A Retrospective 2-Year Follow-up of Late Complications Treated Surgically and Endoscopically After Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) and Laparoscopic Sleeve Gastrectomy (LSG) for Morbid Obesity

Musculoskeletal effects of obesity and bariatric surgery – a narrative review

Obesity affects several areas of the human body, leading to increased morbidity and mortality and the likelihood of other diseases, such as type 2 diabetes mellitus, cardiovascular diseases and musculoskeletal disorders. These conditions predispose to bone fractures and sarcopenic obesity, defined by the presence of an obesity-associated decrease in muscle mass and strength. Both bone fragility and sarcopenic obesity disease are consequences of several factors, such as a low degree of chronic inflammation, insulin resistance, hormonal changes, nutritional deficiencies, ectopic fat deposits and sedentary lifestyle. The diagnosis of obesity-related musculoskeletal disorders is limited by the lack of sarcopenia criteria and lower accuracy of bone mineral density measurement by dual-energy X-ray absorptiometry in overweight people. Reducing body weight provides undeniable benefits to this population, however treating cases of severe obesity with bariatric surgery can cause even greater damage to bone and muscle health, especially in the long term. The mechanisms involved in this process are not yet fully understood, but factors related to nutrient malabsorption and mechanical discharge as well as changes in gut hormones, adipokines and bone marrow adiposity should be taken into account. Depending on the surgical technique performed, greater musculoskeletal damage may occur, especially in cases of malabsorptive surgeries such as Roux-en-Y gastric bypass, when compared to restrictive techniques such as sleeve gastrectomy. This difference is probably due to greater weight loss, nutrient malabsorption and important hormonal changes that occur as a consequence of the diversion of intestinal transit and loss of greater absorptive surface. Thus, people undergoing bariatric procedures, especially malabsorptive ones, should have their musculoskeletal health supervised to allow early diagnosis and appropriate therapeutic interventions to prevent osteoporotic fractures and preserve the functionality of the skeletal muscles.

Management of Complications After Bariatric Surgery: a Survey of Comfort and Educational Needs of General Surgeons in Ontario, Canada

Purpose

Approximately 10% of patients develop complications after bariatric surgery. These patients often present to their local general surgeon rather than the hospital where the primary bariatric operation was performed. The objective of this study was to conduct a survey of general surgeons in Ontario, Canada, to explore their confidence and educational needs regarding management of surgical complications post-bariatric surgery.

Materials and Methods

A 40-item survey was created and piloted with community and academic general surgeons. It was disseminated by mail in August 2020 to general surgeons in Ontario who take acute care surgery call. Bariatric surgeons and surgeons who do not take acute care surgery call were excluded.

Results

A total of 138/715 (19.3%) eligible surgeons completed the survey. Of the respondents, 63/112 (54.3%) had no exposure to bariatric surgery during residency or fellowship. A total of 72/108 (66.7%) respondents agreed that management of complications after bariatric surgery should be within the skillset of a general surgeon; however, 28/108 (25.9%) were not confident managing these complications. Seventy-one of 108 (65.7%) respondents were interested in additional continuing professional development (CPD) resources regarding management of these complications. Hands-on workshops, online resources, and live webinars were the most preferred educational formats for such CPD resources, with 67.1% of participants willing to commit 1–3 h and 42.9% willing to pay >$100 for such CPD resources.

Conclusions

One-quarter of general surgeons in Ontario, Canada, were not comfortable managing complications after bariatric surgery; however, the majority of surgeons were interested in additional CPD resources on this topic.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-022-06095-9.

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.

Multiple Beneficial Effects of Laparoscopic Sleeve Gastrectomy for Patients with Obesity, Type 2 Diabetes Mellitus, and Restrictive Ventilatory Dysfunction

BACKGROUND

Some studies have suggested that bariatric surgery improves pulmonary function in patients with obesity, but whether it alleviates pulmonary ventilation disorders in patients with obesity, type 2 diabetes mellitus (T2DM), and restrictive ventilatory dysfunction(RVD) is unclear. To evaluate the effect of laparoscopic sleeve gastrectomy (LSG) in improving pulmonary ventilation function in patients with obesity, T2DM, and RVD.

METHODS

We studied patients with T2DM and RVD (forced vital capacity (FVC) predicted < 80%, forced expiratory volume in one second/forced vital capacity (FEV1/FVC) > 70%) who underwent LSG from March 2018 to January 2020. Baseline data was recorded and follow-up visits were made at 3, 6, 9, and 12 months after surgery to evaluate glucose, hemoglobin A1c (HbA1c), body mass index (BMI), and pulmonary ventilation function. We used multivariate analyses to assess the remission of RVD (reversion of FVC to ≥80% of the predicted value).

RESULTS

We enrolled 33 patients (mean age 46.9±5.2 years, 21 males). Two patients were lost to follow-up and another patient died. Thirty patients completed follow-up; 24 had remission of RVD (24/33, 72.7%). Multivariate Cox regression analysis showed that lower HbA1c (HR=0.35 (0.16 ~ 0.76), p=0.008), reduced waist size (0.9 (0.83 ~ 0.98), p=0.017), and shorter duration of diabetes (0.67(0.47~0.97), p=0.033) were associated with alleviation of pulmonary ventilation function.

CONCLUSIONS

LSG not only controls the body weight and T2DM; it may also relieve pulmonary ventilation dysfunction in patients with obesity, T2DM, and RVD. The waist size, duration of diabetes, and HbA1c before LSG negatively affect recovery of pulmonary ventilation dysfunction.

Fracture Risk After Bariatric Surgery: A Systematic Literature Review and Meta-Analysis

OBJECTIVE

Bariatric surgery has undeniable benefits for cardiovascular and metabolic health, but it can result in negative effects on mineral and bone metabolism. This study aimed to review the current data on fractures after the main types of bariatric surgery.

METHODS

Therefore, a systematic review was performed using the electronic literature available in the databases LILACS, CENTRAL, Web of Science, Embase, and PubMed/MEDLINE, with results until January 2021. Keywords were descriptors for bariatric surgery or bariatric medicine or bariatrics or gastroplasty and bone or bones or bone fractures, referenced in all words of the text in the study.

RESULTS

The meta-analysis of observational studies and interventional trials showed that the risk of any type of fracture was higher in the surgical group than in the nonsurgical group (relative risk [RR], 1.20 [95% confidence interval {CI}, 1.15-1.26; P < .00001; Phetero < 0.000001; I² = 94%], and RR, 1.16 [95% CI, 1.00-1.33; P = .04; Phetero = 0.27; I² = 23%], respectively). It is worth noting that the included interventional studies have a low rating on the risk of bias assessment scales. Compared with those who underwent restrictive procedures, subjects had an increased fracture risk after malabsorptive procedures (RR, 0.49 [95% CI, 0.40-0.61; P < .00001); Phetero = 0.96; I² = 0%).

CONCLUSION

We found that bariatric procedures are associated with an increased risk of fractures, especially the malabsorptive techniques.

Apprising the choice of bariatric surgery in patients with compensated cirrhosis with morbid obesity: results of a national analysis

Bariatric surgery (BS) was proved safe in carefully selected patients with compensated cirrhosis (CC). However, limited data exist on differential impact of bariatric surgery type on clinical outcomes and health care utilization. This retrospective study utilizes the 2010-2014 Nationwide Readmissions Database. We included obese adults with CC who underwent the two most commonly used BS, Roux-en-Y (RYGB) and laparoscopic sleeve gastrectomy (LSG). Those with decompensation within 6 months of BS were excluded. Rates of hepatic decompensation (new-onset ascites, variceal bleed, encephalopathy, spontaneous bacterial peritonitis, and/or hepatorenal syndrome), surgical complications, health care utilization, and mortality were compared between RYGB and LSG. Multivariable analysis was performed to fit various models. A total of 3032 patients with CC underwent BS, including 1864 (61.5%) RYGB and 1168 (38.5%) LSG. The majority (56%) of BS were performed at large, metropolitan teaching hospitals. There were no significant differences in various decompensations and surgical complications comparing RYGB to LSG. Healthcare utilization including index length of stay (RYGB: 3.4 days vs LSG: 3.0 days), 30-day readmission rate (RYGB: 9.5% vs LSG: 3.7%), and cost of admission (RYGB: $14,006 vs LSG: $12,523) were higher in RYGB (p values < 0.001). Index admission and calendar year mortality could not be analyzed due to the few number of events. Two types of bariatric surgeries in obese patients with compensated cirrhosis have similar rates of decompensated cirrhosis events and surgical complications. However, RYGB procedure incurred increased healthcare utilization. Therefore, LSG may be the preferred BS for patients with CC. Prospective, randomized studies comparing the types of BS are needed to confirm our observations.

Laparoscopic Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy for Type 2 Diabetes Mellitus in Nonseverely Obese Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Recently, randomized controlled trials (RCTs) have indicated that bariatric surgery in nonseverely obese patients with a body mass index (BMI) less than 35 kg/m² might be even superior to medical therapy with regard to type 2 diabetes mellitus (T2DM) remission, but the efficacy of laparoscopic Roux-en-Y gastric bypass (LRYGB) compared with laparoscopic sleeve gastrectomy (LSG) in nonseverely obese patients has not been conclusively determined. The objective of this study is to compare LRYGB versus LSG for T2DM in nonseverely obese patients.

METHODS

A meta-analysis identifying RCTs evaluating LRYGB versus LSG for T2DM in nonseverely obese patients was conducted. The primary outcome was T2DM remission. Additional analyses comprised percent excess weight loss (%EWL), BMI, waist circumference, hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), serum lipid level, medication use, quality of life, and adverse events.

RESULTS

Four RCTs concerning total 296 patients were included. T2DM remission rate and %EWL were of no difference between the two bariatric procedures. LRYGB was associated with lower BMI, waist circumference, low-density lipoprotein, and higher high-density lipoprotein than LSG. However, HbA1c, FPG, total cholesterol, and triglyceride were not significantly different between the two surgical groups. The medication use and quality of life were improved in both two groups. The gastroesophageal reflux diseases of LRYGB group were less than that of LSG group. Dumping syndromes were noted more frequently in the LRYGB group.

CONCLUSIONS

Both LRYGB and LSG have comparative effect on resolving T2DM in nonseverely obese patients at midterm follow-up. Further RCTs should address the potential risks and long-term effects of LRYGB and LSG in nonseverely obese patients.

Lower Baseline Serum Triglyceride Levels Are Associated With Higher Decrease in Body Mass Index After Laparoscopy Sleeve Gastrectomy Among Obese Patients

AIMS

To investigate the predictive value of baseline serum triglyceride (TG) levels for improvements of metabolism after laparoscopic sleeve gastrectomy (LSG).

METHODS

112 obese patients [body mass index (BMI) ≥ 35 kg/m²] underwent LSG and with complete information of anthropometric and metabolic parameters were divided into normal TG group (group A) and high TG group (group B), while group A had TG levels ≤ 1.7 mmol/L, and group B had TG levels > 1.7 mmol/L. The post-operative changes (Δ) in metabolic parameters between the two groups were compared.

RESULTS

In the whole cohort, the metabolic parameters were significantly improved at 6 months after LSG. BMI and waist circumference (WC) decreased significantly in the two groups. The ΔBMI among group A and group B were 11.42±3.23 vs 9.13±2.77 kg/m² (p<0.001), respectively. ΔBMI was positively correlated with ΔWC (r=0.696, p<0.001), Δfasting insulin level (r=0.440, p=0.002), Δfasting serum C peptide level (r=0.453, p=0.002), and Δhomeostasis model assessment insulin resistance index (r=0.418, p=0.004) in group A. Compared with group B, group A had a significantly higher odds ratio (OR) of 2.83 (95% confidence interval [CI]1.25-6.38, p=0.012)and 2.73 (95% CI 1.11-6.72, p=0.029) for ΔBMI and ΔWC after adjustment for age and gender, respectively.

CONCLUSIONS

Obese patients with baseline TG levels under 1.7 mmol/L had greater loss of weight at six months follow-up later LSG. This finding suggests that baseline TG level may have a predictive value for weight loss, at least in the short-term follow-up.

Effectiveness of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy for morbid obesity in achieving weight loss outcomes

OBJECTIVE

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are commonly performed weight loss procedures worldwide. Unfortunately, few studies have compared percentage total weight loss (%TWL) following these procedures. This research compared short-term, mid-term and long-term %TWL by LRYGB and LSG.

METHODS

Selected databases were searched for original articles that compared %TWL by LSG and LRYGB. Review manager 5.3 was used for data analysis. Effect summary was presented by forest plot.

RESULTS

A significantly better %TWL in 5 years was shown by LRYGB than LSG; pooled mean difference (MD) 1.87 (95% CI 0.27-3.48, z statistics = 2.28, p < 0.05). Subgroup analysis showed better %TWL by LRYGB than LSG at 24 months pooled MD 6.47 (95% CI 1.22-11.72, z statistics = 2.42, p < 0.05), however, better %TWL by LSG was noted after 36 months (pooled MD -0.23; 95% CI -0.39-0.06, z statistics = 2.65, p < 0.05). Finally, significantly better %TWL was noted for LRYGB at 60 months.

CONCLUSION

This study shows %TWL of 70.4% by LRYGB and 59.8% following LSG in at least half of patients from selected cohort. A significantly greater %TWL by LRYGB in short and long term, while higher %TWL by LSG in mid-term is reported.

Laparoscopic Management of Dilatation of Excluded Stomach After Roux-en-Y Gastric Bypass

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) is considered as the gold standard for surgical management of morbid obesity due to its good results on weight loss and correction of comorbidities related to obesity and its few complication rates. Here, we describe a present strategy for dealing with an unusual complication after RYGB, responsible for chronic pain, as a chronic dilatation of excluded stomach.

METHODS

The video shows our laparoscopic treatment of an excluded gastric fundus dilatation. A 21-year-old woman with history of RYGB was admitted in our center for recurrent abdominal pain. Many consultations have been performed before for the same reason and without explanation for this chronic abdominal pain.

RESULTS

We found that a dilatation of the excluded gastric fundus was responsible for recurrent abdominal pain and thus required revisional surgery. An abdominal computed tomography with oral contrast study showed an atypical dilatation of the excluded stomach without gastro-gastric fistula or others abnormal findings. Intra-operative exploration then revealed multiple adhesions. During surgery, released of the excluded stomach allow to confirm a dilatation of the excluded fundus due to error in stapling when performing the vertical part of the gastric pouch of the RYGB. We resected the excluded dilated gastric fundus. An uneventful post-operative course enabled rapid discharge (post-operative day 3).

CONCLUSION

Dilatation of the excluded gastric pouch due to staple line misfiring during RYGB is a rare complication and can explain chronic abdominal pain. Laparoscopy can be useful to confirm the diagnosis and allow treatment using gastric resection in our case.

Duodenal intussusception of the remnant stomach after biliopancreatic diversion: a case report

Background

We present a rare case of an antegrade intussusception of the remnant stomach four years after a biliopancreatic diversion.

Case presentation

A 55-year-old female patient presented with epigastric pain in our emergency room. Laboratory parameters showed an anemia as well as elevated transaminases and hyperbilirubinemia. The CT scan showed an intussusception of the remnant stomach into the duodenum followed by cholestasis. At laparotomy the remnant stomach was resected.

Conclusion

Bowel obstruction and intussusception after bariatric surgery are a rare but often unrecognized complication. Sonography as well as a CT scan should be performed. The exploratory laparoscopy however is the most valuable diagnostic tool in patients with suspected intussusception, due to the high rate of non-specific symptoms and misinterpreted radiographic investigations.

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.