Single-stage laparoscopic sleeve gastrectomy: safety and efficacy in the super-obese

Complications in Patients Undergoing Laparoscopic Bariatric Surgery in an ERABS-optimized, High-Volume, Single Center During 2020 and 2021

PURPOSE

Complication rates after fast-track optimization in bariatric surgery are varying. The aim of this study was to identify short-term complications in patients undergoing laparoscopic sleeve gastrectomy (SG) in an ERABS (enhanced recovery after bariatric surgery) optimized setup.

MATERIALS AND METHODS

This study is an observational analysis of a consecutive cohort of 1600 patients undergoing SG at an ERABS-optimized, private hospital during 2020 and 2021. Primary outcomes were length of stay, mortality, readmissions, reoperations, and complications according to the Clavien-Dindo classification (CDC) within postoperative day (POD) 30 and 90. Secondary outcomes were weight loss and quality of life (QoL) according to Moorehead-Ardelt questionnaires during the first postoperative year.

RESULTS

Primary outcomes: 99.1% of patients were discharged within POD 1. The 90-day mortality rate was zero. There were 1% readmissions and 1.2% reoperations within POD 30. Total 30-day complication rate was 4.6%, where 3.4% accounted for CDC grades ≤ II, and 1.3% accounted for CDC grade III. There were zero grade IV-V complications.

SECONDARY OUTCOMES

One year after surgery, weight loss was substantial (p < 0.001), with an excess weight loss of 71.9%, and QoL had significantly increased (p < 0.001).

CONCLUSION

This study demonstrates that the use of an ERABS protocol in bariatric surgery does not compromise neither safety nor efficacy. Complication rates were low, and weight loss was significant. This study thus provides strong arguments that ERABS programs are beneficial in bariatric surgery.

A Single-Center Experience: What is the Effect of Sleeve Gastrectomy in Patients With a BMI ≥ 50 kg/m²?

BACKGROUND

Our research aimed to see how sleeve gastrectomy (SG) affects weight loss and comorbidities in patients with a body mass index (BMI) ≥ 50 kg/m².

MATERIALS AND METHODS

Prospectively kept data of patients with a BMI ≥50 kg/m² who underwent SG between February 2016 and February 2020 were evaluated.

RESULTS

A total of 138 patients with a BMI ≥ 50 kg/m² were operated on. The average BMI was 56.36±7.661, the average age was 37.41±12.33. Forty-eight patients underwent concomitant cholecystectomy and/or hiatal hernia repair (HHR). The percentage of excess weight loss (EWL%) of patients at the 3rd, 6th, 12th, 18th, and 24th months were 36%, 54%, 67%, 72%, and 74%, respectively. Mean BMI values of the 0th, 3rd, 6th, 12th, 18th, and 24th months were 56, 45, 39, 35, 33, and 33, respectively. 0th, 3rd, 6th, 12th, 18th, and 24th months were significantly different for EWL%, total weight loss (TWL%), and BMI variables (p<0.001), but EWL% (p=0.527), TWL% (p=0.396) and BMI (p=0,657) were not found significantly different between the 18th and 24th months. When EWL% ≥ 50 was accepted, the success rate was 93% (n=93) and 92% (n=50) at the 18th and 24th months, respectively. While there was 82% remission in type 2 diabetes mellitus (DM) and 90% in hypertension (HT), the remission rate in patients with obstructive sleep apnea syndrome (OSAS) and gastroesophageal reflux disease (GERD) undergoing HHR was 100%.

CONCLUSIONS

In patients with a BMI ≥ 50 kg/m², SG seems to be an effective and safe therapy option as the first line for weight loss and treatment of comorbid diseases. Further long-term studies are needed to confirm these results.

Early outcome of bariatric surgery for the treatment of type 2 diabetes mellitus in super-obese Malaysian population

Introduction:

Despite many challenges, the benefit of bariatric surgery in super-obese population remains irrefutable with significant improvement in metabolic syndrome and quality of life. There are currently no published data from Malaysia on this topic.

Objective and Methodology:

A single-centre retrospective study aimed at analysing the outcome of laparoscopic bariatric surgery on super-obese Malaysians with type 2 diabetes mellitus (T2DM) at 12 months following surgery. Demographic details, glycaemic control and weight-loss parameters were analysed. P < 0.01 was considered statistically significant.

Results:

Of the 33 patients, 55% were women and 45% were men with a mean age of 40 ± 11 years and body mass index (BMI) of 59.3 ± 9.0 kg/m². Majority of patients were of Malay ethnicity (82%). Malaysian-Indians and Malaysian-Chinese each accounted for 9% of total case volume. The three types of laparoscopic bariatric surgery recorded in this study were sleeve gastrectomy (82%), Roux-en-Y gastric bypass (9%) and mini-gastric bypass (9%) with operative time of 103.5 ± 31.1, 135.8 ± 32.6 and 116.2 ± 32.3 min, respectively. Percentage total body weight loss was 33.11% ± 9.44% at 12 months following surgery (P < 0.01). BMI change and percentage excess BMI loss showed similar improvement. Glycosylated haemoglobin and fasting blood sugar decreased from pre-operative values of 7.0% ± 1.0% and 7.0 ± 0.9 mmol/L to 5.6% ± 0.4% and 5.0 ± 0.6 mmol/L at 12 months (P < 0.01). Remission of T2DM was noted in 93% of patients. There was no correlation between weight loss and improvement in glycaemic status.

Conclusion:

There are significant weight loss and improvement of glycaemic control at 12 months post-laparoscopic bariatric surgery among super-obese Malaysians.

Comparative Effectiveness of Different Bariatric Procedures in Super Morbid Obesity

BACKGROUND

Super obesity (BMI ≥ 50 kg/m²) is associated with significant morbidity and mortality. The best procedure to treat super obesity is not completely established. Our aim was to compare the effectiveness of bariatric procedures (adjustable gastric band [AGB], Roux-en-Y gastric bypass [RYGB], sleeve gastrectomy [SG]) in super obesity.

METHODS

Retrospective observational study of super obese patients who underwent bariatric surgery. Data was assessed preoperatively and in the 1st and 2nd years of follow-up.

RESULTS

We evaluated 213 individuals, 77.9% female, age of 43.38 ± 11.49 years, and preoperative BMI of 54.53 ± 4.54 kg/m²; 19 submitted to AGB, 127 to RYGB, and 67 to SG. In the pre-surgical assessment, there were no significant differences in age, anthropometric parameters, blood pressure, glycemic profile, and lipid profile between the three surgical groups. The percentage of excess weight loss (%EWL) in the 1st year was 67.58% in RYGB, 58.74% in SG, and 38.71% in AGB (p < 0.001), and the percentage of total weight loss (%TWL) was 36.29%, 31.59%, and 21.07%, respectively (p < 0.001). Two years after surgery (n = 147; follow-up rate of 69%), the %EWL and %TWL were significantly higher in the RYGB group (p < 0.001). RYGB had a higher success rate (%EWL ≥ 50% and %TWL ≥ 20%) in both years of follow-up (p < 0.001). In multiple linear regression, after adjusting for other covariates, RYGB was the only strong predictive factor of %EWL and %TWL (p < 0.001).

CONCLUSION

RYGB proved to be more effective in super obesity. The beneficial effects in weight loss were evident both 1 and 2 years after the procedure, regardless of pre-surgical anthropometric characteristics.

Outcomes of Bariatric Surgery in Patients with Inflammatory Bowel Disease

BACKGROUND

Obesity has become prevalent in patients with inflammatory bowel disease (IBD). Bariatric surgery can be considered to be contraindicated in IBD patients. We aimed to evaluate feasibility, safety, and efficacy of bariatric surgery in IBD patients.

METHODS

We retrospectively identified all morbidly obese patients with a known diagnosis of IBD, who underwent bariatric surgery between January 2005 and December 2012. Postoperative outcomes and status of IBD in patients on maintenance therapy for their disease were assessed.

RESULTS

We identified 20 IBD patients including 13 ulcerative colitis (UC) and 7 Crohn's disease (CD) patients with a mean age of 54.0 ± 10.5 years, BMI of 50.1 ± 9.0 kg/m(2), and duration of IBD of 11.3 ± 5.2 years. Eleven patients were on medication for IBD at baseline. Bariatric procedures included sleeve gastrectomy (N = 9), gastric bypass (N = 7), gastric banding (N = 3), and one conversion of band to gastric bypass. There were no intraoperative complications, but two conversions to laparotomy due to adhesions. Mean BMI change and excess weight loss at 1 year was 14.3 ± 5.7 kg/m(2) and 58.9 ± 21.1 %, respectively. Seven early postoperative complications occurred including dehydration (N = 5), pulmonary embolism (N = 1), and wound infection (N = 1). During a mean follow-up of 34.6 ± 21.7 months, five patients developed complications including pancreatitis (N = 2), ventral hernia (N = 2), and marginal ulcer (N = 1). Nine out of ten eligible patients experienced improvement in their IBD status.

CONCLUSIONS

Bariatric surgery is feasible and safe in morbidly obese patients suffering from IBD. In addition to being an effective weight loss procedure, bariatric surgery may help mitigate symptoms in this patient population.

One-Stage vs Two-Stage Laparoscopic Roux-en-Y Gastric Bypass in Obese Patients with Body Mass Index >55 Kg/m2; 5-YEAR FOLLOW UP

BACKGROUND

Surgical strategies in patients with BMI > 55 kg/m² are not well established.

OBJECTIVES

The objective of this study is to compare the long term results and complications of 1- vs. 2-stage laparoscopic "Roux-en-Y″ gastric bypass (LRYGB) for patients with BMI > 55 kg/m².

METHODS

Retrospective review of the complications and outcomes, between January 2007 and January 2010, for patients with a BMI > 55 kg/m² who underwent directly a LRYGB (1-stage) or a LRYGB as a 2nd stage of a laparoscopic sleeve gastrectomy (LSG).

RESULTS

Twenty-four patients were enrolled (no patient was lost during the 5-year follow-up). In the 1-stage LRYGB group, two patients had grade II complications according to Clavien-Dindo classification. In the 2-stage LRYGB group, complications of the first and the second surgery were summed. There were no differences between the two groups despite being heterogenous (more men with a higher BMI in the 2-stage group). There was a statistically significant difference in the final BMI in 1-stage LRYGB group compared to the 2-stage LRYGB group (34.46 ± 6.29 vs. 40.40 ± 3.47; p = 0.01, respectively) and in percentage of excess of BMI loss (%EBMIL; 69.80 ± 19.96 vs. 54.54 ± 13.93; p = 0.04, respectively).

CONCLUSIONS

In patients with a BMI > 55 kg/m², both 1- and 2-stage LRYGB give good long-term results. If feasible, a 1-stage LRYGB obtains a better percentage of excess of BMI loss but if not possible, the strategy of initially performing a laparoscopic sleeve gastrectomy followed by a LRYGB is safe and there were no differences in complications.

Perioperative complications following bariatric surgery according to the clavien-dindo classification. Score validation, literature review and results in a single-centre series

BACKGROUND

There is no unified system for reporting surgical complications after bariatric surgery. One increasingly used system for notifying postoperative complications is the Clavien-Dindo classification, which focuses on their therapeutic implications.

OBJECTIVE

The aim of this study is to validate and apply the Clavien-Dindo scale to a series of cases of bariatric surgery and systematically review its use worldwide.

SETTING

University hospital.

METHODS

A cohort of 321 patients with morbid obesity (Mean BMI: 45.4±5.5 kg/m²) underwent surgery by the same team of surgeons, fundamentally using a laparoscopic gastric bypass. Initially, the Clavien-Dindo scale was translated and validated for its acceptability and reproducibility using the Kappa index. The scale was then applied to the whole of the bariatric series. A systematic review was also conducted in the literature regarding the use of the Clavien-Dindo classification after bariatric surgery. Lastly, a comparison was made with our results.

RESULTS

The classification was validated without any difficulty. Most of the postoperative complications are grades I (8.4%) and III (7.8%). We found it used in 15 series (including our own), which accounts for 10,347 patients. The overall results are analogous to our series.

CONCLUSIONS

The Clavien-Dindo scale has been validated and translated into Spanish. Application is quick and simple and enables comparisons to be made between centers and series. Our results are similar to those reported by other authors.

Long-Term Outcome of Laparoscopic Sleeve Gastrectomy in Morbidly Obese Japanese Patients

BACKGROUND

Recently, laparoscopic sleeve gastrectomy (LSG) as a standalone bariatric procedure has rapidly gained popularity worldwide mainly because of its technical simplicity and the relatively good short-term outcome. In Japan, according to a domestic survey, 71 % of the bariatric procedures performed were LSG. However, the number of studies reporting long-term results are still not enough; particularly, data for Asian patients are scarce.

OBJECTIVE

The objective of this study was to evaluate the long-term outcomes for LSG in morbidly obese Japanese regarding weight loss and safety.

METHODS

Between October 2005 and July 2013, 179 morbidly obese Japanese patients (Female 89/Male 90) underwent LSG as a standalone procedure. The mean age was 40.7 years (range, 20-72 years), and the mean preoperative body weight and body mass index (BMI) were 120.4 kg (range, 71.4-231.6 kg) and 43.3 kg/m(2) (range, 30.9-76.5 kg/m(2)), respectively. All patients were evaluated and managed under a strict multidisciplinary team approach.

RESULTS

The mean BMI declined to 30.0 ± 8.7 kg/m(2) at 1 year, 29.1 ± 8.6 kg/m(2) at 2 years, 28.8 ± 8.7 kg/m(2) at 3 years, 29.3 ± 9.2 kg/m(2) at 4 years, and 32.7 ± 13.6 kg/m(2) at 5 years or more (p < 0.001). The mean percent total body weight loss (%TWL) achieved was 32.4 ± 12.9 % at 1 year, 34.3 ± 12.9 % at 2 years, 34.4 ± 11.6 % at 3 years, 32.8 ± 10.9 % at 4 years, and 29.5 ± 11.8 % at 5 years or more. Super morbidly obese patients and patients whose gastric tube was created using a thicker (45 Fr.) bougie had a tendency to achieve less weight loss. Early and late complications occurred in 16 patients (8.9 %) and in seven patients (3.9 %), respectively. Revision surgeries were required in six patients (3.4 %). The reasons for revision surgery were insufficient weight loss in five patients and intractable gastroesophageal reflux disease (GERD) in one patient.

CONCLUSION

LSG for Japanese morbidly obese patients is safe, effective, and acceptably durable up to 5 years although some complications unique to the procedure such as leakage from the staple line and intractable GERD occur. For super morbidly obese patients, other surgical options may be required.

Laparoscopic sleeve gastrectomy at a new bariatric surgery centre in Canada: 30-day complication rates using the Clavien-Dindo classification

BACKGROUND

Newfoundland and Labrador (NL) has the highest rate of obesity in Canada, prompting the establishment of a bariatric surgery program at the Health Sciences Centre in NL. This retrospective study examined 30-day complication rates in more than 200 consecutive patients who underwent laparoscopic sleeve gastrectomy (LSG) between May 2011 and February 2014.

METHODS

We performed a chart review and collected data on 30-day postoperative complications. Complications were graded and reported using the Clavien-Dindo classification. Grades I and II were defined as minor and grades III and higher were defined as major complications.

RESULTS

We reviewed the charts of the first 209 patients to undergo LSG. The mean body mass index was 49.2, 81% were women and the average age was 43 years. Comorbidities included hypertension (55.0%), obstructive sleep apnea (46.4%), dyslipidemia (42.1%), diabetes (37.3%), osteoarthritis (36.4%) and cardiovascular disease with previous cardiac stents (5.3%). Furthermore, 38.3% of patients reported psychiatric diagnoses, such as depression and anxiety. The overall 30-day complication rate was 15.3%. The complication rate for minor complications was 13.4% and for major complications was 1.9% (2 leaks, 1 stricture and 1 fistula).

CONCLUSION

Our results support the feasibility of safely performing LSG surgery at bariatric centres completing fewer than 125 procedures annually.

Weight loss outcomes and complications from bariatric surgery in the super super obese

BACKGROUND

Bariatric surgery has been established as the most effective long-term treatment for morbid obesity.

METHODS

We performed a retrospective review of SSO patients treated at our institute between 2008 and 2013 who underwent a laparoscopic gastric bypass (LGBP) or sleeve gastrectomy (LSG). The primary end point for this study was excess weight loss (EWL) at 1, 3, 6, and 12 months. Secondary end points included procedure length (PL), length of stay (LOS), diabetes management and postoperative complications.

RESULTS

We identified 135 SSO patients who underwent bariatric surgery (93 LGBP, 42 LSG) at our institute from 2008 to 2013 with a median follow-up of 49 months. The incidence of EWL > 30 % for patients in the LGBP group was 3.9, 29.0, 72.2 and 94.6 % at 1, 3, 6 and 12 months, respectively, while the incidence of EWL > 30 % in patients in the LSG group was 4.2, 25.0, 59.1 and 100 % at 1, 3, 6 and 12 months, respectively. PL was 124 ± 49 min for the LGBP group and 98 + 51 min for the LSG group (p < 0.005). LOS was on average 3.0 days (range 1-21) for the LGBP group and 3.4 days (range 1-13) for the LSG group (p = 0.41). Patients experienced a decrease in their hemoglobin A1C level by 10 % for the LGBP group and 9 % for the LSG group at 1 year (p = 0.89). Postoperative complications were seen in 15.1 % of LGBP patients and 4.8 % of LSG patients.

CONCLUSIONS

Bariatric surgery is feasible in the SSO patients with comparable EWL outcomes and postoperative complications to historical non-SSO patients.

Bariatric and metabolic outcomes in the super-obese elderly

BACKGROUND

Numerous reports address bariatric outcomes in super-obese or elderly patients, but data addressing this high-risk combination is lacking.

OBJECTIVE

The objective of this study was to assess outcomes of bariatric surgery in the super-obese elderly.

SETTING

Academic institution, United States.

METHODS

All primary bariatric cases performed on patients aged 65 years or older with a body mass index (BMI) ≥ 50 kg/m(2) were retrospectively analyzed. Surgical approaches included laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB).

RESULTS

Thirty patients (26 female, 4 male) with a mean age of 67.1 ± 2.7 years and BMI of 55.9 ± 3.9 kg/m(2), who had LRYGB (n = 16), LSG (n = 6), or LAGB (n = 8), were identified. There were no deaths, conversions, or intraoperative complications. Three patients were lost to follow-up after the 3-month visit. The early (<30 d) major morbidity rate was 10.0%. At a median follow-up of 37 (range, 6-95) months, the cohort had a mean BMI of 42.3 ± 6.7 kg/m(2), which corresponded to a mean percent excess weight loss of 44.5% ± 20.5% and mean percent total weight loss of 24.4% ± 12.2%. The most percent excess weight loss was achieved after LRYGB (54.1% ± 19.4%), followed by LSG (48.3% ± 10.2%) and then LAGB (26.2% ± 14.4%). Diabetic medication reduction in number and/or dosage was observed in 40% (6/15) patients, and 33% (5/15) of patients were completely off antidiabetic agents.

CONCLUSIONS

Although further research is needed, the present data suggest that successful weight loss and metabolic improvement can be achieved safely in the high-risk population of super-obese elderly.

Five-year results after laparoscopic sleeve gastrectomy: a prospective study

BACKGROUND

Whilst the early to mid-term efficacy of laparoscopic sleeve gastrectomy (SG) is well established, there is comparatively less detailing of long-term efficacy. The objectives of this study were to evaluate the long-term outcomes of patients undergoing SG at the authors' institution.

METHODS

All patients undergoing SG during the past 5 or more years were eligible. Outcomes included baseline demographic data, preoperative characteristics, percentage excess weight loss (%EWL), co-morbidity improvement and resolution, serum hemoglobin A(1c) (HbA(1c)), serum lipid profile, and the Bariatric Analysis Reporting Outcome System (BAROS) questionnaire. A subset analysis was also performed with patients stratified in to super obese (body mass index ≥ 50 kg/m(2)).

RESULTS

There were 96 patients who underwent surgery between March 2007 and July 2008. Of these, 10 declined to participate, 28 were unable to be contacted, and 3 were deceased; therefore, 55 patients were included in the analysis. The mean yearly %EWL to postoperative year 5 was 56% (year 1), 55% (year 2), 46% (year 3), 43% (year 4), and 40% (year 5). Combined improvement and resolution rates at 5 years were 79%, 61%, and 73% for type 2 diabetes, hypertension, and obstructive sleep apnea, respectively. The HbA(1c) was significantly reduced at long-term follow-up. The mean BAROS score was 3.13 (95% CI: 2.4, 3.9). Weight loss outcomes were less favorable in super obese patients.

CONCLUSION

Weight loss outcomes at 5 year follow-up were modest after SG though improvement in co-morbidity status was maintained.

Body Mass Index is Predictive of Higher In-hospital Mortality in Patients Undergoing Laparoscopic Gastric Bypass but Not Laparoscopic Sleeve Gastrectomy or Gastric Banding

High body mass index (BMI) has been shown to be a factor predictive of increased morbidity and mortality in several single-institution studies. Using the University HealthSystem Consortium clinical database, we examined the impact of BMI on in-hospital mortality for patients who underwent laparoscopic gastric bypass, sleeve gastrectomy, and gastric banding between October 2011 and February 2014. Outcomes were examined within each procedure according to BMI groups of 35 to 49.9, 50.0 to 59.9, and 60.0 kg/m2 or greater. Outcome measures included in-hospital mortality, major complications, length of hospital stay, 30-day readmission, and cost. A total of 40,102 bariatric procedures were performed during this time period. For gastric bypass, there was an increase of in-hospital mortality (0.01 and 0.02 vs 0.34%; P < 0.01) and major complications (0.93 and 0.99 vs 2.62%; P < 0.01) in the BMI 60 kg/m2 or greater group. In contrast, sleeve gastrectomy and gastric banding had no association between BMI and rates of mortality and major complications. Cost increased with increasing BMI groups for all procedures. A strong association was found between BMI 60 kg/m2 or greater and higher in-hospital mortality and major complication rates for patients who underwent laparoscopic gastric bypass but not in patients who underwent sleeve gastrectomy or gastric banding.

Morbid obesity-the new pandemic: medical and surgical management, and implications for the practicing gastroenterologist

The gastroenterologist, whether in academic or clinical practice, must face the reality that an increasingly large percentage of adult patients are morbidly obese. Morbid obesity is associated with significant morbidity and mortality including enhanced morbidity from cardiovascular, cerebrovascular, hepatobiliary and colonic diseases. Most of these associated diseases are actually preventable. Based on the 1991 NIH consensus conference criteria, for most patients with a body mass index (BMI=weight in kilograms divided by the height in meters squared) of 40 or more, or for patients with a BMI of 35 or more and significant health complications, surgery may be the only reliable option. Currently in the United States, over 250,000 bariatric surgical procedures are being performed annually. The practicing gastroenterologist in every community, large and small, must be familiar with the various surgical procedures together with their associated anatomic changes. These changes may dramatically increase the prevalence of nutritional deficiencies and profoundly alter the clinical and endoscopic approaches to diagnosis and management.

Randomized clinical trial of enhanced recovery versus standard care after laparoscopic sleeve gastrectomy

BACKGROUND

Optimized perioperative care within an enhanced recovery after surgery (ERAS) protocol is designed to reduce morbidity after surgery, resulting in a shorter hospital stay. The present study evaluated this approach in the context of sleeve gastrectomy for patients with morbid obesity.

METHODS

Patients were allocated to perioperative care according to a bariatric ERAS protocol or a control group that received standard care. These groups were also compared with a historical group of patients who underwent laparoscopic sleeve gastrectomy at the same institution between 2006 and 2010, selected using matched propensity scores. The primary outcome was median length of hospital stay. Secondary outcomes included readmission rates, postoperative morbidity, postoperative fatigue and mean cost per patient.

RESULTS

Of 116 patients included in the analysis, 78 were allocated to the ERAS (40) or control (38) group and there were 38 in the historical group. There were no differences in baseline characteristics between groups. Median hospital stay was significantly shorter in the ERAS group (1 day) than in the control (2 days; P < 0·001) and historical (3 days; P < 0·001) groups. It was also shorter in the control group than in the historical group (P = 0·010). There was no difference in readmission rates, postoperative complications or postoperative fatigue. The mean cost per patient was significantly higher in the historical group than in the ERAS (P = 0·010) and control (P = 0·018) groups.

CONCLUSION

The ERAS protocol in the setting of bariatric surgery shortened hospital stay and was cost-effective. There was no increase in perioperative morbidity.

REGISTRATION NUMBER

NCT01303809 (http://www.clinicaltrials.gov).