One-Year Mortality after Contemporary Laparoscopic Bariatric Surgery: An Analysis of the Bariatric Outcomes Longitudinal Database

Binge drinking at time of bariatric surgery is associated with liver disease, suicides, and increases long-term mortality

BACKGROUND AND AIMS

Alcohol use disorder has been reported in patients undergoing bariatric procedures, but the pattern of alcohol consumption has not been evaluated. We investigated the prevalence, risk factors, and impact of binge drinking (BD) at the time of surgery and during follow-up.

METHODS

A prospective, longitudinal study of subjects undergoing bariatric surgery was included in the LABS-2 registry between 2006 and 2009. Participants with AUDIT questionnaire at the time of surgery and a minimum of 12 months follow-up were included. BD was defined as consuming ≥5 drinks on at least 1 occasion in the previous month. Liver biopsies were obtained during bariatric procedures in not all cases. Survival analysis was performed with the adjusted Cox regression model and competing risk.

RESULTS

A total of 2257 subjects were included, with a median follow-up of 79 months. The prevalence of BD at time of surgery was 12%, and it raised up to 23% during follow-up. Patients with BD predominantly had a binge eating disorder (OR=1.35 [95% CI: 1.04-1.76]), regularly consumed fast food [OR=1.4 (95% CI: 1.07-1.85)] and used other drugs (OR=2.65 [95% CI: 1.74-4.04]). Within liver biopsies evaluation, BD showed higher hepatic iron deposits (OR=3.00 [95% CI: 1.25-7.21]). BD at the time of surgery was associated with a higher risk of BD during follow-up (OR=10.49 [95% CI: 7.86-14.00]) and long-term mortality (HR: 3.21 [95% CI: 1.67-6.18]). Specific causes of death in these patients with BD were liver disease (p=0.020), suicide (p=0.015), neoplasms (p=0.034), and respiratory (p=0.025).

CONCLUSIONS

The prevalence of BD in patients undergoing bariatric surgery is high and increases the risk of postoperative liver disease, suicides, and long-term mortality.

Comparative Analysis of Mortality Rates among Morbidly Obese Individuals: A Study of Patients Undergoing Bariatric Surgery, Nonsurgical Morbidly Obese Individuals, and the General Population

INTRODUCTION

Mortality decreases following bariatric surgery. We explored the extent of the reduction and whether or not it reaches the general population level in a large cohort of patients with obesity. This study aimed to compare all-cause mortality between patients with obesity who undergo bariatric surgery and those who do not, with the general Iranian population during the same period.

METHOD

Data from Iran's National Obesity Surgery Database were used to establish a large cohort of patients registered between 2009 and 2019. The current vital status of the patients was determined by utilizing post-surgery follow-up data for those who underwent the operation. For patients without a surgery record, a predefined checklist was filled out through telephone interviews. Death data from the National General Registrar's office were obtained for all cohort members.

RESULTS

Of 13,313 cohort members, 12,915 were eligible for analysis. The median age at the first visit was 38 years, and 78% were women. 6,190 patients (47.9%) underwent bariatric surgery, and 6,725 patients (52.1%) were not yet operated on at the time of analysis. We observed 139 deaths during 53,880 person-years follow-ups. The median follow-ups for operated-on and not operated-on groups were 4 and 4.8 years. The mortality rates among nonoperated patients were 2.89 times higher (standardized mortality ratio [SMR] = 2.89, 95% CI: 2.36-3.53) than those in the general population, while in operated patients, the mortality rate decreased to 1.82 as high (SMR = 1.82, 95% CI: 1.34-2.46).

CONCLUSION

The risk of death has been diminished in the operated-on group. It still remains considerably higher than the risk in the general population.

Bariatric surgery efficacy in patients with mood disorders

BACKGROUND

Mood disorders are comorbid in patients with obesity and found in approximately 22.0% to 54.8% of patients who are eligible for bariatric surgery. Given the unclear effect of mood disorders on bariatric surgery outcomes, we aimed this study to assess the impact of mood disorders index bariatric surgery weight loss outcomes.

METHODS

A retrospective study institutional database of index bariatric surgery patients at University Hospitals Cleveland Medical Center between 2016 and 2018. The primary outcome of body mass index was followed over a 4-year period. The secondary outcomes measured were mortality and suicide rates. Mood disorders defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, included depressive and bipolar disorders obtained from electronic medical records International Classification of Diseases, Tenth Revision, coding.

RESULTS

A total of 790 patients underwent bariatric surgery between 2016 and 2018. Of these, 15 patients were excluded due to death in the postoperative period or insufficient weight loss data, and a total of 775 patients (620 women and 155 men) were included. Two hundred and ninety-five (38.1%) had an electronic medical record mood disorder diagnosis before surgery, while 480 (61.9%) did not. Both groups had a significant decrease in postoperative body mass index; however, there was no significant difference in the body mass index change between the mood disorder group (mean = 37.63, standard deviation = 9.88) and the control group (mean = 38.72, standard deviation = 9.54; t[294] = 1.40; P = .1634).

CONCLUSION

Patients with mood disorders are as successful with weight loss after index bariatric surgery as those without mood disorders. There was no significant difference in mortality rates between the mood disorder group and the control group. Hence, mood disorders should not be prohibitive for weight loss surgery.

Achieving durable compliance with venous thromboembolism prophylaxis in bariatric surgery: 3-year data from a major academic medical center

BACKGROUND

Metabolic and bariatric surgery (MBS) venous thromboembolism (VTE) prescribing practices vary widely. Our institutional VTE prophylaxis protocol has historically been unstandardized.

OBJECTIVES

To create a standardized MBS VTE prophylaxis protocol, track protocol compliance, and identify barriers to protocol compliance and address them with Plan-Do-Study-Act (PDSA) cycles.

SETTING

Single Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program-accredited academic hospital.

METHODS

We conducted a retrospective study for all patients undergoing MBS (January 2019 to September 2022). A multidisciplinary group of bariatric clinicians reviewed literature and developed the following standardized VTE prophylaxis protocol: 5000 units preoperative subcutaneous (SC) heparin within 60 minutes of anesthesia induction and postoperative 40 mg SC low molecular weight heparin (LMWH) within 24 hours of surgery. This protocol was distributed to relevant clinical stakeholders. We assessed monthly compliance rates through chart review. Goal compliance was ≥90%. We identified sources of noncompliance and addressed them with PDSA methodology.

RESULTS

A total of 796 patients were included. Preoperative heparin administration increased from a mean of 47% (107/228) preintervention to 96% (545/568) postintervention (P < .0001), and postoperative LMWH administration increased from 71% (47/66) to 96% (573/597, P = .0002). These compliance rates were sustained for 3 years. Barriers to protocol noncompliance included order set timing errors (n = 45), surgeon error (n = 44), surgeon discretion (n = 40), and nursing error (n = 20). No change in bleeding or VTE rates was observed.

CONCLUSIONS

Developing a standardized VTE prophylaxis protocol, monitoring process measures, and engaging relevant stakeholders in PDSA cycles resulted in drastic and durable improvement in VTE prophylaxis compliance rates.

When do leaks occur? An analysis of the metabolic and bariatric surgery accreditation and quality improvement program

BACKGROUND

Leak is a feared complication of bariatric surgeries. Time to presentation is important in their management. We used the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) to evaluate the rate and timing of leaks.

OBJECTIVES

To determine when leaks present after bariatric surgery.

SETTING

MBSAQIP database.

METHODS

The MBSAQIP Participant Use Files (PUF) for the years 2015-2020 were evaluated. Outcomes of interest were "organ space infection" and "leak." We evaluated the time to presentation for these variables as well as patient characteristics, operative time, complication rates and 30-day outcomes.

RESULTS

There were 370,369 sleeve gastrectomies (SG) and 159,280 Roux-en-Y gastric bypasses (RYGB). We identified 598 (.16%) SG leaks with an average time to presentation of 13.2 ± 7.8 days. For RYGB, there were 520 leaks (.32%) with an average time to presentation of 9.5 ± 7.4 days. Both procedures had longer operative times for the patients with leak; RYGB was 115 minutes versus 131 minutes and SG was 67 minutes versus 77 minutes (both P < .01). SG and RYGB patients with a leak had a higher relative risk (RR) of grade 4 and 5 Clavien-Dindo complication rates. RR of mortality rates in SG patients with leak was 35.2 (confidence interval (CI): 20-61) and in RYGB with leak was 31.4 (CI: 19-50).

CONCLUSIONS

The length of time for SG leak presentation was more delayed than RYGB leak presentation. Surgeons should be vigilant for leaks for at least 3 weeks after surgery. Leaks increase the mortality rate and overall serious complications.

Bariatric surgery and left ventricular assist device in patients with heart failure: A systematic review and meta-analysis

BACKGROUND

The role of metabolic and bariatric surgery (MBS), in synergy with left ventricular assist device (LVAD) implantation, in the scope of end-stage heart failure management for patients with severe obesity is not well elucidated.

METHODS

We conducted a meta-analysis using Cochrane, Embase, PubMed, and Scopus databases to include articles from their inception to November 2022.

RESULTS

A total of 271 patients who underwent MBS during or after the LVAD implantation were included from eleven separate studies. After surgery, 67.4% of patients were listed on the heart transplant waitlist with 32.5% undergoing a successful transplant. We reported a mean listing time of 13.8 months. Finally, the pooled postoperative complication rate, 30-day readmission rate, and one-year mortality rate were 47.6%, 23.6% and 10.2% respectively.

CONCLUSIONS

MBS and LVAD is a safe and effective approach to bridge patients with severe obesity and end-stage heart failure for definitive heart transplantation.

Management of Staple Line Leaks after Laparoscopic Sleeve Gastrectomy

Background and Objectives:

Laparoscopic sleeve gastrectomy has become one of the most popular bariatric surgeries in the United States with a low rate of morbidity and effective weight loss. However, staple line leak remains a feared complication requiring a lengthy and difficult treatment course until resolution. This study outlines the various treatment methods used within a high-volume bariatric practice for successful leak resolution without necessitating a conversion procedure.

Methods:

A retrospective review was conducted on all patients with staple line leak after laparoscopic sleeve gastrectomy in a three-surgeon bariatric practice from January 1, 2010 to December 31, 2019.

Results:

A total of 10 staple line leaks were identified with a leak rate of 0.9%. Patients presented on average 29.3 days postoperatively and were all diagnosed on computed tomography. Three patients were initially managed operatively with washout and drainage procedure. Six patients were managed endoscopically initially with either stent or over-the-scope clip placement. Most patients required multiple interventions with an average of 2.4 interventions per patient. Average time to leak resolution was 48.2 days (15–95 days).

Conclusion:

Management of staple line leaks after laparoscopic sleeve gastrectomy requires a multimodal approach usually requiring multiple interventions before leak resolution. We demonstrate effective utilization of varying interventions that lead to effective leak resolution and avoid conversion operations.

META‐ANALYSIS OF PATIENT RISK FACTORS ASSOCIATED WITH POST‐BARIATRIC SURGERY LEAK

Objective

Modifiable risk factors such as diabetes, hyperlipidemia, hypertension, obstructive sleep apnea (OSA), chronic kidney disease (CKD), chronic steroid use and smoking, have been shown in observational studies to negatively affect surgical outcomes. The purpose of this study is to identify and determine the effect of modifiable risk factors on post-operative bariatric surgery leak, as pre-operative risk modification has been shown to reduce the impact on complications.

Methods

Electronic literature searches of MEDLINE, PUBMED, OVID and Cochrane Library databases were performed, including a manual reference check, over the period of 2010 and 2020. 620 articles were screened according to the PRISMA protocol.

Results

Twenty articles were included in the meta-analysis of risk factors. Significant risk factors and the associated effect sizes include: 1. Smoking with an overall OR of 1.31 [1.06, 1.61] and an OR of 1.72 [1.44, 2.05] in Sleeve gastrectomy (SG) patient cohorts; 2. Diabetes with an overall OR of 1.23 [1.08, 1.39] and an OR of 1.33 [1.02, 1.73] in Roux-en-Y patient cohorts; 3. Chronic kidney disease with an overall OR of 2.41 [1.62, 3.59] and 4. Steroid use with an overall OR of 1.57 [1.22, 2.02]. Non-significant risk factors include hypertension with an OR of 0.85, 1.83, OSA with an OR of 1.08 [0.83, 1.39] and hyperlipidemia with an OR of 0.80 [0.61, 1.04]. Combined SG and Roux-en-Y patient cohorts with hyperlipidemia have shown a protective effect of 0.78 [0.65, 0.94].

Conclusions

Significant risk factors for leak post bariatric surgery are smoking in all patients and particularly SG patients, diabetes for all patients and particularly Roux-en-Y patients, and CKD and chronic steroid for all patients. Hyperlipidemia in two combined patient cohorts (SG and Roux-en-Y) appears to have a weak protective effect.

Comparison of Ambulatory Health Care Costs and Use Associated With Roux-en-Y Gastric Bypass vs Sleeve Gastrectomy

IMPORTANCE

Studies comparing contemporary bariatric surgical types could facilitate procedure selection for patients interested in reducing their frequency of health care visits and reliance on prescription drugs.

OBJECTIVE

To compare the association of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) with ambulatory health care costs and use for as long as 4 years after surgery.

DESIGN, SETTING, AND PARTICIPANTS

This comparative effectiveness study, which included patients undergoing bariatric surgery who were aged 18 to 64 years with at least 24 months of enrollment data before surgery and 12 months of enrollment data after surgery, used a retrospective interrupted time series with a comparison group. Data represent insurance claims dated January 2006 to June 2017, with analyses completed in September 2021. Data were collected from US commercial and Medicare Advantage claims database. Cohorts were matched on characteristics including baseline body mass index category, diabetes status, baseline ambulatory care costs, region of the United States, and year of surgery.

EXPOSURES

SG or RYGB, based on procedure codes.

MAIN OUTCOMES AND MEASURES

Annual ambulatory health care costs, and subtypes of cost and use including prescriptions, office visits, laboratory encounters, and radiology.

RESULTS

Matched cohorts included 3049 patients who underwent SG and 3251 patients who underwent RYGB, with a mean (SD) age of 45.2 (10.0) years; 4820 (77%) were women. Full follow-up was 37% for SG (514 patients) and 38% for RYGB (643 patients) among those eligible for 4-year follow-up. There were no significant differences between SG and RYGB in total ambulatory costs, office visit costs, or radiology costs in all follow-up years. Patients who underwent SG had significantly higher prescription costs than those who underwent RYGB bypass in year 4 ($852.8 per patient per year; 95% CI: $395.6-$1310.0 per patient per year) with more cardiometabolic medication fills in each year (eg, year 4: 42.5%; 95% CI, 13.7%-71.2%). In contrast, early after surgery, patients who underwent SG had relatively fewer specialist visits (eg, year 1: -7.2%; 95% CI, -14.3% to -0.2%) and lower laboratory costs (eg, year 1: -$118.9 per patient per year; 95% CI, -$220.2 to -$17.5 per patient per year).

CONCLUSIONS AND RELEVANCE

Despite clinical studies showing greater weight loss and comorbidity improvement with RYGB vs SG, this study found no difference in total ambulatory costs for as long as 4 years after SG and RYGB. These findings may reflect the trade-off between greater improvements in cardiometabolic health and additional surgery-related care among patients undergoing RYGB. Studies with longer follow-up time could determine whether greater sustained weight loss from RYGB eventually results in lower costs compared with SG.

Assessment of the Role of Omentopexy in Laparoscopic Sleeve Gastrectomy: A Tertiary Center Experience

Background: Laparoscopic sleeve gastrectomy is one of the most common bariatric procedures due its high success and low complication rates. However, acid reflux and food intolerance remain drawbacks of the procedure, with high frequency of postoperative gastroesophageal reflux disease (GERD) and eating disorders reported by previous studies. Omentopexy is not a standard technique in laparoscopic sleeve gastrectomy and showed promising results in preventing these sequelae. The present study aimed to evaluate whether omentopexy would decrease the incidence of postoperative GERD, food intolerance, and gastric volvulus without increasing additional complications rates in comparison with laparoscopic sleeve gastrectomy (LSG) without omentopexy. Patients and Methods: Our study included all the patients undergoing laparoscopic sleeve gastrectomy in our bariatric unit, who were divided into two groups. Group II had the added step of omentopexy. Comparison between both groups was done regarding incidence of acid reflux, food tolerance, and postoperative complications. Results: Omentopexy decreased the incidence of acid reflux, gastric kink, volvulus, and intrathoracic migration. Moreover, food tolerance significantly improved in patients, which in turn led to higher compliance with the postoperative dietary plan and better outcome with regard to weight loss. In addition, omentopexy showed lower incidence of postoperative leakage. Conclusion: Omentopexy is a valuable step in laparoscopic sleeve gastrectomy, which should be considered a standard step in all cases.

Risk Factors for Early and Late Complications after Laparoscopic Sleeve Gastrectomy in One-Year Observation

BACKGROUND

Although laparoscopic sleeve gastrectomy (LSG) is considered a safe bariatric procedure in the treatment of obesity, it still involves a risk of developing postoperative complications. Knowledge of risk factors for possible complications would allow appropriate preoperative planning, optimization of postoperative care, as well as early diagnosis and treatment. The aim of this study was to evaluate risk factors for complications after laparoscopic sleeve gastrectomy.

METHODS

A retrospective study of 610 patients who underwent LSG at a tertiary institution were included in the study through retrospective analysis of the medical data. Complications were categorized as early (<30 days) and late (≥30 days) and evaluated according to the Clavien-Dindo Classification.

RESULTS

Early complications were observed in 35 patients (5.74%) and late complications occurred in 10 patients (1.64%). Independent risk factors of early complications after laparoscopic sleeve gastrectomy included hypercholesterolemia (OR 3.73; p-value = 0.023) and smoking (OR = 274.66, p-value < 0.001). Other factors that may influence the postoperative course are length of hospital stay and operation time. Smoking, peptic ulcer diseases and co-existence of hiatal hernia were found to be an independent predictors of late complications.

CONCLUSIONS

Smoking is associated with the higher risk of both, early and late complications, while hypercholesterolemia with only <30 days complications after laparoscopic sleeve gastrectomy.

The SAGES MASTERS program presents the 10 seminal articles for Roux-en-Y gastric bypass

BACKGROUND

One of the eight clinical pathways of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Masters Program is bariatric surgery which includes three anchoring procedures. For each anchoring procedure sentinel articles have been identified to enhance participant surgeon lifelong learning. Roux-en-Y gastric bypass (RYGB) is one of the 3 anchoring procedures for the Bariatric Pathway. In this article we present the top 10 seminal articles regarding the RYGB which surgeons should be familiar with.

METHODS

The literature was systematically searched to identify the most cited papers on RYGB. The SAGES Metabolic and Bariatric Surgery committee reviewed the most cited article list and using expert consensus selected the seminal articles that every bariatric surgeon should read. These articles were reviewed in detail by committee members and are presented here.

RESULTS

The top 10 most cited sentinel papers on RYGB focus on operative safety, outcomes, surgical technique, and physiologic changes after the procedure. A summary of each paper is presented here, including expert appraisal and commentary.

CONCLUSION

The seminal articles presented here have supported the widespread acceptance and use of the RYGB by bolstering the understanding of its mechanism of action and by demonstrating its safety and excellent patient outcomes. All bariatric surgeons should be familiar with these 10 landmark articles.

Endoscopic Negative Pressure Therapy (ENPT) Is Superior to Stent Therapy for Staple Line Leak After Sleeve Gastrectomy: a Single-Center Cohort Study

PURPOSE

Staple line leak (SLL) is a serious complication after sleeve gastrectomy (SG). Common endoscopic treatment options include self-expandable metallic stent (SEMS), endoscopic internal drainage (EID), and endoscopic closure. The endoscopic negative pressure therapy (ENPT) is a promising treatment option combining temporary sealing of the defect with drainage of the inflammatory bed. In this study, we compare the outcome of ENPT and SEMS for the treatment of SLL following SG.

MATERIALS AND METHODS

A retrospective cohort of 27 patients (21 females) treated at a single center for SLL after SG was included. ENPT was primary therapy for 14 patients and compared with 13 patients treated primarily using SEMS.

RESULTS

ENPT was associated with a significant reduction of hospital stay (19 ± 15.1 vs. 56.69 ± 47.21 days, p = 0.027), reduced duration of endoscopic treatment (9.8 ± 8.6 vs. 44.92 ± 60.98 days, p = 0.009), and shorter transabdominal drain dwell time (15 (5-96) vs. 45 (12-162) days, p = 0.014) when compared to SEMS. Whereas endoscopic management was successful in 12/14 (85.7%) of patients from the ENPT group, SEMS was successful in only 5/13 (38.5%) of patients (p = 0.015). Furthermore, ENPT was associated with a significant reduction of endoscopic adverse events compared with SEMS (14.3% vs. 76.92% p = 0.001).

CONCLUSION

Compared with SEMS, ENPT is effective and safe in treating SLL after SG providing higher success rates, shorter treatment duration, and lower adverse events rates.

Five-year Longitudinal Cohort Study of Reinterventions After Sleeve Gastrectomy and Roux-en-Y Gastric Bypass

OBJECTIVE

To compare the long-term risks of reintervention following sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) in a large surgical cohort.

BACKGROUND

The use of SG has increased dramatically relative to RYGB for the treatment of obesity. However, long-term risks following SG compared with RYGB have not been adequately defined in a large population-based study.

METHODS

A retrospective longitudinal cohort study of all adult health-plan members undergoing SG or RYGB for obesity in a multistate integrated health care system from January 2005 through September 2015. The risks of nutritional, endoscopic, radiologic, and surgical reintervention as well as the overall risk of any reinterventions at 1, 3, and 5 years were identified using diagnosis and procedure codes from comprehensive electronic medical records.

RESULTS

The study included 15,319 patients who underwent SG and 19,954 patients who underwent RYGB with a follow-up of 79.2%. The overall risk of any reintervention at 5 years was 21.3% for SG and 28.3% for RYGB (P < 0.0001). After adjustment, SG was associated with fewer reinterventions through 5 years than RYGB (hazard ratio, 0.78; 95% confidence interval, 0.74-0.84). When comparing subcategories, SG also had a lower risk of nutritional, endoscopic, radiologic, and surgical reinterventions when examined versus RYGB. The findings for risks of reinterventions were consistent across clinical subgroups.

CONCLUSION

SG has significantly lower risk of reintervention in all categories studied when compared with RYGB at 5-year follow-up. The long-term safety profile of LSG compared with RYGB should be an essential part of the discussion in patient-centered decision making when choosing between bariatric procedure options.

Association of bariatric surgery with all-cause mortality and incidence of obesity-related disease at a population level: A systematic review and meta-analysis

BACKGROUND

Previous clinical trials and institutional studies have demonstrated that surgery for the treatment of obesity (termed bariatric or metabolic surgery) reduces all-cause mortality and the development of obesity-related diseases such as type 2 diabetes mellitus (T2DM), hypertension, and dyslipidaemia. The current study analysed large-scale population studies to assess the association of bariatric surgery with long-term mortality and incidence of new-onset obesity-related disease at a national level.

METHODS AND FINDINGS

A systematic literature search of Medline (via PubMed), Embase, and Web of Science was performed. Articles were included if they were national or regional administrative database cohort studies reporting comparative risk of long-term mortality or incident obesity-related diseases for patients who have undergone any form of bariatric surgery compared with an appropriate control group with a minimum follow-up period of 18 months. Meta-analysis of hazard ratios (HRs) was performed for mortality risk, and pooled odds ratios (PORs) were calculated for discrete variables relating to incident disease. Eighteen studies were identified as suitable for inclusion. There were 1,539,904 patients included in the analysis, with 269,818 receiving bariatric surgery and 1,270,086 control patients. Bariatric surgery was associated with a reduced rate of all-cause mortality (POR 0.62, 95% CI 0.55 to 0.69, p < 0.001) and cardiovascular mortality (POR 0.50, 95% CI 0.35 to 0.71, p < 0.001). Bariatric surgery was strongly associated with reduced incidence of T2DM (POR 0.39, 95% CI 0.18 to 0.83, p = 0.010), hypertension (POR 0.36, 95% CI 0.32 to 0.40, p < 0.001), dyslipidaemia (POR 0.33, 95% CI 0.14 to 0.80, p = 0.010), and ischemic heart disease (POR 0.46, 95% CI 0.29 to 0.73, p = 0.001). Limitations of the study include that it was not possible to account for unmeasured variables, which may not have been equally distributed between patient groups given the non-randomised design of the studies included. There was also heterogeneity between studies in the nature of the control group utilised, and potential adverse outcomes related to bariatric surgery were not specifically examined due to a lack of available data.

CONCLUSIONS

This pooled analysis suggests that bariatric surgery is associated with reduced long-term all-cause mortality and incidence of obesity-related disease in patients with obesity for the whole operated population. The results suggest that broader access to bariatric surgery for people with obesity may reduce the long-term sequelae of this disease and provide population-level benefits.

Laparoscopic Sleeve Gastrectomy or Laparoscopic Gastric Bypass for Patients with Metabolic Syndrome: An MBSAQIP Analysis

In patients undergoing bariatric surgery, the presence of metabolic syndrome (MetS) contributes to perioperative morbidity. We aimed to evaluate the utilization and outcome of severely obese patients with MetS who underwent laparoscopic sleeve gastrectomy (LSG) versus laparoscopic Roux-en-Y gastric bypass (LRYGB). Using the 2015 and 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, data were obtained for patients with MetS undergoing LSG or LRYGB. There were 29,588 MetS patients (LSG: 58.7% vs LRYGB: 41.3%). There was no significant difference in 30-day mortality (0.1% for LSG vs 0.2% for LRYGB, adjusted odds ratio (AOR) 0.58, confidence interval (CI) 0.32–1.05, P = 0.07) or length of stay between groups (2 ± 2 for LSG vs 2.2 ± 2 days for LRYGB, P = 0.40). Compared with LRYGB, LSG was associated with significantly shorter operative time (78 ± 39 vs 122 ± 54 minutes, P < 0.01), lower overall morbidity (2.3% vs 4.4%, AOR 0.53, CI 0.46–0.60, P < 0.01), lower serious morbidity (1.5% vs 2.3%, AOR 0.64, CI 0.53–0.76, P < 0.01), lower 30-day reoperation (1.2% vs 2.3%, AOR 0.52, CI 0.43–0.63, P < 0.01), and lower 30-day readmission (4.2% vs 6.6%, AOR 0.62, CI 0.55–0.69, P < 0.01). In conclusion, LSG is the predominant operation being performed for severely obese patients with MetS, and its popularity may in part be related to its improved perioperative safety profile.

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

INTRODUCTION

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

STUDY AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Multidisciplinary Management of Leaks After One-Anastomosis Gastric Bypass in a Single-Center Series of 2780 Consecutive Patients

PURPOSE

Few data exist in the literature concerning leaks after one-anastomosis gastric bypass (OAGB). Our aim was to describe the incidence, presentation, and management of leaks after OAGB.

SETTING

A private clinic in France.

METHODS

Between May 2010 and December 2017, 2780 consecutive patients underwent OAGB. A retrospective chart review was performed on the 46 patients (1.7%) who experienced postoperative leaks.

RESULTS

Leaks arose from the anastomosis in 6 cases (13%) and from the gastric pouch in 27 cases (59%), while the remaining 13 patients (28%) had leaks from an undetermined origin. Management followed a standardized algorithm taking into consideration the clinical situation and findings on an oral contrast computed tomography (CT) scan. All patients were treated by fasting, total parenteral nutrition, and antimicrobial therapy. Nine patients (20%) could be managed by medical treatment only, 13 patients (28%) underwent laparoscopic management (washout and drainage plus T-tube placement in 5 cases or conversion to Roux-en-Y gastric bypass (RYGB) in one case). The remaining 23 patients (50%) were managed by percutaneous drainage and/or endoscopy. No mortality was observed; the major morbidity rate was 20%. The median length of a hospital stay was 17 days (5-80).

CONCLUSION

Management of leaks after OAGB depends on clinical conditions and presence, size, and location of an abscess and/or a fistula. If endoscopy and interventional radiology are available, reoperation can be avoided in most patients. In most leaks at the gastrojejunal anastomosis, inserting a T-tube in the leak orifice avoids the necessity for conversion to RYGB.

Perioperative outcomes of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in super-obese and super-super-obese patients: a national database analysis

BACKGROUND

Evidence remains contradictory for perioperative outcomes of super-obese (SO) and super-super-obese (SSO) patients undergoing bariatric surgery.

OBJECTIVE

To identify national 30-day morbidity and mortality of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in SO and SSO patients.

SETTING

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.

METHODS

All LSG and LRYGB patients from 2015 through 2017 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database were grouped based on body mass index (BMI) as follows: morbidly obese (MO; BMI 35.0-49.9 kg/m²), SO (BMI 50.0-59.9 kg/m²), and SSO (BMI ≥60.0 kg/m²). Complications and mortality within 30 days were compared between BMI groups using Pearson X² or Fischer's exact tests. Multivariate logistic regression was used to adjust for demographic characteristics and co-morbidities, and adjusted odds ratio (AOR) was reported for each outcome.

RESULTS

Of 356,621 patients, 71.6% had LSG and 28.4% LRYGB. A total of 272,195 patients were in the MO group, 65,565 in the SO group, and 18,861 in the SSO group. Higher BMI was associated with increased overall morbidity and mortality. The overall complication rate was significantly higher for SO (AOR = 1.20, 95% confidence interval [CI] 1.13-1.28 for LSG; AOR = 1.08, 95% CI 1.01-1.15 for LRYGB) and SSO (AOR = 1.44, 95% CI 1.31-1.58 for LSG; AOR = 1.31, 95% CI 1.19-1.45 for LRYGB) compared with the MO group. Mortality was also significantly higher for SO (AOR = 1.65, 95% CI 1.10-2.48 for LSG; AOR = 1.85, 95% CI 1.23-2.80 for LRYGB) and SSO (AOR = 3.30, 95% CI 1.98-5.48 for LSG; AOR = 3.32, 95% CI 1.93-5.73 for LRYGB) compared with the MO group.

CONCLUSIONS

SO and SSO patients are at increased risk of 30-day morbidity and mortality compared with MO patients. Despite this elevated perioperative risk, the overall risk of these procedures remains low and acceptable especially as bariatric surgery is the durable treatment option for obesity.

Comparison of laparoscopic sleeve gastrectomy leak rates in five staple-line reinforcement options: a systematic review

Background

Staple-line leaks following laparoscopic sleeve gastrectomy (LSG) remain a concerning complication. Staple-line buttressing is largely adopted as an acceptable reinforcement but data regarding leaks have been equivocal. This study compared staple-line leaks in five reinforcement options during LSG: no reinforcement (NO-SLR), oversewing (suture), nonabsorbable bovine pericardial strips (BPS), tissue sealant or fibrin glue (Seal), or absorbable polymer membrane (APM).

Methods

This systematic review study of articles published between 2012 and 2016 regarding LSG leak rates aligned with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Variables of interest included leak rates, bleeding, and complications in addition to surgical and population parameters. An independent Fisher’s exact test was used to compare the number of patients with and without leaks for the different reinforcement options.

Results

Of the 1633 articles identified, 148 met inclusion criteria and represented 40,653 patients. Differences in age (older in APM; p = 0.001), starting body mass index (lower in Suture; p = 0.008), and distance from pylorus (closer in BPS; p = 0.04) were observed between groups, but mean bougie size was equivalent. The overall leak rate of 1.5% (607 leaks) ranged from 0.7% for APM (significantly lower than all groups; p ≤ 0.007 for next lowest leak rate) to 2.7% (BPS).

Conclusions

This systematic review of staple-line leaks following LSG demonstrated a significantly lower rate using APM staple-line reinforcement as compared to oversewing, use of sealants, BPS reinforcement, or no reinforcement. Variation in surgical technique may also contribute to leak rates.

Electronic supplementary material

The online version of this article (10.1007/s00464-019-06782-2) contains supplementary material, which is available to authorized users.

Obesity

The role of internists in evaluating obesity is to assess the burden of weight-related disease, mitigate secondary causes of weight gain (medications, sleep deprivation), and solicit patient motivation for weight loss. Internists should assess these factors and emphasize the importance of weight loss for the individual patient. All patients wishing to lose weight should be encouraged to monitor their diet and physical activity and should be referred to high-intensity behavioral programs. Some patients with obesity may also benefit from pharmacotherapy or bariatric surgery.

Surgical management of obesity

Weight loss surgery is the most effective intervention for addressing obesity and related metabolic disorders such as diabetes. We describe common surgical procedures as well as emerging and investigational procedures in terms of their capacity to induce weight reduction and their risk profiles. We then discuss the impact of weight loss surgery on important obesity related disorders including diabetes, cardiovascular disease, and non-alcoholic fatty liver disease. The question of operative choice is discussed with respect to benefits and risks of common procedures. Reoperative weight loss surgery, an increasingly common element of weight loss surgical practice, is reviewed. We briefly discuss the metabolic mechanism of action of weight loss surgery. Lack of access to and under-utilization of weight loss surgery represent important challenges to adequate obesity treatment, and we review these topics as well.

Impact of Prior Bariatric Surgery on Perioperative Liver Transplant Outcomes

Bariatric surgery (BS) is effective in treating morbid obesity, but the impact of prior BS on candidacy for liver transplantation (LT) is unclear. We examined 78 patients with cirrhosis with prior BS compared with a concurrent cohort of 156 patients matched by age, Model for End-Stage Liver Disease score, and underlying liver disease. We compared rates of transplant denial after evaluation, delisting on the waiting list, and survival after LT. The median time from BS to LT evaluation was 7 years. Roux-en-Y gastric bypass was the most common BS procedure performed (63% of cohort). Nonalcoholic fatty liver disease was the leading etiology for liver cirrhosis (47%). Delisting/death on the waiting list was higher among patients with BS (33.3% versus 10.1%; P = 0.002), and the transplantation rate was lower (48.9% versus 65.2%; P = 0.03). Intention-to-treat (ITT) survival from listing to 1 year after LT was lower in the BS cohort versus concurrent cohort (1-year survival, 84% versus 90%; P = 0.05). On adjusted analysis, a history of BS was associated with an increased risk of death on the waiting list (hazard ratio [HR], 5.7; 95% confidence interval [CI], 2.2-15.1), but this impact was attenuated (HR, 4.9; 95% CI, 1.8-13.4) by the presence of malnutrition. When limited to matched controls by sex, mortality attributed to BS was no longer significant for females (P = 0.37) but was significant for males (P = 0.046). Sarcopenia, as captured by skeletal muscle index, was calculated in a subset of patients (n = 49). The total skeletal surface area was lower in the BS group (127 [105-141] cm² versus 153 [131-191] cm² ; P = 0.005). Rates of sarcopenia were higher among patients delisted after listing (71.4% versus 16.7%; P = 0.04). In conclusion, a history of BS was associated with higher rates of delisting on the waiting list as well as lower survival from the time of listing on ITT analysis. Presence of malnutrition and sarcopenia among patients with BS may contribute to worse outcomes.

Outcomes of Roux-en-Y gastric bypass versus sleeve gastrectomy in super-super-obese patients (BMI ≥60 kg/m2): 6-year follow-up at a single university

BACKGROUND

Among the population of morbidly obese people, super-super-obese (SSO) individuals (body mass index >60 kg/m²) present a treatment challenge for bariatric surgeons.

OBJECTIVES

To compare the long-term outcomes between laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB) and to evaluate the efficacy of SG as a stand-alone bariatric procedure for SSO patients.

SETTING

University hospital, Paris, France.

METHODS

We retrospectively reviewed the data outcomes of 210 SSO patients who underwent SG or RYGB between January 2000 and December 2011. The 6-year follow-up data were analyzed and compared.

RESULTS

Follow-up data at 6 years were collected for 57.1% and 52.1% of patients in the SG group and RYGB groups, respectively. Both procedures were effective at promoting weight loss. Most weight loss was achieved at 24 months with both procedures. The average percent excess weight loss and change in body mass index of SG versus RYGB showed no significant differences at the 4-year follow-up. Except for sleep apnea, RYGB showed slightly better resolution of the evaluated co-morbidities. The composite endpoint of major short-term adverse events (<30 d) occurred in 11.7% of patients with RYGB and 6.4% of those with SG (P = .02). Postoperative complications were seen in 26% of RYGB patients and 16.1% of SG patients.

CONCLUSIONS

SG as a primary procedure for SSO patients remains effective even though RYGB achieves better midterm outcomes. SG can be proposed as the primary-option p+rocedure. Further investigations are needed to identify the ideal procedure for patients with symptoms of gastroesophageal reflux disease.

Robotic versus laparoscopic sleeve gastrectomy: a MBSAQIP analysis

BACKGROUND

Laparoscopic sleeve gastrectomy has become the procedure of choice for the treatment of morbid obesity. Robotic sleeve gastrectomy is an alternative surgical option, but its utilization has been low. The aim of this study was to evaluate the contemporary outcomes of robotic sleeve gastrectomy (RSG) versus laparoscopic sleeve gastrectomy (LSG) using a national database from accredited bariatric centers.

STUDY DESIGN

Using the 2015 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, clinical data for patients who underwent RSG or LSG were examined. Emergent and revisional cases were excluded. A multivariate logistic regression model was utilized to compare the outcomes between RSG and LSG.

RESULTS

A total of 75,079 patients underwent sleeve gastrectomy with 70,298 (93.6%) LSG and 4781 (6.4%) RSG. Preoperative sleep apnea and hypoalbumenia were significantly higher in the RSG group (P < 0.01). Mean length of stay was similar between RSG and LSG (1.8 ± 2.0 vs. 1.7 ± 2.0 days, P = 0.17). Operative time was longer in the RSG group (102 ± 43 vs. 74 ± 36 min, P < 0.01). There was no significant difference in 30-day mortality between the RSG versus LSG group (0.02% vs. 0.01%, AOR 0.85; 95% CI 0.11-6.46, P = 0.88). However, RSG was associated with higher serious morbidity (1.1% vs. 0.8%, AOR 1.40; 95% CI 1.05-1.86, P < 0.01), higher leak rate (1.5% vs. 0.5%, AOR 3.14; 95% CI 2.65-4.42, P < 0.01), and higher surgical site infection rate (0.7% vs. 0.4%, AOR 1.55; 95% CI 1.08-2.23, P = 0.01).

CONCLUSIONS

Robotic sleeve gastrectomy has longer operative time and is associated with higher postoperative morbidity including leak and surgical site infections. Laparoscopy should continue to be the surgical approach of choice for sleeve gastrectomy.