Perioperative Interventions to Prevent Gastroesophageal Reflux Disease and Marginal Ulcers After Bariatric Surgery - an International Experts' Survey

Obesity, Challenges, and Weight-Loss Strategies for Patients With Ventricular Assist Devices

For adults with advanced heart failure, class II/III obesity (body mass index ≥35 kg/m2) represents major challenges, and it is even considered a contraindication for heart transplantation (HT) at many centers. This has led to growing interest in preventing and treating obesity to help patients with advanced heart failure become HT candidates. Among all weight-loss strategies, bariatric surgery (BSx) has the greatest weight loss efficacy and has shown value in enabling select patients with left ventricular assist devices (LVADs) and obesity to lose sufficient weight to access HT. Nevertheless, both BSx and antiobesity medications warrant caution in the LVAD population. In this review, the authors describe and interpret the available published reports on the impact of obesity and weight-loss strategies for patients with LVADs from general and HT candidacy standpoints. The authors also provide an overview of the journey of LVAD recipients who undergo BSx and review major aspects of perioperative protocols.

Comprehensive outcomes after Roux-en-Y gastric bypass with a near-complete 15-year follow-up

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass has a well-established safety and efficacy profile in the short and mid-term. Long-term outcomes remain limited in the literature, especially for follow-up periods of >10 years. The purpose of the study is to evaluate the long-term durability and safety of laparoscopic Roux-en-Y gastric bypass over a near-complete 15-year follow-up.

METHODS

This is a single-center retrospective cohort study of patients who underwent primary laparoscopic Roux-en-Y gastric bypass between 2008 and 2009 with ≥14-year follow-up. Data collected and analyzed were weight loss, obesity-related medical condition resolution and recurrence, weight recurrence, complication rate, and mortality rate.

RESULTS

A total of 264 patients were included. Patients were predominantly female (81.8%), and the mean age and preoperative body mass index were 48.5 ± 12.2 years and 44.9 ± 7.3 kg/m2, respectively. The maximum mean percentage total weight loss achieved at 1 year was 31.5% ± 5.7% and was consistently >20% throughout follow-up. Sustained resolution of obesity-related medical conditions was achieved with a remission rate of 60.8% for type 2 diabetes mellitus, 46.7% for denoted dyslipidemia, and 40% for hypertension. Obesity-related medical condition recurrence was observed with a recurrence rate of 24.1% for type 2 diabetes mellitus, 17.9% for hypertension, and 14.8% for denoted dyslipidemia. Significant factors associated with weight loss were maximum percentage total weight loss and preoperative type 2 diabetes mellitus. Over 15 years, the weight recurrence rate was 51.1%, with predictors of higher preoperative body mass index and preoperative type 2 diabetes mellitus.

CONCLUSION

Laparoscopic Roux-en-Y gastric bypass provides sustainable weight loss over a 15-year period, with consistent long-term weight-loss outcomes and resolution of obesity-related medical conditions sustained for ≥10 years after surgery.

Effect of anti-reflux suture on gastroesophageal reflux symptoms after one anastomosis gastric bypass: a randomized controlled trial

PURPOSE

Gastroesophageal reflux disease (GERD) is an issue after one anastomosis gastric bypass (OAGB) and modification of OAGB with adding an anti-reflux system may decrease the incidence of postoperative GERD. This study aimed to compare the efficacy of the anti-reflux mechanism to treat preoperative GERD and prevent de novo GERD.

METHODS

A prospective randomized clinical trial study was conducted on patients with a body mass index of 40 and more from August 2020 to February 2022. Patients undergoing one anastomosis gastric bypass with and without anti-reflux sutures (groups A and B, respectively). These patients had follow-ups for one year after the surgery. GERD symptoms were assessed in all the patients using the GERD symptom questionnaire.

RESULTS

The mean age was 39.5 ± 9.8 years and 40.7 ± 10.2 years in groups A and B respectively. GERD symptoms remission occurred in 76.5% and 68.4% of patients in groups A and B, respectively. The incidence of de novo GERD symptoms was lower in group A, compared to group B (6.2% and 16.1% in groups A and B respectively), without any statistically significant difference (p-value: 0.239).

CONCLUSION

GERD symptoms and de novo GERD after OAGB seems to be under-reported after OAGB. This study suggests that applying an anti-reflux suture can decrease de novo GERD symptoms.

IMPACT OF HELICOBACTER PYLORI ON EARLY POSTOPERATIVE COMPLICATIONS AFTER SLEEVE GASTRECTOMY: A SYSTEMATIC REVIEW AND META-ANALYSIS

The impact of Helicobacter pylori (HP) on postoperative outcomes after sleeve gastrectomy (SG) is still controversial. A systematic review and meta-analysis were performed to compare the incidence of early complications after SG between HP-positive and HP-negative patients. Eight retrospective comparative studies were included, comprising 4,877 individuals. The prevalence of HP infection in gastric resected specimens ranged from 7.77 to 43.20%. There were no statistically significant differences between groups for overall complications (OR 1.46; 95%CI 0.95-2.23; p=0.08), bleeding (OR 1.35; 95%CI 0.70-2.60; p=0.38), and leak (OR 1.74; 95%CI 0.80-3.81; p=0.17) rates. The need for routine screening and treatment of HP infection before SG remains ambiguous.

Comparison of weight loss after Roux-en-Y gastric bypass in Helicobacter pylori-negative and Helicobacter pylori eradicated patients during five years follow-ups

PURPOSE

Helicobacter pylori (HP) is the most common human infection that has affected up to 50% of the population worldwide. The relationship between HP eradication and weight loss is under debate. The present study aimed to compare weight loss outcomes after Roux-en-Y gastric bypass (RYGB) in HP-negative (HP-) and HP-eradicated (HPe) patients during five years follow-ups.

METHODS

This retrospective cohort study was conducted on 305 patients aged 18 and more with severe obesity, who underwent primary RYGB from February 2014 to November 2017. The HP-negative and HP-eradicated patients were evaluated for weight loss outcomes during five years follow-ups.

RESULTS

Patients' mean age, mean weight, and mean body mass index were 38.78 ± 9.9, 114.8 ± 13.6, and 43.37 ± 2.55, respectively. 27.2% of patients who were HP-positive were treated before RYGB. There was no significant difference between the HP- and HPe patients in terms of total weight loss percent (%TWL), 12 to 60 months after RYGB. Excess weight loss percent (%EWL) was higher in HPe patients compared to HP- patients (P = 0.04) at 12-month after RYGB. However, there was no difference in %EWL between these two groups of patients, 36 and 60 months after RYGB.

CONCLUSION

The results of the present study showed that TWL% had no significant difference in HP- and HPe groups during five years follow-ups after RYGB. The %EWL was higher in HPe patients only at 12 months after RYGB and the difference did not persist over time.

Should Biologics Be Used Before Aspirin Desensitization in Aspirin-Exacerbated Respiratory Disease?

There has been a paradigm shift in the management of aspirin-exacerbated respiratory disease (AERD). It started in 2015 when the first biologic was Food and Drug Administration (FDA) approved for severe eosinophilic asthma. Thus, there emerged a new era in the treatment of patients with type 2-mediated airway diseases. This has led to an increasing number of options for patients, undoubtably a great thing, but has left clinicians without a clear answer for how to balance the therapies that exist for AERD, what to recommend for treatment, and how to best assess the benefits and risks of each therapy. This paper aims to explore these benefits and risks, and to provide a roadmap for future studies.

Long-Term Outcomes of Bariatric Surgery in Patients on Chronic Anticoagulation

BACKGROUND

Approximately 3% of patients undergoing metabolic and bariatric surgery (MBS) are receiving chronic anticoagulation therapy (CAT) prior to operation. The management of these patients is complex, as it involves balancing the potential risk of thrombosis against that of bleeding. Our primary objective is to assess the long-term bleeding risk in patients undergoing MBS. We also aim to observe the trends in anticoagulant dosing after MBS.

METHODS

A single-center retrospective review of patients who underwent either primary Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) with preoperative CAT between 2008 and 2022 was performed. Data on baseline demographics, indication for anticoagulation, type of CAT, and dosing were collected. Events of bleeding and the CAT at event were subsequently evaluated.

RESULTS

A total of 132 patients (82 RYGB and 50 SG) initially on CAT were identified, with atrial fibrillation being the most common indication. Incidence of long-term bleeding was significantly higher in the RYGB group (18.3%) compared to the SG group (4%) (p = 0.017) over a total of 5.2 ± 3.8 years. Bleeding marginal ulcer (MU) was the most common cause of bleeding in the RYGB group (13.4%). 84.2% of all bleeding events occurred in patients on chronic Warfarin therapy.

CONCLUSION

Long-term CAT is associated with an increased risk of bleeding in RYGB patients, particularly MU bleeds. Patients on CAT seeking MBS should be counseled regarding this risk and potential implications. Direct-acting oral anticoagulants offer promise as an alternative to Warfarin in these patients; further research is necessary to better understand their safety.