight, Hb1Ac, need of glucose lowering drugs, and presence of diabetes.

RESULTS

Body mass index (BMI) decreased after every surgical procedure when compared to baseline (- 0.9 ± 0.8 kg/m² for BII vs - 4.3 ± 2.6 kg/m² for RY vs - 4.6 ± 2.5 kg/m² for no-R, p < 0.05), which was only significantly different after RY surgeries. Diabetes remission occurred in 5.9% of BII patients, in 27.8% of RY patients, and 0% of no-R patients, while in patients with persistent T2D, the needs for glucose-lowering drugs were significantly also decreased after RY (31.3% BII vs 66.7% RY vs 25% no-R, p = 0.03).

CONCLUSIONS

T2D Caucasian patients undergoing post-gastrectomy GI reconstructions without a bariatric intention experience a significant improvement of T2D, in a magnitude that could be influenced by the technical procedure performed in favor of RY reconstruction. Thus, presence of T2D should be taken into consideration when deciding for the type of post-gastrectomy GI reconstruction.

A Predictive Model of Weight Loss After Roux-en-Y Gastric Bypass up to 5 Years After Surgery: a Useful Tool to Select and Manage Candidates to Bariatric Surgery

INTRODUCTION

Different factors, such as age, gender, preoperative weight but also the patient's motivation, are known to impact outcomes after Roux-en-Y gastric bypass (RYGBP). Weight loss prediction is helpful to define realistic expectations and maintain motivation during follow-up, but also to select good candidates for surgery and limit failures. Therefore, developing a realistic predictive tool appears interesting.

PATIENTS/METHODS

A Swiss cohort (n = 444), who underwent RYGBP, was used, with multiple linear regression models, to predict weight loss up to 60 months after surgery considering age, height, gender and weight at baseline. We then applied our model on two French cohorts and compared predicted weight to the one finally reached. Accuracy of our model was controlled using root mean square error (RMSE).

RESULTS

Mean weight loss was 43.6 ± 13.0 and 40.8 ± 15.4 kg at 12 and 60 months respectively. The model was reliable to predict weight loss (0.37 < R² < 0.48) and RMSE between 5.0 and 12.2 kg. High preoperative weight and young age were positively correlated to weight loss, as well as male gender. Correlations between predicted weight and real weight were highly significant in both validation cohorts (R ≥ 0.7 and P < 0.01) and RMSE increased throughout follow-up between 6.2 and 15.4 kg.

CONCLUSION

Our statistical model to predict weight loss outcomes after RYGBP seems accurate. It could be a valuable tool to define realistic weight loss expectations and to improve patient selection and outcomes during follow-up. Further research is needed to demonstrate the interest of this model in improving patients' motivation and results and limit the failures.

Surgery in Patients with Super Obesity: Medium-Term Follow-Up Outcomes at a High-Volume Center

OBJECTIVE

There is a need to determine which bariatric operations are the most effective for patients with super obesity and super-super obesity.

METHODS

A retrospective cohort study was performed on patients with super obesity and super-super obesity at Mohak Bariatrics and Robotics Surgery Center in Indore, India.

RESULTS

Five hundred fourteen patients with super obesity and super-super obesity had surgery at our center from January 2010 through December 2013. The baseline characteristics were different in different operations. The initial average age, weight, and BMI were 44.4 (SD 11.9) years, 145.4 (SD 24.2) kg, and 55.48 (SD 5.32) kg/m² , respectively. Sleeve gastrectomy (SG) (227 [44.2%]) was the most common procedure, followed by one-anastomosis gastric bypass (OAGB) (124 [24.1%]), Roux-en-Y gastric bypass (RYGB) (102 [19.8%]), banded sleeve gastrectomy (BSG) (33 [6.4%]), and banded Roux-en-Y gastric bypass (BRYGB) (28 [5.4%]). After 3 years, the percentages of excess body weight loss (%EBWL) for SG, OAGB, RYGB, BSG, and BRYGB were 62.38%, 78.59%, 69.55%, 85.11%, and 75.77% (P < 0.0001), respectively. Failure to achieve BMI < 35 kg/m² was more frequent in the group who underwent SG (67.9%), followed by RYGB (29.16%), BRYGB (22.2%), OAGB (9.87%), and none in the BSG group.

CONCLUSIONS

BSG, OAGB, and BRYGB have very good to excellent midterm outcomes for patients with super obesity and super-super obesity, whereas RYGB and SG have average outcomes at 3 years. There is a need for multicenter, long-term, and prospective studies to be performed to confirm these findings.

Duodenal switch in revisional bariatric surgery: conclusions from an expert consensus panel

BACKGROUND

Duodenal switch (BPD/DS) is gaining popularity as a secondary procedure for inadequate weight loss after an initial operation.

OBJECTIVES

We aimed to generate expert consensus points on the appropriate use of BPD/DS in the revisional bariatric surgical setting.

SETTING

Data were gathered at an international conference with attendees from a variety of different institutions and settings.

METHODS

Sixteen lines of questioning regarding revisional BPD/DS were presented to an expert panel of 29 bariatric surgeons. Current available literature was reviewed extensively for each topic and proposed to the panel before polling. Responses were collected and topics defined as achieving consensus (≥70% agreement) or no consensus (<70% agreement).

RESULTS

Consensus was present in 10 of 16 lines of questioning, with several key points most prominent.

CONCLUSIONS

As a second-stage procedure, BPD/DS is most appropriate after sleeve gastrectomy (SG) for the treatment of super morbid obesity (96.7% agree) or as a subsequent operation for a reliable patient with insufficient weight loss after SG (88.5%). In a patient with weight regain and reflux and/or enlarged fundus after SG, Roux-en-Y gastric bypass is preferable and BPD/DS should be avoided (90%). BPD/DS should not be used prophylactically in patients with a history of jejunoileal bypass who are otherwise doing well (80.8%). Applicability of BPD/DS is limited by technical difficulty; 86.2% of experts would routinely recommend or consider the procedure if it were more technically feasible after failed bypass. No consensus was found on approaches to revision of BPD/DS for protein malnutrition.

Single- or double-anastomosis duodenal switch versus Roux-en-Y gastric bypass as a revisional procedure for sleeve gastrectomy: A systematic review and meta-analysis

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) is one of the most commonly performed bariatric procedure worldwide. There is currently no consensus on which revisional procedure is best after an initial SG.

OBJECTIVES

To compare the efficacy and safety between single-anastomosis duodeno-ileal bypass (SADI) or biliopancreatic diversion with duodenal switch (BPD-DS) versus Roux-en-Y gastric bypass (RYGB) as a revisional procedure for SG.

SETTING

University Hospital, Canada.

METHODS

MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and PubMed were searched up to August 2018. Studies were eligible for inclusion if they compared SADI or BPD-DS with RYGB as a revisional bariatric procedure for SG. Primary outcome was absolute percentage of total weight loss. Secondary outcomes were length of stay, adverse events, and improvement or resolution of co-morbidities (diabetes, hypertension, or hypercholesterolemia). Pooled mean differences were calculated using random effects meta-analysis.

RESULTS

Six retrospective cohort studies involving 377 patients met the inclusion criteria. The SADI/BPD-DS group achieved a significantly higher percentage of total weight loss compared with RYGB by 10.22% (95% confidence interval, -17.46 to -2.97; P = .006). However, there was significant baseline equivalence bias with 4 studies reporting higher initial body mass index (BMI) in the SADI/BPD-DS group. There were no significant differences in length of stay, adverse events, or improvement of co-morbidities between the 2 groups.

CONCLUSION

SADI, BPD-DS, and RYGB are safe and efficacious revisional surgeries for SG. Both SADI and RYGB are efficacious in lowering initial BMI but there is more evidence for excellent weight loss outcomes with the conversion to BPD-DS when the starting BMI is high. Further randomized trials are required for definitive conclusions.

IFSO Worldwide Survey 2016: Primary, Endoluminal, and Revisional Procedures

BACKGROUND AND AIM

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), being a Federation of 62 national societies, is the ideal network to monitor the number and type of procedures at a global level. The IFSO survey, enriched with a special section on revisional procedures, aims to report the number and types of bariatric procedures performed worldwide in 2016 and analyzes the surgical trends from 2008 to 2016.

METHODS

The 2016 IFSO Survey form was emailed to all IFSO societies. Each Society was requested to indicate the number and type of bariatric procedures performed in the country. Trend analyses from 2008 to 2016 were also performed.

RESULTS

The total number of bariatric/metabolic procedures performed in 2016 was 685,874; 634,897 (92.6%) of which were primary and 50,977 were revisional (7.4%). Among the primary interventions, 609,897 (96%) were surgical and 25,359 (4%) were endoluminal. The most performed primary surgical bariatric/metabolic procedure was sleeve gastrectomy (SG) (N = 340,550; 53.6%), followed by Roux-en-Y gastric bypass (N = 191,326; 30.1%), and one-anastomosis gastric bypass (N = 30,563; 4.8%).

CONCLUSIONS

In 2016, there was an increase in the total number both of surgical and endoluminal bariatric/metabolic procedures. Revisional procedures represent about 7% of the total bariatric interventions. SG remains the most performed surgical procedure in the world.

Failed Sleeve Gastrectomy: Single Anastomosis Duodenoileal Bypass or Roux-en-Y Gastric Bypass? A Multicenter Cohort Study

BACKGROUND

Sleeve gastrectomy (SG) has become the most performed bariatric procedure to induce weight loss worldwide. Unfortunately, a significant portion of patients show insufficient weight loss or weight regain after a few years.

OBJECTIVE

To investigate the effectiveness of the single anastomosis duodenoileal (SADI) bypass versus the Roux-en-Y gastric bypass (RYGB) on health outcomes in morbid obese patients who had undergone SG previously, with up to 2 years of follow-up.

METHODS

From 2007 to 2017, 140 patients received revisional laparoscopic surgery after SG in four specialized Dutch bariatric hospitals. Data was analyzed retrospectively and included comparisons for indication of surgery, vitamin/mineral deficiencies, and complications; divided into short-, medium-term. To compare weight loss, linear regression and linear mixed models were used.

RESULTS

Conversion of a SG to SADI was performed in 66 patients and to RYGB in 74 patients. For patients in which additional weight loss was the main indication for surgery, SADI achieved 8.7%, 12.4%, and 19.4% more total body weight loss at 6, 12, and 24 months compared to RYGB (all p < .001). When a RYGB was indicated in case of gastroesophageal reflux or dysphagia, it greatly reduced complaints almost directly after surgery. Furthermore, a similar amount of complications and nutritional deficiencies was observed for both groups. There was no intra- or post-operative mortality.

CONCLUSION

Conversion into a SADI resulted in significantly more weight loss while complications rates and nutritional deficiencies were similar and may therefore be considered the recommended operation for patients in which only additional weight loss is required.

Three-trocar laparoscopic duodenal switch after sleeve gastrectomy

Laparoscopic duodenal switch is a recognized bariatric procedure, which can be performed in one step or as a second step after laparoscopic sleeve gastrectomy (LSG). Mainly, indications as primary surgery are super-obese or super super-obese patients, and after LSG indications are the presence of insufficient weight loss or weight regain, associated with morbid obesity co-morbidities, without gastroesophageal reflux. In this video, the authors report the technique of reduced port laparoscopic duodenal switch after LSG. The procedure is performed using a 12-mm trocar in the umbilicus, a 5-mm trocar in the right flank, and a 5-mm trocar in the left flank. One or more temporary percutaneous sutures are passed into the hepatic ligaments to increase the exposure of the first duodenum. The optical system is switched from 10 mm to 5 mm and introduced in the left 5-mm flank trocar at the step of the linear stapler insertion through the umbilical trocar. Classic construction with 150-cm alimentary limb and 100-cm common limb is performed. The duodeno-jejunostomy is fashioned in an end-to-side handsewn technique and the jejuno-ileostomy in the side-to-side semimechanical linear stapler technique. Both Petersen and mesenteric defects are closed. The umbilical access is finally meticulously closed, avoiding incisional hernia. Reduced port laparoscopic duodenal switch after LSG is a safe and feasible technique. Besides the enhanced cosmetic outcomes, this surgery is associated with a reduced use of painkillers, fewer trocar complications, and quick patient convalescence.

Changes in bowel habits and patient-scored symptoms after Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch

BACKGROUND

Bariatric procedures are increasingly being used, but data on bowel habits are scarce.

OBJECTIVES

To assess changes in gastrointestinal function and patient-scored symptoms after Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch (BPD/DS).

SETTING

University hospital in Sweden.

METHODS

We recruited 268 adult patients (mean age of 42.5 yr, body mass index 44.8, 67.9% female) listed for RYGB and BPD/DS. Patients answered validated questionnaires prospectively concerning bowel function, the Fecal Incontinence Quality of Life Scale, and the 36-Item Short Form Health Survey before and after their operation.

RESULTS

Postoperatively, 208 patients (78.2% of 266 eligible patients) answered the questionnaires. RYGB patients had fewer bowel motions per week (8 versus 10) and more abdominal pain postoperatively (P<.001). Postoperatively, the 35 BPD/DS patients (69% versus 23%) needed to empty their bowel twice or more than twice daily, reported more flatus and urgency, and increased need for keeping a diet (P<.001). Concerning Fecal Incontinence Quality of Life Scale, coping and behavior was slightly reduced while depression and self-perception scores were improved after RYGB. Lifestyle, coping and behavior, and embarrassment were reduced after BPD/DS (P<.05). In the 36-Item Short Form Health Survey, physical scores were markedly improved, while mental scores were largely unaffected.

CONCLUSION

RYGB resulted in a reduced number of bowel movements but increased problems with abdominal pain. In contrast, BPD/DS-patients reported higher frequency of bowel movements, more troubles with flatus and urgency, and increased need for keeping a diet. These symptoms affected quality of life negatively, however, general quality of life was markedly improved after both procedures. These results will be of great value for preoperative counseling.