Is laparoscopic sleeve gastrectomy a lower risk bariatric procedure compared with laparoscopic Roux-en-Y gastric bypass? A meta-analysis

Update on comparison of laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass: a systematic review and meta-analysis of weight loss, comorbidities, and quality of life at 5 years

BACKGROUND

Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) are the two most commonly performed bariatric surgeries for the treatment of obesity. This meta-analysis was performed with the aim of summarizing the available evidence on weight loss, remission of comorbidities, and quality of life in LRYGB and LSG, complementing the current literature.

METHODS

We searched PubMed, EMBASE and the Cochrane Library from January 2012 to June 2023 for randomized controlled trials and non-randomized interventional studies. We finally selected 18 eligible studies.

RESULTS

LRYGB resulted in greater weight loss compared with LSG at 5 years [WMD= -7.65 kg/m², 95% confidence interval (CI) -11.54 to -3.76, P = 0.0001], but there exists high heterogeneity with I²=84%. Resolution rate of type 2 diabetes mellitus (T2D) (OR = 0.60, 95%Cl 0.41-0.87, p = 0.007) and dyslipidemia (OR = 0.44, 95%Cl 0.23-0.84, p = 0.01) was higher in the LRYGB group than that in the LSG group at 5 years. There was no difference between LRYGB and LSG for remission of hypertension, and obstructive sleep apnea. No differences were observed in the QoL after LRYGB or LSG. Morbidity was lower in the LSG group (WMD = -0.07, 95% CI: -0.13, -0.02, P = 0.01) than in the LRYGB group. No statistically significant difference was found in mortality between the two procedures.

CONCLUSION

At 5 years after surgery, LRYGB resulted in greater weight loss and achieved better remission rate of T2D and dyslipidemia than LSG. However, LSG has a lower morbidity rate than that of LRYGB.

Ambulatory discharge of patients undergoing sleeve gastrectomy results in significantly more adverse outcomes

BACKGROUND

Same-day discharge after sleeve gastrectomy (SDSG) has become more common during the COVID pandemic. Several payers have suggested that they would no longer reimburse for planned inpatient hospital stay for patients undergoing SG. The goal of our study was to determine which, if any, patient groups could safely undergo SDSG.

METHODS

A retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Project (MBSAQIP) from 2015-2021 was performed. Multivariable logistic regression analysis was performed using demographics, comorbid disease, and participant use data file (PUF) year to determine the risk of adverse events within 30 days of SG by postoperative discharge day.

RESULTS

A total of 702,622 SGs were performed during the study period: 31,308 (4.46%) patients were SDSGs and 409,622 (58.3%) on postoperative day (POD) 1. From 2015 to 2019, the mean percentage of cases that were SDSG was 2.9%. The proportion of SDSG increased to 6.3% in 2020 and 9.6% in 2021. Compared with those discharged on POD 1, SDSG patients were at increased risk for any complication (OR 1.22, 95% CI 1.1-1.36), minor complications (OR 1.17, 95% CI 1.03-1.32), major complications (OR 1.36, 95% CI 1.15-1.61), readmission (OR 1.09, 95% CI 1.00-1.18), and reoperation (OR 1.37, 95% CI 1.16-1.62). Other interventions within 30 days were not statistically significant.

CONCLUSION

Compared with those discharged on POD 1, SDSG patients are at significantly increased risk for all adverse events analyzed. With growing pressure to shorten or eliminate the use of hospital beds, identification of appropriate candidates for safe SDSG is crucial.

Applications of gastric peroral endoscopic myotomy in the treatment of upper gastrointestinal tract disease

Gastric peroral endoscopic myotomy (G-POME) is an emerging minimally invasive endoscopic technique involving the establishment of a submucosal tunnel around the pyloric sphincter. In 2013, Khashab et al used G-POME for the first time in the treatment of gastroparesis with enhanced therapeutic efficacy, providing a new direction for the treatment of gastroparesis. With the recent and rapid development of G-POME therapy technology, progress has been made in the treatment of gastroparesis and other upper digestive tract diseases, such as congenital hypertrophic pyloric stenosis and gastric sleeve stricture, with G-POME. This article reviews the research progress and future prospects of G-POME for the treatment of upper digestive tract gastrointestinal diseases.

Feasibility of same-day discharge after laparoscopic sleeve gastrectomy in the Netherlands

BACKGROUND

There is a trend towards laparoscopic sleeve gastrectomy (SG) with same-day discharge (SDD), as an efficient healthcare pathway to alleviate the burden on clinical capacity. This approach seems to be safe, if patients are carefully selected. In our bariatric center, a protocol for Roux-en-Y gastric bypass with SDD has already been successfully implemented. The aim of this study was to evaluate feasibility of applying the same SDD protocol for SG.

METHODS

A single-center prospective feasibility study was conducted at a high-volume bariatric center. Low-risk patients who were scheduled for primary SG were included. Strict criteria were used for approval upon SDD. The primary outcome was the rate of successful SDD without readmission within 48 h. Secondary outcomes included short-term complications, emergency department visits, readmissions, and mortality.

RESULTS

Fifty patients were included in the study, of whom 45 were successfully discharged on the same day of the surgery. Nausea and vomiting were the most common reasons for overnight hospitalization (three patients). One patient was readmitted within the first 48 h due to a mild complication related to bleeding, resulting in a success rate of 88% for SDD without readmission within 48 h. No severe complications or mortality were reported in the cohort.

CONCLUSION

Our SDD protocol for SG has demonstrated feasibility, with a high success rate of SDD and no severe complications. Strict conditions should be met for the safe implementation of a SDD protocol, including careful patient selection and the establishment of a safety net to detect early complications.

Endoscopic Administration of Combined Autologous Mesenchymal Stem Cells and Platelet-Rich Plasma for the Treatment of Gastric Staple Line Leaks After Sleeve Gastrectomy

BACKGROUND

Gastric staple line leak treatment after laparoscopic sleeve gastrectomy (LSG) remains challenging. Regenerative medicine is gaining place in the accelerated treatment of damaged tissues. This study presents the first series of gastric leak treatment after LSG using endoscopic intragastric administration of combined autologous mesenchymal stem cells (MSC) and platelet-rich plasma (PRP).

METHODS

MSC-PRP harvesting and endoscopic administration techniques are described in detail. Data were prospectively gathered and analyzed. Primary endpoints were morbidity/mortality rates and fistula closure time.

RESULTS

Twelve patients (9 women, 3 men) were included. Median age was 41.5 years, median weight 105.5 kg and median BMI 38.9 kg/m2. Median time to gastric staple line leak detection was 10 days post-LSG. Median time between re-laparoscopy and MSC-PRP administration was 5 days. MSC-PRP endoscopic administration was successfully performed and tolerated by all patients, with median procedure duration of 27 min and minimal blood loss. Four postoperative complications were noted: two patients with increased tibial pain at tibial puncture site, one with tibial hematoma, and one with epigastric pain/dysphagia. Median length of hospital stay was 1 day. Gastric leak healing occurred after a median of 14 days, only two patients requiring a second MSC-PRP endoscopic injection. Median follow-up was 19 months, all patients being in good health at last contact.

CONCLUSION

Endoscopic administration of combined autologous MSC-PRP seems to be a good option for treatment of gastric leaks after sleeve gastrectomy. It is a challenging procedure that should be performed in specialized bariatric centers by expert bariatric surgeons and endoscopists after meticulous patient selection.

Evaluation of Postoperative Care Protocol for Roux-en-Y Gastric Bypass Patients with Same-Day Discharge

INTRODUCTION

Same-day discharge (SDD) after bariatric surgery is increasingly being performed and is safe with careful patient selection. However, detecting early complications during the first postoperative days can be challenging. We developed a postoperative care protocol for these patients and aimed to evaluate its effectiveness in detecting complications and monitoring patient recovery.

METHODS

A single-center retrospective observational study was conducted with patients with who underwent Roux-en-Y Gastric Bypass (RYGB) with successful SDD. The study evaluated the effectiveness of the safety net that included simple remote monitoring with a pulsoximeter and thermometer, a phone consultation on postoperative day (POD) 1, and a physical consultation on POD 2-4. Furthermore, an analysis was performed on various factors including pain scores, painkiller usage, and incidences of nausea and vomiting on POD 1.

RESULTS

In this study, 373 consecutive patients were included, of whom 19 (5.1%) were readmitted until POD 4. Among these, 12 patients (3.2%) reached out to the hospital themselves, while 7 (1.9%) were readmitted after phone or physical consultations. Ten of the readmitted patients had tachycardia. On POD 1, the mean numeric rating scale was 4 ± 2, and 96.6% of the patients used acetaminophen, 35.5% used naproxen, and 9.7% used oxynorm. Of the patients, 13.9% experienced nausea and 6.7% reported vomiting.

CONCLUSION

A postoperative care protocol for SDD after RYGB, comprising simple remote monitoring along with a phone consultation on POD 1 and a physical checkup on POD 2-4, was effective in monitoring patient recovery and detecting all early complications.

Feasibility of Same-Day Discharge After Laparoscopic Roux-en-Y Gastric Bypass in Patients with Well-Regulated Obstructive Sleep Apnea

INTRODUCTION

Same-day discharge after bariatric surgery is increasingly being performed. In current practice, patients with only minor comorbidities are considered eligible for same-day discharge after laparoscopic Roux-en-Y gastric bypass (RYGB). Obstructive sleep apnea (OSA) is a common comorbidity in patients with morbid obesity, with a prevalence of around 70-80% among patients undergoing bariatric surgery. Continuous positive airway pressure (CPAP) is the current gold standard treatment for OSA. We aimed to investigate whether same-day discharge after RYGB is feasible for patients with compliant use of CPAP.

METHODS

In this single-center prospective feasibility study, patients were selected who were scheduled for RYGB and were adequately treated for OSA. Compliance on the use of CPAP had to be proved (> 4 h per night for 14 consecutive nights). There were strict criteria on approval upon same-day discharge. The primary outcome was the rate of successful same-day discharge. Secondary outcomes included short-term complications, emergency department presentations, readmissions, and mortality.

RESULTS

Forty-nine patients underwent RYGB with intended same-day discharge, of whom 45 (92%) were successfully discharged. Three patients had an overnight stay because of divergent vital signs and one patient due to a delayed start of the surgery. Two patients (4%) were readmitted in the first 48 h postoperatively, both due to intraluminal bleeding which was managed conservatively (Clavien-Dindo 2). There were no severe complications in the first 48 h after surgery.

CONCLUSION

Same-day discharge after RYGB can be considered feasible for selected patients with well-regulated OSA.

Same-Day Discharge After Laparoscopic Roux-en-Y Gastric Bypass: a Cohort of 500 Consecutive Patients

INTRODUCTION

There is an increasing demand on hospital capacity worldwide due to the COVID-19 pandemic and local staff shortages. Novel care pathways have to be developed in order to keep bariatric and metabolic surgery maintainable. Same-day discharge (SDD) after laparoscopic Roux-en-Y gastric bypass (RYGB) is proved to be feasible and could potentially solve this challenge. The aim of this study was to investigate whether SDD after RYGB is safe for a selected group of patients.

METHODS

In this single-center cohort study, low-risk patients were selected for primary RYGB with intended same-day discharge with remote monitoring. All patients were operated according to ERAS protocol. There were strict criteria on approval upon same-day discharge. It was demanded that patients should contact the hospital in case of any signs of complications. Primary outcome was the rate of successful same-day discharge without readmission within 48 h. Secondary outcomes included short-term complications, emergency department visits, readmissions, and mortality.

RESULTS

Five hundred patients underwent RYGB with intended SDD, of whom 465 (93.0%) were successfully discharged. Twenty-one patients (4.5%) were readmitted in the first 48 h postoperatively. None of these patients had a severe bleeding. This results in a success rate of 88.8% of SDD without readmission within 48 h.

CONCLUSIONS

Same-day discharge after RYGB is safe, provided that patients are carefully selected and strict discharge criteria are used. It is an effective care pathway to reduce the burden on hospital capacity.

Choosing the best endoscopic approach for post-bariatric surgical leaks and fistulas: Basic principles and recommendations

Post-surgical leaks and fistulas are the most feared complication of bariatric surgery. They have become more common in clinical practice given the increasing number of these procedures and can be very difficult to treat. These two related conditions must be distinguished and characterized to guide the appropriate treatment. Leak is defined as a transmural defect with communication between the intra and extraluminal compartments, while fistula is defined as an abnormal communication between two epithelialized surfaces. Traditionally, surgical treatment was the preferred approach for leaks and fistulas and was associated with high morbidity with significant mortality rates. However, with the development of novel devices and techniques, endoscopic therapy plays an increasingly essential role in managing these conditions. Early diagnosis and endoscopic therapy initiation after clinical stabilization are crucial to success since clinical success rates are higher for acute leaks and fistulas when compared to late and chronic leaks and fistulas. Several endoscopic techniques are available with different mechanisms of action, including direct closure, covering/diverting or draining. The treatment should be individualized by considering the characteristics of both the patient and the defect. Although there is a lack of high-quality studies to provide standardized treatment algorithms, this narrative review aims to provide a summary of the current scientific evidence and, based on this data and our extensive experience, make recommendations to help choose the best endoscopic approach for the management of post-bariatric surgical leaks and fistulas.

Difference in 30-Day Readmission Rates After Laparoscopic Sleeve Gastrectomy Versus Laparoscopic Roux-En-Y Gastric Bypass: a Propensity Score Matched Study Using ACS NSQIP Data (2015-2019)

PURPOSE

There are very few studies that have compared the short-term outcomes of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). Among short-term outcomes, hospital readmission after these procedures is an area for quality enhancement and cost reduction. In this study, we compared 30-day readmission rates after LSG and LRYGB through analyzing a nationalized dataset. In addition, we identified the reasons of readmission.

MATERIALS AND METHODS

The current study was a retrospective analysis of data from National Surgical Quality Improvement Program (NSQIP) All adult patients, ≥ 18 years of age and who had LSG or LRYGB during 2014 to 2019 were included. Current Procedural Terminology (CPT) codes were used to identify the procedures. Multivariate logistic regressions were used to calculate propensity score adjusted odds ratios (ORs) for all cause 30-day re-admissions.

RESULTS

There were 109,900 patients who underwent laparoscopic bariatric surgeries (67.5% LSG and 32.5% LRYGB). Readmissions were reported in 4168 (3.8%) of the patients and were more common among RYGB recipients compared to LSG (5.6% versus 2.9%, P < 0.001). The odds of 30-day readmissions were significantly higher among LRYGB group compared to LSG group (AOR, 2.20; 95% CI; 1.83, 2.64). In addition, variables such as age, chronic obstructive pulmonary disease, hypertension, bleeding disorders, blood urea nitrogen, SGOT, alkaline phosphatase, hematocrit, and operation time were significantly predicting readmission rates.

CONCLUSIONS

Readmission rates were significantly higher among those receiving LRYGB, compared to LSG. Readmission was also affected by many patient factors. The factors could help patients and providers to make informed decisions for selecting appropriate procedures.

Effectiveness of prophylactic doses of tranexamic acid in reducing hemorrhagic events in sleeve gastrectomy

PURPOSE

Laparoscopic sleeve gastrectomy (LSG) is currently the most common bariatric surgery in the world. Although it appears to be a safe treatment for obesity, it is still at risk of complications. The latest literature shows that postoperative bleeding occurs in 2-4% of cases, and up to 3% of cases requires reoperation for hemostasis. The aim of the study is to assess the effect of tranexamic acid (TXA) on hemorrhagic events and the reoperation rate in patients undergoing LSG.

METHODS

The study was designed as a retrospective analysis of patients undergoing LSG. We investigate the patients 6 months before and 6 months after introducing the prophylaxis doses of TXA into our bariatric protocol (non-TXA group vs TXA group).

RESULTS

Three hundred fourteen patients underwent LSG in a high-volume center from 2016 to 2017. After introducing TXA, a statistically significant reduction in the incidence of hemorrhage during surgery was observed (22.3% vs 10.8%, p = 0.006). There was a statistically significant reduction in the need for the staple line oversewing (10.2% vs 1.9%, p = 0.002). The mean operating time and the mean length of hospital stay were significantly higher in the non-TXA group than TXA group (63.1 vs 53.7 min, p < 000.1; 2.3 vs 2.1, p = 0.02). In both groups of patients, no venous thromboembolism or other complications occurred within 6 months after the surgery.

CONCLUSIONS

The prophylactic doses of TXA may be useful in reducing the hemorrhagic events during LSG. It may also shorten the length of hospital stay and the operating time.

Endoscopic Vacuum Therapy (EVT) for the Treatment of Post-Bariatric Surgery Leaks and Fistulas: a Systematic Review and Meta-analysis

Bariatric surgery remains the most effective treatment for morbid obesity and its comorbidities. However, post-surgical leaks and fistulas can occur in about 1-5% of patients, with challenging treatment approaches. Endoscopic vacuum therapy (EVT) has emerged as a promising tool due to its satisfactory results and accessibility. In this first systematic review and meta-analysis on the subject, EVT revealed rates of 87.2% clinical success, 6% moderate adverse events, and 12.5% system dislodgements, requiring 6.47 EVT system exchanges every 4.39 days, with a dwell time of 25.67 days and a total length of hospitalization of 44.43 days. Although our results show that EVT is a safe and effective therapy for post-surgical leaks and fistulas, they should be interpreted with caution due to the paucity of available data.

Single anastomosis sleeve jejunal (SAS-J) bypass as a treatment for morbid obesity, technique and review of 1986 cases and 6 Years follow-up. Retrospective cohort

BACKGROUND

Santoro's operation is a sleeve gastrectomy with transit bipartition. The operation aims to maintain passage to the duodenum to minimize nutritional deficiency. This procedure is rapidly changed to single anastomosis sleeve ileal (SASI) bypass. SAS-J bypass is a modification of SASI with a short biliary limb.

MATERIAL AND METHODS

This study is a retrospective study of prospectively collected data. The study includes a comprehensive review of 1986 patients who underwent SAS-J bypass over 6 years. The total number is used to evaluate the perioperative data. One- and two-year follow-up was used to evaluate weight loss and comorbidities; follow-up of more than 5 years was used to obtain long-term results.

RESULTS

In this study, 70.4% of patients were female and 29.6% were male. The mean body mass index (BMI) was 44.7. The mean age was 42 years. Regarding comorbidities, 25.8% of the patients had type 2 diabetes, 31% were hypertensive, 14.2% had sleep apnea syndrome, 6.6% had gastroesophageal reflux disease (GERD), and 39.6% had hyperlipidemia. Of the 1294 patients who complete one-year follow up, %EWL reached 87%. Blood glucose levels were normalized in 98.5% of patients, hypertension remitted in 93%, hyperlipidemia improved in 97%, SAS is improved in all cases, and GERD improved in 89% of patients. After 5 years, 94 patients' BMI decreased from 44.3 to 28.3 without significant nutritional deficiency.

CONCLUSIONS

Laparoscopic SAS-J bypass is an effective and simple alternative bariatric procedure at short- and long-term follow-up.

Care of the Patient After Metabolic and Bariatric Surgery

Weight loss surgery, also known as metabolic and bariatric surgery (MBS), is an effective weight loss treatment and is associated with reduced mortality and improvements in obesity-related health conditions and quality of life. Postsurgical anatomical and physiologic changes include decreased absorption of micronutrients and alterations in gut-brain hormonal regulation that affect many aspects of health. Patients require ongoing monitoring of their physical and mental health for lasting success. Internists, particularly primary care clinicians, are in an ideal position to monitor for nonserious complications in the short and long term, adjust management of chronic diseases accordingly, and monitor for mental health changes. This article reviews key issues that internists should be aware of for supporting patients' health in the short and long term after MBS.

Portomesenteric vein thrombosis following sleeve gastrectomy: Case report focusing on the role of pathogenetic factors

INTRODUCTION

Sleeve gastrectomy has currently become the most commonly performed bariatric. procedure worldwide according to the last IFSO survey, overtaking gastric bypass with. a share of more than 50% of all primary bariatric-metabolic surgery. Gastric leak, intraluminal bleeding, bleeding from the staple-line and strictures are the most common complications. Portomesenteric vein thrombosis (PMVT)after sleeve gastrectomy is. another complication that has been increasingly reported in case-series in recent.years, although it remains uncommon. In this case report is described an extended portomesenteric vein thrombosis after. sleeve gastrectomy interesting splenic vein too with a favorable course and an. uneventful follow-up. We try to search in this case for pathogenetic factors involved in. this complication.

CASE REPORT

A 42-year old man, with a body mass index (BMI) of 45 kg/m2, with a medical history of Obstructive Sleep Apnea Sindrome (OSAS) underwent laparoscopic sleeve gastrectomy. Early postoperative course was uneventful. Six days after discharge he complained abdominal pain and was admitted at the Emergency Department. A CT scan with intravenous contrast showed an occlusion of the portal vein, of the intrahepatic major branches and an extension to the superior mesenteric vein and the splenic vein. The patient received heparin and oral anticoagulation together with intravenous hydration and proton pump inhibitors. Considering the favourable course the patient was discharged after six days with long-term oral anticoagulation therapy. Anticoagulation with acenocumarol was continued for six months after a CT scan showed resolution of the PMVT without cavernoma. He had no recurrence of symptoms.

DISCUSSION

Porto-mesenteric thrombosis after sleeve gastrectomy is a rare complication but it has been increasingly reported over the last 10 years along with the extensive use of sleeve gastrectomy. Because PMVT is closely associated with sleeve gastrectomy in comparison with other bariatric procedures, we need to investigate what pathogenetic factors are involved in sleeve gastrectomy. Thrombophylic state, prolonged duration of surgery, high levels of pneumoperitoneum, thermal injury of the gastroepiploic vessels during greater curvature dissection, high intragastric pressure, inadequate antithrombotic prophylaxis and delayed mobilization of the patient after surgery have been reported as pathogenetic factors of portmesenteric vein thrombosis. Most of the cases presented in the literature such as our clinical case resolve with medical therapy, although portal vein thrombus extends into the superior mesenteric vein and the splenic vein.

CONCLUSION

Portomesenteric venous thrombosis is a rare but serious complication of bariatric surgery, especially associated with sleeve gastrectomy. Diagnosis is based on CT examination with intravenous contrast, and initial therapy is anticoagulation. Etiologic factors reported in the literature include a long duration of surgery, a high degree of pneumoperitoneum, high intragastric pressure after sleeve gastrectomy and thermal injury to the short gastric vessels and gastroepiploic arcade. Limited operative time, controlled values of pneumoperitoneum, careful dissection with energy device of gastric greater curvature, appropriate prophylaxis with low molecular weight heparin may be useful tools to prevent and limit this complication. Nonetheless we have to search which factors may condition the evolution of an extended PMVT as that described in this case towards resolution or to a further worsening clinical state. Early diagnosis? Correct treatment? Undiscovered patientrelated factors?

Mesenchymal Stem Cells and PRP Therapy Favorize Leak Closure After Sleeve Gastrectomy in Zucker Rats

INTRODUCTION

Sleeve gastrectomy (SG) is the most performed bariatric surgery but gastric leaks following SG occur in up to 2% of cases. Regenerative medicine is emerging as a promising field offering multiple possibilities in wound healing. We studied the efficiency of locally administered mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP) on leak closure following SG in rats.

METHODS

The amount of PRP and MSCs extracted from one rat was analyzed and a model of gastric leak was developed in 10-week-old male Zucker rats. Twenty-four rats underwent SG fashioned with a leak. After 24 h, a second surgery was performed. The control group was treated by peritoneal lavage and drainage only while the experimental group received an additional treatment of locally administered MSCs and PRP at the leak orifice. Analysis of the leak healing process was done by an anatomopathological examination of the stomach 1, 2, 3, and 4 weeks after SG.

RESULTS

The extraction of MSCs and PRP from one rat was necessary for three recipients. Anatomopathological examination suggests that the closure of the leak orifice was faster in the experimental group. Statistical analysis revealed a significantly increased mucosae renewal and fibrosis score at the leak orifice after treatment with MSCs and PRP (p < 0.001).

CONCLUSION

These results suggest that PRP and MSCs may accelerate the closure of leaks following SG in rats and may become a new tool in the treatment of human gastric leaks but more research on this topic is needed to confirm these findings.

Postbariatric EArly discharge Controlled by Healthdot (PEACH) trial: study protocol for a preference-based randomized trial

Introduction

Performing bariatric surgery in a daycare setting has a potential reduction in hospital costs and increase in patients’ satisfaction. Although the feasibility and safety of such care pathway has already been proven, its implementation is hampered by concerns about timely detection of short-term complications. This study is designed to evaluate a combined outcome measurement in outpatient bariatric surgery supplemented by a novel wireless remote monitoring system versus current standard of care.

Methods and analysis

A total of 200 patients with multidisciplinary team approval for primary bariatric surgery will be assigned based on their preference to one of two postoperative trajectories: (1) standard of in-hospital care with discharge on the first postoperative day or (2) same day discharge with ongoing telemonitoring up to 7 days after surgery. The device (Healthdot R Philips) transfers heart rate, respiration rate, activity, and body posture of the patient continuously by LoRaWan network to our hospital’s dashboard (Philips Guardian). The primary outcome is a composite outcome measure within 30 days postoperative based on mortality, mild and severe complications, readmission, and prolonged length-of-stay. Secondary outcomes include patients’ satisfaction and data handling dimensions.

Trial registration

ClinicalTrials.govNCT04754893, Registered on 12 February 2021.

Does powered stapler improve the mechanical integrity of gastrojejunal anastomosis compared to the current techniques? Experimental study in ex vivo porcine models

BACKGROUND

Numerous techniques have been described for fashioning gastrojejunostomy (GJ) in a Roux-en-Y gastric bypass. These include hand-sewn anastomosis (HSA) and mechanical anastomosis; the latter includes circular stapled anastomosis (CSA) or manual linear stapled anastomosis (mLSA). More recently, this list also includes powered linear stapled anastomosis (pLSA). The aim of this study was to analyse if addition of power to stapling would improve the integrity of GJ anastomosis in ex vivo porcine models.

SUBJECTS AND METHODS

The present study included five groups - mLSA1, mLSA2, HSA, CSA, and pLSA. Sequential infusions of methylene blue-coloured saline were performed into the GJ models. Pressure readings were recorded till the point of leak denoting burst pressure (BP). Total volume (TV) and site of leak were recorded. Compliance was calculated from the equation ΔTV/ΔBP.

RESULTS

Differences in pouch and intestinal thickness were not statistically significant between the models. BPs were higher in the mechanical anastomosis groups, i.e., pLSA 21 ± 9.85 mmHg, CSA 20.33 ± 5.78 mmHg, mLSA1 18 ± 4.69 mmHg and mLSA2 11 ± 2.94 mmHg, when compared to HSA 9.67 ± 3.79 mm Hg, which was found to be statistically significant (Kruskal-Wallis test, P = 0.03). Overall, the highest BP was recorded for powered stapling followed by circular, and then, linear stapling; however, this difference was not statistically significant (P = 0.86). There was no statistically significant difference among groups with regard to compliance (Kruskal-Wallis test, P = 0.082).

CONCLUSION

Despite the limited number of samples, mechanical anastomosis showed a statistically higher BP when compared to HSA, suggesting better anastomotic integrity. The pLSA group showed promising results with the highest BP recorded among all groups; however, this did not reach statistical significance.

Outcomes of bariatric surgery in elderly patients: a registry-based cohort study with 3-year follow-up

BACKGROUND

Elderly patients undergo bariatric surgery less frequently than younger patients. Short- and medium-term outcomes after bariatric surgery in the elderly population remain largely unknown. The objective of the present retrospective, registry-based cohort study was to compare short- and medium-term outcomes between patients <65 and ≥65 years undergoing bariatric surgery, hypothesizing similar outcomes between groups.

METHODS

In this retrospective, registry-based cohort study, the Ontario Bariatric Registry was used to compare data of patients <65 and ≥65 years who underwent Roux-en-Y gastric bypass and sleeve gastrectomy between January 2010 and August 2019 in all accredited bariatric centers of excellence in Ontario, Canada. Primary outcomes were overall postoperative complications. Secondary outcomes included early (<30 days) complications, readmissions, reoperations, mortality, weight loss and comorbidities improvement at 1 and 3 year after surgery.

RESULTS

Data of 22,981 patients <65 and 532 patients ≥65 years were analyzed. Overall postoperative complications were similar between patients <65 and ≥65 years (3388/22,981 [14.7%] vs. 73/532 [13.7%], p = 0.537). Early (<30 days) postoperative complications, readmissions, reoperations, and mortality rates were also similar between groups. Both groups had significant weight loss and comorbidities improvement at 1- and 3-year follow-up. Patients <65 years had superior weight loss (+3.5%, 95% CI: 1.6-5.4, p < 0.001) and higher rates of remission for diabetes mellitus (63.8% vs. 39.3%, p < 0.001), hypertension (37.9% vs. 14.5%, p < 0.001), dyslipidemia (28.2% vs. 9.5%, p < 0.001) and gastroesophageal reflux (65.1% vs. 24.0 %, p < 0.001) compared to patients ≥65 years at 3 year.

CONCLUSIONS

Patients <65 and ≥65 years had similar perioperative morbidity and mortality after bariatric surgery. Even though patients <65 years had overall better medium-term outcomes, bariatric surgery is safe and yields significant weight loss and comorbidities improvement in patients ≥65 years.

Effect of Laparoscopic Sleeve Gastrectomy on Heart Transplant Status in 4 Patients with Left Ventricular Assist Devices

Bariatric surgery helps many morbidly obese patients lose substantial weight. However, few data exist on its long-term safety and effectiveness in patients who also have continuous-flow left ventricular assist devices and in whom heart transplantation is contemplated. We retrospectively identified patients at our institution who had undergone ventricular assist device implantation and subsequent laparoscopic sleeve gastrectomy from June 2015 through September 2017, and we evaluated their baseline demographic data, preoperative characteristics, and postoperative outcomes. Four patients (3 men), ranging in age from 32 to 44 years and in body mass index from 40 to 57, underwent sleeve gastrectomy from 858 to 1,849 days after left ventricular assist device implantation to treat nonischemic cardiomyopathy. All had multiple comorbidities. At a median follow-up duration of 42 months (range, 24-47 mo), median body mass index decreased to 31.9 (range, 28.3-44.3) at maximal weight loss, with a median percentage of excess body mass index lost of 72.5% (range, 38.7%-87.4%). After achieving target weight, one patient was listed for heart transplantation, another awaited listing, one was kept on destination therapy because of positive drug screens, and one regained weight and remained ineligible. On long-term follow-up, laparoscopic sleeve gastrectomy appears to be safe and feasible for morbidly obese patients with ventricular assist devices who must lose weight for transplantation consideration. Additional studies are warranted to evaluate this weight-loss strategy after transplantation and immunosuppression.

Endoscopic Management of Sleeve Stenosis

PURPOSE

Sleeve gastrectomy is one of the most popular bariatric procedures performed. A complication of this surgery is sleeve stenosis, causing significant morbidity and the need for corrective intervention. Endoscopic treatment using pneumatic dilation has evolved as an effective, and minimally invasive, technique to successfully treat this complication. Here we report our experience with endoscopic management of sleeve stenosis at a tertiary bariatric center.

MATERIAL AND METHODS

We identified all patients that underwent endoscopic management of sleeve stenosis at a tertiary bariatric center from 2010. We reviewed patient demographics, operative data, interval to endoscopic treatment, and outcomes of pneumatic dilations.

RESULTS

Sixty seven patients underwent 130 endoscopic dilations. The majority of these patients were female (71%), and at the time of sleeve gastrectomy average age was 43.3 years (range 18-68 years) and average BMI was 41.5 kg/m² (range 31-63 kg/m²). The time interval to first endoscopic procedure was 7.2 months (range 0.75-53 months), with an average of 2 procedures per patient. During the follow-up period, the success rate of endoscopic dilatation was 76.1%, while the remaining 16 patients underwent conversion to gastric bypass. Two patients underwent emergency conversion to gastric bypass for sleeve perforation during the procedure (1.5%). There was a modest weight gain of 3 kg (4.2% total body weight) after sleeve dilatation.

CONCLUSIONS

Endoscopic management of sleeve stenosis is safe and effective, with a success rate of over 75%. During endoscopic management, there was a 1.5% risk of sleeve perforation requiring emergency surgery. Mild weight regain occurred following endoscopic sleeve dilation.

Obstruction after Sleeve Gastrectomy, Prevalence, and Interventions: a Cohort Study of 9,726 Patients with Data from the Scandinavian Obesity Surgery Registry (SOReg)

Background

Sleeve gastrectomy (SG) is the most common bariatric procedure worldwide. Obstructive symptoms, together with leaks, are among the most serious postoperative complications. This study aimed to investigate the incidence of symptomatic obstruction after SG in Sweden and to explore risk factors, treatment strategies, and outcome.

Methods

A retrospective analysis of prospectively collected data from the Scandinavian Obesity Surgery Registry (SOReg) of patients undergoing SG and developed obstruction symptoms within the first postoperative year was performed. For patients who had undergone any re-intervention, such as endoscopic dilatation or remedial surgery, medical charts were reviewed.

Results

From 2007 to 2018, a total of 9,726 SG were performed, and 59 (0.6%) of them developed postoperative obstruction. Intolerance of solid food was the most common symptom associated with obstruction (80%). Sixty-one percent of the patients had obstruction at the level of incisura angularis. Longer operative time, higher rate of perioperative complications, longer hospital stay, and oversewing the staple line were associated with an increased risk of obstruction. Endoscopic balloon dilatation was performed in 59% of patients (n=35) and successful in 18 patients (51%). Twenty-one patients (36%) underwent surgical conversion to Roux-en-Y gastric bypass (RYGB). After revisional surgery, 11 (52%) reported complete relief of symptoms.

Conclusions

Obstruction was rare (0.6%) and most often located at the incisura angularis. Obstruction was associated with longer operative time, perioperative complications, oversewing of the staple line, and longer hospital stay. Endoscopic dilatation or surgical conversion to RYGB frequently alleviates symptoms, but despite treatment, almost 50% reported residual symptoms.

Graphical abstract

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

BACKGROUND

Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus.

OBJECTIVE

To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed.

DESIGN

A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes.

RESULTS

Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise.

CONCLUSION

Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.

Roux-En-Y Gastric Bypass Versus Sleeve Gastrectomy Plus Procedures for Treatment of Morbid Obesity: Systematic Review and Meta-Analysis

Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the most commonly performed bariatric procedures globally, but both techniques have shortcomings. Several modifications of SG (SG plus procedures) have been developed, but the efficacy of the different procedures has not been completely elucidated. In this meta-analysis, we aimed to evaluate the efficacy and safety of SG plus procedures. Out of the initially identified 2357 studies, thirteen were selected for this meta-analysis: two studies on banded sleeve gastrectomy (BSG), four studies on sleeve gastrectomy plus duodenal-jejunal bypass (SG + DJB) or sleeve gastrectomy with loop duodenal-jejunal bypass (SADJB), two studies on sleeve gastrectomy with jejunal-jejunal bypass (SG + JJB), four studies on single anastomosis duodenal-ileal switch (SADI-S), and one study on stomach intestinal pylorus-sparing surgery (SIPS). SADI-S procedure was found to achieve significantly greater percentage of excess weight loss than the RYGB. SG + DJB and SADJB achieved greater weight loss than the RYGB. Major complications were fewer with SG + JJB than with RYGB, but the difference was not significant. Overall, SG plus procedures appear to achieve better weight loss and cause fewer complications than RYGB.

Complications associated with laparoscopic sleeve gastrectomy - a review

Laparoscopic sleeve gastrectomy (LSG) is an essential bariatric procedure performed in obese patients, which provides significant weight loss and has a positive impact on obesity-related diseases. However, as with any surgical procedure, it carries the risk of complications. The complications that can arise in patients following LSG are divided into acute (diagnosed within 30 days after the surgery) and late. Early complications that require rapid management include haemorrhage (intraluminal or extraluminal), leak in the staple line, and abscess formation. Late complications include gastric stenosis, nutrient deficiencies, mediastinal pouch migration, and the development or exacerbation of gastroesophageal reflux diseases. In this review, we present the basic information about most common complications following LSG, and their symptoms, diagnostic tools, and management.

The influence of obstructive sleep apnea syndrome on anthropometric parameters at 12 months after laparoscopic sleeve gastrectomy

The aim of this study was to assess the influence of obstructive sleep apnea syndrome (OSAS) on the change in anthropometric parameters and body composition, in patients undergoing laparoscopic sleeve gastrectomy (LSG). This prospective study included patients undergoing LSG who had pre-operative polysomnography data and were also evaluated at six and 12 months after surgery. All patients included also had whole body composition analysis data before surgery and at six and 12 months after surgery. The results are presented in comparison between patients with and without OSAS. We included 73 patients in the analysis with a mean ± SD age and body mass index (BMI) of 40.3 ± 10.9 years and 45.4 ± 6.3 kg/m², respectively. As compared to the baseline levels, at 6 months there was a significant decrease in BMI, weight, waist circumference, serum glucose and HbA1c. At 12 months there was no further decrease as compared to the 6 months levels, irrespective of OSAS status. We observed a significant decrease at 6 months in percentage of fat, in both types of patients. However, as compared to the 6 months levels, at 12 months the percent fat had a significant decrease only in patients without OSAS (− 4.6%, 95% CI − 7.6 to − 1.7%) and not in those with OSAS (− 2.2%, 95% CI − 4.5 to 0.2%). In our study, patients with OSAS showed a similar decrease in different anthropometric parameters as those without OSAS after LSG. However, at 12 months of follow-up there was a significant decrease in the percent fat only in patients without OSAS.

Endoscopic treatment of postoperative esophagogastric leaks with fully covered self-expanding metal stents

BACKGROUND

the management of postoperative esophageal leaks is a huge therapeutic challenge. Thanks to the advances in endoscopy, treatment with esophageal stents has been proposed as a valid option.

AIMS

the main objective of the study was to evaluate the effectiveness and safety of the use of fully covered esophageal metal stents in the treatment of postoperative esophageal leaks.

METHODS

a retrospective observational study was performed in patients with postoperative esophageal leaks, treated with fully covered self-expandable metal stents between June 2011 and May 2018.

RESULTS

twenty-five patients were evaluated and 34 stents were placed. The closure of the leak was observed in 21 patients after removal of the stent, with an overall technical success rate of 84 %. The mean time with a stent placed for closure of the fistula was 55.7 ± 27.11 days/patient (mean of 39 ± 24.30 days/stent). The most frequent complication was a partial distal stent migration (7/34 stents), followed by five cases of complete migration into the stomach.

CONCLUSIONS

endoscopic treatment with fully covered self-expandable metal stents seems to be an effective and safe first-line treatment for postoperative esophageal leaks, according to the experience in our center.

The role of extended antral resection on weight loss and metabolic response after sleeve gastrectomy: A retrospective cohort study

Objective:

The impact of extended antral resection (AR) after laparoscopic sleeve gastrectomy (LSG) on clinical results is still not clearly elucidated with conflicting results. Our study aimed to determine whether AR is superior to antral preservation (AP) regarding clinical results.

Methods:

Patients were divided into two groups according to the distance of gastric division as AR group (2cm from pylorus) and AP group (6cm from pylorus). Postoperative excess weight loss percentile (%EWL) and total body weight loss percentiles (%TBWL) at the end of first, 6^th and 12 months were compared. Secondly, metabolic parameters and complications were compared.

Results:

The first 68 patients underwent AP, and the following 43 patients underwent AR. Although statistically not significant, AR achieve more %EWL and %TBWL at the end of the first year, (P>0.05). On the other hand, metabolic parameters were similar at the end of the first year, (P>0.05). Resolution of comorbidities were statistically not different, (P>0.05). Staple line leak occurred in two patients of the AR group (4.7%) and two patients of the AP group (2.9%), (P>0.05).

Conclusion:

Both AR and AP seem to be equally effective in resolution of metabolic response. Although statistically not significant- AR provided more %EWL and %TBWL at the end of 12 months.

[SOFFCO-MM guidelines for the resumption of bariatric and metabolic surgery during and after the Covid-19 pandemic]

Face à l’émergence de la pandémie à COVID 19, l’activité de chirurgie bariatrique/métabolique a été arrêtée. Le confinement et l’arrêt de cette chirurgie ont eu un impact sous-estimé sur la population obèse avec prise de poids, et aggravation des comorbidités. Un certain nombre de candidats à cette chirurgie sont exposés à un risque important de mortalité liée à la pandémie. En effet, l’obésité et le diabète sont deux facteurs de risque majeurs de forme grave d’infection à COVID-19. Le seul traitement efficace actuel de l’obésité est la chirurgie métabolique avec un bénéfice rapide et durable. Il paraît donc nécessaire de reprendre une activité de chirurgie métabolique. Le but de ce travail est de hiérarchiser la reprise chirurgicale afin qu’elle soit progressive et cohérente. Les organigrammes proposés aideront les centres à déterminer les patients prioritaires selon la balance bénéfice-risque. Le diabète a une place centrale dans l’arbre décisionnel. Les modalités de reprise seront variables d’un centre à l’autre selon les ressources humaines, matérielles et médicamenteuses, et seront à adapter à l’évolution épidémique. Un consentement éclairé spécifique sera nécessaire. Un dépistage chez les patients obèses est à envisager dont les modalités de dépistage sont élaborées sur la base des connaissances disponibles. En cas de suspicion de COVID, la chirurgie doit être différée. Il faut insister sur les mesures et gestes barrières afin de protéger le patient et le personnel soignant. Un confinement est fortement suggéré pour le patient durant le premier mois postopératoire. Le suivi des patients sera effectué de préférence par téléconsultation.

SOFFCO-MM guidelines for the resumption of bariatric and metabolic surgery during and after the Covid-19 pandemic

Bariatric/metabolic surgery was paused during the Covid-19 pandemic. The impact of social confinement and the interruption of this surgery on the population with obesity has been underestimated, with weight gain and worsened comorbidities. Some candidates for this surgery are exposed to a high risk of mortality linked to the pandemic. Obesity and diabetes are two major risk factors for severe forms of Covid-19. The only currently effective treatment for obesity is metabolic surgery, which confers prompt, lasting benefits. It is thus necessary to resume such surgery. To ensure that this resumption is both gradual and well-founded, we have devised a priority ranking plan. The flow charts we propose will help centres to identify priority patients according to a benefit/risk assessment. Diabetes holds a central place in the decision tree. Resumption patterns will vary from one centre to another according to human, physical and medical resources, and will need adjustment as the epidemic unfolds. Specific informed consent will be required. Screening of patients with obesity should be considered, based on available knowledge. If Covid-19 is suspected, surgery must be postponed. Emphasis must be placed on infection control measures to protect patients and healthcare professionals. Confinement is strongly advocated for patients for the first month post-operatively. Patient follow-up should preferably be by teleconsultation.

The Prognostic Value of the Dutch Sweet Eating Questionnaire on Weight Loss After Metabolic Surgery: a Randomized Controlled Trial

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) have shown different weight loss results. These differences might be partly due to dumping after LRYGB, forcing sweet eaters to switch to a healthy diet. The Dutch Sweet Eating Questionnaire (DSEQ) is validated to measure sweet eating. This study aims to investigate if sweet eating measured with the DSEQ influences weight loss.

METHODS

In this multicenter randomized controlled trial, patients were included between 2013 and 2017 in two Dutch high-volume hospitals, and randomized with a 1:1 ratio between LRYGB and LSG. Primary outcome measure was weight loss. Secondary outcome measure was sweet eating behavior, measured with the DSEQ. Data was collected at baseline, 1 year and 2 years postoperatively.

RESULTS

Data was analyzed of 623 patients who underwent LRYGB (n = 308; 49.4%) or LSG (n = 315; 50.6%). Follow-up rates at 2 years postoperative were 67.1% for weight and 35.3% for DSEQ. At 2 years postoperative, mean BMI was significantly higher after LSG than LRYGB (respectively 30.88 versus 28.87 kg/m², p < 0.001), and the percentage of sweet eaters was significantly higher after LSG than LRYGB (respectively 8.6% versus 2.6%, p = 0.049). None of the preoperative sweet eaters were sweet eaters 2 years after LRYGB (0.0%), versus 11.8% 2 years after LSG. No correlation was found between postoperative sweet eating behavior and %EBMIL.

CONCLUSION

No significant correlation was found between preoperative or postoperative sweet eating measured with the DSEQ and weight loss. The decision-making for the procedure type is more complex than weight loss and dietary habits, and should also involve quality of life and presence of comorbidities. These factors should be addressed in future research along with longer term results.

TRIAL REGISTRATION

Dutch Trial Register NTR-4741.

Trial protocol: preoperative administration of tranexamic acid in sleeve gastrectomy (PATAS) to reduce haemorrhage rates. A randomised controlled trial

INTRODUCTION

Fast-track protocols often include short-term thromboprophylaxis and short length of hospital stay. These treatment strategies may negatively affect the occurrence and diagnosis of postoperative haemorrhage. Over the years, the rates of venous thromboembolic events (VTEs) have decreased, while there seems to be an increase in the occurrence of postoperative haemorrhage. Tranexamic acid (TXA) can potentially lower the incidence of postoperative haemorrhage. This trial aims to investigate whether preoperative administration of TXA reduces the preoperative and postoperative haemorrhage rates in laparoscopic sleeve gastrectomy (LSG).

METHODS AND ANALYSIS

This is a single centre double-blind randomised placebo-controlled trial. Patients undergoing an LSG are included after obtaining informed consent. Patients are randomised between two groups: (1) administration of placebo infusion and (2) administration of 1500 mg TXA. In both groups, the infusions will be administered during the induction phase of the procedure. Primary outcome measures are preoperative use of haemostatic clips, postoperative haemoglobin decrease and postoperative haemorrhage. Secondary outcome measure is the rates of VTE.

ETHICS AND DISSEMINATION

The protocol version 3 was approved by the medical ethical committee Medical Research Ethics Committees United (MEC-U), Nieuwegein, on 29 July 2019. The trial results will be submitted for publication in a peer-reviewed journal and at conference presentations.

TRIAL REGISTRATION NUMBER

The Netherlands Trial Registry (NL8029); Pre-results.

Mentorship Programs in Bariatric Surgery Reduce Perioperative Complication Rate at Equal Short-Term Outcome-Results from the OPTIMIZE Trial

OBJECTIVES

The aim of this study was to determine the efficacy of coaching on outcome in low volume centers of excellence and to evaluate the influence of mentorship programs on the center development.

BACKGROUND

The number of bariatric procedures has increased steadily in the last years. Providing nationwide bariatric care on a high professional level needs structures to train and guide upcoming centers and ensure high quality in patient care.

METHODS

A prospective multicentered, observational study including laparoscopic sleeve gastrectomies (SG) and Roux-en-Y gastric bypass (RYGB) procedures was performed. Twelve emerging bariatric centers were coached by five experienced bariatric centers. Surgeons of the mentor centers gave guidance on pre- and postsurgical management of their patients including complications and proctored the first interventions. The results were compared regarding operative outcomes, percentage of excess weight loss, complications, and resolution of comorbidities.

RESULTS

A total of 214 of 293 patients (73.0%) completed the study. The most frequently reported complications were wound infection (4.4%), disorder of emptying stomach/new reflux (2.4%), anastomotic leaks, intra-abdominal secondary hemorrhage, and dumping syndrome (2.0% each). The mortality rate was zero. We found no difference in overall complication rates or resolution of obesity-related comorbidities when comparing experienced surgeons with less experienced surgeons.

CONCLUSIONS

Our results suggest that under the conditions of the practices of this study, coaching and mentoring were associated with comparable outcomes both in experienced and emerging centers. In addition, mentorship programs ensure equal outcome quality in terms of improvement of obesity-associated comorbidities.

TRIAL REGISTRATION

NCT Number: NCT01754194 .

Sleeve Gastrectomy: You Might Lose your Liver!

Sleeve gastrectomy (SG) is currently the most popular bariatric procedure. Portomesenteric venous thrombosis (PVT) is a feared and increasingly reported complication. Herein, we describe the history of a patient who developed a post-operative PVT after SG, aggravated with refractory ascites, and finally required orthotopic liver transplantation (LT). Acquired thrombophilia-anti-cardiolipin syndrome was present. As SG expands worldwide, this first case of LT for PVT following SG may warrant a systematic screening for prothrombotic condition and information on the possible consequences of PVT prior to bariatric surgery.

Sleeve Gastrectomy in Morbidly Obese HIV Patients: Focus on Anti-retroviral Treatment Absorption After Surgery

CONTEXT

Anti-retroviral therapy (ART) dramatically reduced AIDS development, thus enabling patients to live as long as the general population. New challenges have emerged particularly cardiometabolic diseases and weight gain, with some HIV patients seeking bariatric surgery (BS). However, BS outcomes during HIV remain poorly described, with scarce data on ART pharmacokinetic post-BS.

OBJECTIVE

Describing sleeve gastrectomy (SG) results in HIV patients in terms of ART pharmacokinetic, HIV control, weight loss, and metabolic outcomes.

DESIGN, SETTING, AND PATIENTS

Prospective study of HIV patients undergoing SG in a referral academic center, with at least 6 months follow-up.

MAIN OUTCOME MEASURE

Clinical and biological parameters, HIV medical history, and ART pharmacokinetics were gathered before and post-SG.

RESULTS

Seventeen patients (mean BMI = 44.2 ± 5.7 kg m^-2) and major obesity-related diseases (47% type-2 diabetes, 64% obstructive sleep apnea, 70% hypertension) underwent SG during a mean 2 years of follow-up. They displayed an average of 20% reduction of initial BMI and improved body composition, similarly to obese non-HIV patients. SG improved metabolic status. All patients had undetectable viral load before BS. Upon HIV follow-up, 12 patients had undetectable viral load with correct ART kinetic parameters (3 and 6 months); 4 displayed detectable viral load along with significant decrease in raltegravir and atazanavir treatment exposure, leading to ART change with subsequent undetectable viral load; and 1 had persistent detectable viral load despite ART change.

CONCLUSIONS

SG seems effective and safe in obese HIV patients. However, ART treatment should be monitored post-SG to control HIV infection. We suggest that some ART should be adapted before SG conjoints with infectious disease specialists.

Laparoscopic Sleeve Gastrectomy Is Associated with Lower 30-Day Morbidity Versus Laparoscopic Gastric Bypass: an Analysis of the American College of Surgeons NSQIP

PURPOSE

Laparoscopic sleeve gastrectomy (LSG) has rapidly gained popularity as a single-stage operation for the treatment of morbid obesity, as patients undergoing LSG have been shown to achieve similar weight loss and resolution of obesity-related comorbidities in comparison to those undergoing Roux-en-Y gastric bypass (RYGB), the "gold standard" bariatric operation. Although LSG poses fewer technical challenges than RYGB, little is known about differences in short-term outcomes among patients undergoing LSG and RYGB. We hypothesized that LSG is associated with lower 30-day risk-adjusted serious morbidity.

METHODS

Preoperative characteristics and 30-day outcomes from the American College of Surgeons National Surgical Quality Improvement Program (ACSNSQIP) Participant Use Files (PUF) 2010-2014 were selected for all patients who underwent LSG or RYGB. Descriptive comparisons were performed using chi-square and Wilcoxon's rank-sum tests as appropriate. The primary outcome was a risk-adjusted composite measure of 30-day serious morbidity and mortality.

RESULTS

We analyzed records for 47,982 (42.0%) and 66,380 (58.0%) patients undergoing LSG and RYGB, respectively. On univariate analysis, LSG patients had a lower rate of organ space infection (0.45% vs. 0.68%, p < 0.001), lower rate of bleeding requiring transfusions (1.00% vs. 1.60%, p < 0.001), lower rate of sepsis (0.34% vs. 0.49%, p < 0.001), and septic shock (0.12% vs. 0.22%, p < 0.001) and required fewer unplanned reoperations (1.34% vs. 2.56%, p < 0.001) than RYGB patients. Both groups had similar rates of deep venous thrombosis (0.33% vs. 0.28%, p = 0.15) and pulmonary embolism (0.17% vs. 0.21%, p = 0.15). Mortality was lower among LSG patients (0.09% vs. 0.14%, p = 0.01). On multivariate analysis, RYGB was associated with higher risk-adjusted 30-day serious morbidity than LSG (odds ratio 1.61; 95% CI 1.52-1.71, p < 0.001). Older age, female gender, higher BMI, and insulin-dependent diabetes were also associated with risk of serious morbidity (C-statistic = 0.60).

CONCLUSION

Serious morbidity following bariatric surgery is uncommon; however, LSG may be associated with modest protection from adverse 30-day outcomes in comparison to RYGB. Our conclusion is limited by the difference in baseline risk factors of the populations studied.

The Distance between the Pylorus and Left Vagus Nerve during Sleeve Gastrectomy

The sleeve gastrectomy (SG) can be performed with or without antral preservation (distance from the pylorus <50 mm). The objective of this study was to evaluate the distance between the pylorus and the end of the left vagus nerve in order to determine whether it could be used as a constant anatomical landmark to start gastric transection. This was a prospective, nonrandomized study of 120 patients undergoing SG from January to October 2018. The distance measurement between pylorus and vagus nerve was performed at the beginning of the SG. The primary endpoint was the distance between the beginning of the pylorus and the end of the second branch of the vagus nerve on the upper edge of the antrum. The secondary endpoints was the correlation factors between the preoperative data and the position of the end of the vagus nerve. A total of 120 patients, with a mean body mass index of 42.2 kg/m² , underwent primary SG. The mean distance between pylorus and the end of the vagus nerve was 50.4 mm (35-64) on the upper part of the antrum. When considering the inferior part of the antrum, the minimum distance was 50 mm. No correlations were found between preoperative data and distance measurements. The vagus nerve can be considered as a constant and reliable anatomical landmark for performing SG with antral preservation. However, no correlation was found between the preoperative data and the location of the end of the vagus nerve. Clin. Anat. 33:562-566, 2020. © 2019 Wiley Periodicals, Inc.