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Keller DS, Curtis N, Burt HA, Ammirati CA, Collings AT, Polk HC, Carrano FM, Antoniou SA, Hanna N, Piotet LM, Hill S, Cuijpers ACM, Tejedor P, Milone M, Andriopoulou E, Kontovounisios C, Leeds IL, Awad ZT, Barber MW, Al-Mansour M, Nassif G, West MA, Pryor AD, Carli F, Demartines N, Bouvy ND, Passera R, Arezzo A, Francis N. EAES/SAGES evidence-based recommendations and expert consensus on optimization of perioperative care in older adults. Surg Endosc 2024; 38:4104-4126. [PMID: 38942944 PMCID: PMC11289045 DOI: 10.1007/s00464-024-10977-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 05/30/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND As the population ages, more older adults are presenting for surgery. Age-related declines in physiological reserve and functional capacity can result in frailty and poor outcomes after surgery. Hence, optimizing perioperative care in older patients is imperative. Enhanced Recovery After Surgery (ERAS) pathways and Minimally Invasive Surgery (MIS) may influence surgical outcomes, but current use and impact on older adults patients is unknown. The aim of this study was to provide evidence-based recommendations on perioperative care of older adults undergoing major abdominal surgery. METHODS Expert consensus determined working definitions for key terms and metrics related to perioperative care. A systematic literature review and meta-analysis was performed using the PubMed, Embase, Cochrane Library, and Clinicaltrials.gov databases for 24 pre-defined key questions in the topic areas of prehabilitation, MIS, and ERAS in major abdominal surgery (colorectal, upper gastrointestinal (UGI), Hernia, and hepatopancreatic biliary (HPB)) to generate evidence-based recommendations following the GRADE methodology. RESULT Older adults were defined as 65 years and older. Over 20,000 articles were initially retrieved from search parameters. Evidence synthesis was performed across the three topic areas from 172 studies, with meta-analyses conducted for MIS and ERAS topics. The use of MIS and ERAS was recommended for older adult patients particularly when undergoing colorectal surgery. Expert opinion recommended prehabilitation, cessation of smoking and alcohol, and correction of anemia in all colorectal, UGI, Hernia, and HPB procedures in older adults. All recommendations were conditional, with low to very low certainty of evidence, with the exception of ERAS program in colorectal surgery. CONCLUSIONS MIS and ERAS are recommended in older adults undergoing major abdominal surgery, with evidence supporting use in colorectal surgery. Though expert opinion supported prehabilitation, there is insufficient evidence supporting use. This work has identified evidence gaps for further studies to optimize older adults undergoing major abdominal surgery.
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Affiliation(s)
- Deborah S Keller
- Department of Digestive Surgery, University of Strasbourg, Strasbourg, FR, USA
| | - Nathan Curtis
- Surgical Unit, Dorset County Hospital, Dorchester, Dorset, UK
| | | | | | - Amelia T Collings
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Hiram C Polk
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY, USA
| | - Francesco Maria Carrano
- Department of General and Minimally Invasive Surgery, Busto Arsizio Circolo Hospital, ASST-Valle Olona, Varese, Italy
| | - Stavros A Antoniou
- Department of General Surgery, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Nader Hanna
- Department of Surgery, Queen's University, Kingston, ON, Canada
| | | | - Sarah Hill
- Department of Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Anne C M Cuijpers
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Patricia Tejedor
- Department of Colorectal Surgery, University Hospital Gregorio Marañón, Madrid, Spain
| | - Marco Milone
- Department of Clinical and Surgical Gastrointestinal Diseases, University of Naples "Federico II", Via Pansini 5, Naples, Italy
| | - Eleni Andriopoulou
- Department of Surgery, Hellenic Red Cross Korgialeneio Benakeio NHS, Athens, Greece
| | - Christos Kontovounisios
- Department of Surgery and Cancer, Imperial College London, Chelsea and Westminster Campus and the Royal Marsden Hospital, London, UK
| | - Ira L Leeds
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Ziad T Awad
- Department of Surgery, University of Florida, Jacksonville, FL, USA
| | - Meghan Wandtke Barber
- Department of Surgery, The University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Mazen Al-Mansour
- Department of Surgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - George Nassif
- Department of Colorectal Surgery, AdventHealth, Orlando, FL, USA
| | - Malcolm A West
- Cancer Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
- Complex Cancer and Exenterative Service, University Hospitals Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, Perioperative and Critical Care Theme, University of Southampton, Southampton, UK
| | - Aurora D Pryor
- Long Island Jewish Medical Center and System Chief for Bariatric Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Great Neck, NY, USA
| | - Franco Carli
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| | | | - Nicole D Bouvy
- Innovative Surgical Techniques, Endoscopic and Endocrine Surgery, Department of Surgery, Maastricht University Medical Center, Amsterdam, Netherlands
| | - Roberto Passera
- Division of Nuclear Medicine, University of Torino, Turin, Italy
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - Nader Francis
- Department of Surgery, Yeovil District Hospital, Higher Kingston, Yeovil, UK.
- The Griffin Institute, Northwick Park and St Mark's Hospital, Y Block, Watford Rd, Harrow, HA1 3UJ, UK.
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Mabeza RM, Vadlakonda A, Chervu N, Ebrahimian S, Sakowitz S, Yetasook A, Benharash P. Short-term outcomes of bariatric surgery in patients with inflammatory bowel disease: a national analysis. Surg Obes Relat Dis 2024; 20:146-152. [PMID: 38030456 DOI: 10.1016/j.soard.2023.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 08/15/2023] [Accepted: 10/04/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND While considered standard of care for obesity management, bariatric surgery is uncommon in patients with co-morbid inflammatory bowel disease (IBD). OBJECTIVES The present study aimed to assess the association of IBD with postoperative outcomes and resource use following bariatric surgery. SETTING Academic, university-affiliated; United States. METHODS All elective adult hospitalizations for laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) were identified in the 2016-2019 Nationwide Readmissions Database. Patients were classified based on diagnosis of ulcerative colitis (UC) or Crohn's disease (CD). Multivariable regression models were developed to evaluate the association of IBD with outcomes of interest. RESULTS Of an estimated 719,270 eligible patients, 860 and 1214 comprised the UC and CD cohorts, respectively. Compared to non-IBD, UC and CD had a higher Elixhauser comorbidity index (UC: 3.0 ± 1.4; CD: 3.1 ± 1.5; non-IBD: 2.7 ± 1.4, P < .001) and more frequently underwent sleeve gastrectomy (UC: 77.5%; CD: 83.2%; non-IBD: 68.8%, P < .001). All IBD patients survived to discharge. After adjustment, IBD was not associated with significant differences in most clinical outcomes analyzed. UC (adjusted odds ratio: 2.86; 95% confidence interval: 1.14-7.13) and CD (adjusted odds ratio: 4.40; 95% confidence interval: 2.20-8.80) were associated with increased odds of gastric outlet obstruction after RYGB but not sleeve gastrectomy. CD, but not UC, was linked to significantly higher odds of small bowel obstruction following RYGB (adjusted odds ratio: 4.50; 95% confidence interval: 1.76-11.49). There was no difference in index LOS, hospitalization costs, or odds of 30-day readmission based on IBD. CONCLUSIONS Patients with obesity and IBD faced low rates of adverse outcomes following bariatric surgery. There is an increased risk of gastrointestinal obstruction for patients with IBD undergoing RYGB. Given its safety profile, bariatric surgery can be utilized as a weight loss intervention for the growing proportion of patients with obesity and co-morbid IBD.
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Affiliation(s)
- Russyan Mark Mabeza
- Division of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California; Department of Surgery, University of California, San Francisco, California
| | - Amulya Vadlakonda
- Division of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Nikhil Chervu
- Division of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Shayan Ebrahimian
- Division of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Sara Sakowitz
- Division of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Amy Yetasook
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Peyman Benharash
- Division of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, California.
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3
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Paşaoğlu HE, Özcan TB, Öztürk Ç, Çelik E, Şavlı TB, Vartanoğlu T. Histopathological Findings in Turkish Patients Undergoing Sleeve Gastrectomy: Is Histopathologic Examination of Sleeve Gastrectomy Specimens Clinically Important? Obes Surg 2023; 33:2808-2815. [PMID: 37474865 DOI: 10.1007/s11695-023-06728-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/29/2023] [Accepted: 07/06/2023] [Indexed: 07/22/2023]
Abstract
PURPOSE Sleeve gastrectomy (SG) is a widely used surgical method in the treatment of obesity. This study aimed to reveal the histopathological changes in SG materials and to investigate the prevalence of clinically important lesions requiring follow-up. MATERIALS AND METHODS Three hundred five patients' data who underwent SG were analyzed. Cases were divided into three groups as normal, chronic inactive gastritis (CIG), and chronic active gastritis (CAG). Age, gender, and body mass index (BMI) of the three groups and the differences in the gastritis parameters of CIG and CAG groups were compared. RESULTS Thirty-three patients (10.8%) were in the normal group, 145 (47.5%) were in the CIG group, and 127 (41.6%) were in the CAG group. Preoperative endoscopic examination was performed in all cases, but Helicobacter pylori (HP) treatment was not applied. HP were detected in 39.3%, atrophy in 3.9%, intestinal metaplasia (IM) in 4.9%, and lymphoid follicle (LF) in 30% of the cases. Inflammation, atrophy, IM, LF, and HP were significantly higher in the CAG group. The proton pump inhibitor (PPI)-related changes were seen in 20 cases and it was more frequent in the CIG group. Intramucosal signet ring cell carcinoma was detected in 1 case. Endocrine cell hyperplasia and dysplasia were present in 7 cases with CAG. Multiple grade 1 neuroendocrine tumors were detected in just 1 case. CONCLUSION In our SG specimens, HP and clinically important lesions were significantly higher in the CAG group. Pathological examination should be carefully done as the lesions detected in SG specimens can change patient management.
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Affiliation(s)
- Hüsniye Esra Paşaoğlu
- Pathology Department, Health Sciences University Bagcilar Training and Research Hospital, Istanbul, Turkey.
| | - Tevhide Bilgen Özcan
- Pathology Department, Health Sciences University Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Çiğdem Öztürk
- Pathology Department, Health Sciences University Bagcilar Training and Research Hospital, Istanbul, Turkey
- Pathology Department, Faculty of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | - Elif Çelik
- Pathology Department, Health Sciences University Bagcilar Training and Research Hospital, Istanbul, Turkey
- Pathology Department, Mardin State Hospital, Mardin, Turkey
| | - Tuğçe Bölme Şavlı
- Pathology Department, Health Sciences University Bagcilar Training and Research Hospital, Istanbul, Turkey
- Pathology Department, Gaziantep Cengiz Gökçek Maternity and Children's Hospital, Gaziantep, Turkey
| | - Talar Vartanoğlu
- Pathology Department, Health Sciences University Bagcilar Training and Research Hospital, Istanbul, Turkey
- General Surgery Department, Istanbul Gaziosmanpasa Medical Park Hospital, Istanbul, Turkey
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4
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Su YT, Su YH, Tam KW, Yen YC, Wang W, Huang MT, Wang SY, Pai FY, Kuo CY, Shen SC. Prediction of 5-Year Weight Loss and Weight Regain According to Early Weight Loss after Sleeve Gastrectomy. Obes Surg 2023; 33:1366-1372. [PMID: 36940019 DOI: 10.1007/s11695-023-06527-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 02/16/2023] [Accepted: 02/23/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Patients with morbid obesity exhibit sustained weight loss after sleeve gastrectomy (SG), but some individuals exhibit subsequent weight regain in the following years. Early weight loss was proven as a predictor of short- and mid-term weight loss and regain. However, the long-term effects of early weight loss have yet to be fully investigated. This study investigated the predictive effects of early weight loss on long-term weight loss and regain after SG. METHODS Data of patients who underwent SG from November 2011 to July 2016 and followed through July 2021 were collected retrospectively. Weight regain was defined by weight increase more than 25% of their lost weight at the first postoperative year. Linear regression analysis and Cox proportional hazards analysis were performed to evaluate the correlations among early weight loss, weight loss, and weight regain. RESULTS Data of 408 patients were included. The percentages of total weight loss (%TWL) at postoperative months 1, 3, 12, and 60 were 10.6%, 18.1%, 29.3%, and 26.6%, respectively. The %TWL at months 1 and 3 were significantly correlated with %TWL after 5 years (P < .01). The weight regain rate was 29.8% at 5 years. The %TWL at months 1 and 3 significantly influenced weight regain (hazard ratio: 0.87 and 0.89, P = .017 and .008). CONCLUSION Early weight loss may be used to predict weight loss and regain 5 years after SG. Patients with poor early weight loss are recommended to receive early interventions to achieve long-term weight loss and prevent weight regain.
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Affiliation(s)
- Yi-Ting Su
- Department of General Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yen-Hao Su
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, 291, Zhongzheng Road, Zhonghe District, New Taipei City, 23561, Taiwan.,Metabolic and Weight Management Center, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,TMU Research Center of Cancer Translational Medicine, Taipei Medical University, Taipei, 11031, Taiwan.,TMU Research Center for Digestive Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ka-Wai Tam
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, 291, Zhongzheng Road, Zhonghe District, New Taipei City, 23561, Taiwan.,Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
| | - Yu-Chun Yen
- Clinical Information Department, Quality Management Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Weu Wang
- Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of General Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan
| | | | - Shih-Yun Wang
- Metabolic and Weight Management Center, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Fang-Yi Pai
- Metabolic and Weight Management Center, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Chih-Ying Kuo
- Metabolic and Weight Management Center, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Shih-Chiang Shen
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, 291, Zhongzheng Road, Zhonghe District, New Taipei City, 23561, Taiwan. .,Metabolic and Weight Management Center, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan. .,Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. .,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. .,TMU Research Center of Cancer Translational Medicine, Taipei Medical University, Taipei, 11031, Taiwan. .,TMU Research Center for Digestive Medicine, Taipei Medical University, Taipei, Taiwan.
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5
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Negm S, Mousa B, Shafiq A, Abozaid M, Allah EA, Attia A, AbdelKader T, Farag A. Endoscopic management of refractory leak and gastro-cutaneous fistula after laparoscopic sleeve gastrectomy: a randomized controlled trial. Surg Endosc 2023; 37:2173-2181. [PMID: 36326931 PMCID: PMC10017559 DOI: 10.1007/s00464-022-09748-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Gastro-cutaneous fistula is a rare complication after laparoscopic sleeve gastrectomy (LSG) with incidence of occurrence 1-2%. Most of gastro-cutaneous fistulae do not respond to conservative management and need intervention either surgically or endoscopically. METHODS This prospective randomized clinical study included referred patients who had LSG performed at our department or other centers, and complicated with post-LSG leak or gastro-cutaneous fistula between December/2019 and March/2021. Included patients were ASA Physical status I-II. Primary and secondary outcomes were recurrence of the fistula and mortality in each group after the intervention during the 18 months follow-up period, respectively. RESULTS Thirty patients were randomized into two groups: Surgery Group (SG, n = 15) and Endoscopy Group (EG, n = 15). Mean age of patients was 42.3 ± 8.7 and 42.6 ± 8.3 years-old in SG and EG, respectively. Females constituted 73.3% and 80% in SG and EG, respectively. Median time-to-gastric leak post LSG was six (range: 4-7) days in both groups. SG patients were surgically managed with primary repair of the gastric fistula and gastrojejunostomy in 13 patients or converting SG into Roux-en-Y gastric bypass in two patients, while EG patients were endoscopically managed with stitching, stenting, stenting and dilation, and clipping and dilation in 5, 4, 4 and 2 patients, respectively. Incidence of recurrent leak during 1st week was significantly higher in SG than EG (p < 0.001). No mortality reported in EG, while 2 patients died in SG (p = 0.48). CONCLUSION Endoscopic intervention may offer a successful modality in managing post-LSG gastric leak and gastro-cutaneous fistula that do not respond to conservative measures in stable patients.
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Affiliation(s)
- Said Negm
- grid.31451.320000 0001 2158 2757Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Bassam Mousa
- grid.31451.320000 0001 2158 2757Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed Shafiq
- grid.31451.320000 0001 2158 2757Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mohamed Abozaid
- grid.31451.320000 0001 2158 2757Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ehab Abd Allah
- grid.31451.320000 0001 2158 2757Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Adel Attia
- grid.31451.320000 0001 2158 2757Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Taha AbdelKader
- grid.415762.3Shepeen alkom teaching hospital, Ministry of health, Monufia, Egypt
| | - Ahmed Farag
- grid.31451.320000 0001 2158 2757Faculty of Medicine, Zagazig University, Zagazig, Egypt
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6
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Johnson AM, Storm AC, Mahmoud T, Ghazi R, Rapaka B, Abboud DM, Loftus EV, Dayyeh BKA. Endoscopic Bariatric Therapies for the Management of Obesity in Patients with Inflammatory Bowel Disease. Obes Surg 2023; 33:676-681. [PMID: 36474097 DOI: 10.1007/s11695-022-06376-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/21/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Amanda M Johnson
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA.
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Tala Mahmoud
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Rabih Ghazi
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Babusai Rapaka
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Donna M Abboud
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Edward V Loftus
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, MN, 55905, USA
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7
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Hort A, Cheng Q, Morosin T, Yoon P, Talbot M. Optimal common limb length in
Roux‐en‐Y
gastric bypass surgery: is it important for an ideal outcome? – a systematic review. ANZ J Surg 2022; 93:851-858. [PMID: 36480354 DOI: 10.1111/ans.18192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/07/2022] [Accepted: 11/27/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND In Roux-en-Y gastric bypass (RYGB) surgery the common limb length (CLL) is thought to significantly impact on nutritional and metabolic outcomes. However, there has been little focus on establishing routine standardized CLL measurements and its subsequent effect on weight loss and nutritional status. This review aimed to determine the effect of variations of CLL in RYGB surgery on post-operative outcomes, particularly nutritional status, while considering the need for routine CLL measurements in addition to measuring biliopancreatic limb and alimentary limb lengths. METHODS A systematic review was performed in accordance with the PRISMA guidelines. All English language articles addressing CLL and impact on weight loss, nutritional and metabolic outcomes were retrieved and reviewed. RESULTS Thirteen relevant studies were identified with CLLs varying from 76 to >600 cm. No significant difference in total body weight loss or excess weight loss was observed. Significant metabolic improvements occurred with shorter CLLs. Nutritional deficiencies were more severe when the CLL was <400 cm. CONCLUSION The data from this systematic review suggests that reasonable weight loss and positive impacts on metabolic outcomes can be achieved with CLLs of >400 cm.
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Affiliation(s)
- Amy Hort
- Department of Surgery Westmead Hospital Sydney New South Wales Australia
- Department of Surgery, The School of Medicine The University of Sydney Sydney New South Wales Australia
| | - Qiuye Cheng
- Department of Surgery Westmead Hospital Sydney New South Wales Australia
- UNSW St George and Sutherland Clinical School Sydney New South Wales Australia
| | - Tia Morosin
- Department of Surgery Westmead Hospital Sydney New South Wales Australia
| | - Peter Yoon
- Department of Surgery Westmead Hospital Sydney New South Wales Australia
| | - Michael Talbot
- UNSW St George and Sutherland Clinical School Sydney New South Wales Australia
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DEZZANI EO. Bariatric surgery: state of the art. Chirurgia (Bucur) 2022. [DOI: 10.23736/s0394-9508.22.05493-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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9
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The utility of endoscopy prior to bariatric surgery: an 11-year retrospective analysis of 885 patients. Surg Endosc 2022; 37:3127-3135. [PMID: 35941309 DOI: 10.1007/s00464-022-09485-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/13/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION Our aim was to evaluate the diagnostic yield of routine preoperative esophagogastroduodenoscopy (p-EGD) in patients undergoing bariatric surgery. Many medical problems that are common in patients with obesity, including gastroesophageal reflux disease (GERD) and hiatal hernias, have important implications for patients undergoing bariatric surgery. While p-EGD is considered standard of care prior to antireflux surgery, the role of p-EGD in bariatric surgery patients remains controversial. METHODS AND PROCEDURES We performed a retrospective chart review of 885 patients who underwent primary bariatric surgery at a university hospital-based bariatric surgery program between March 2011 and February 2022. Clinical history, demographics, and preoperative EGD reports were reviewed for abnormal findings. RESULTS Of the 885 patients evaluated in this study, one or more abnormal EGD findings were observed in 83.2% of patients. More than half of our patients (54.7%) presented with history of heartburn, reflux, or GERD. EGD findings demonstrated a hernia in 43.1% of patients [(Type I: 40.6%; Type II: 0.5%; Type III: 2.1%)]. 68.0% of patients were biopsied. Among patients who were biopsied, other findings included gastritis (32.4%), esophagitis (8.0%), eosinophilic esophagitis (4.7%), or duodenitis (2.7%). We found ulcers in 6.7% of patients. Pathology was consistent with H. pylori in 9.8% of biopsies taken and consistent with BE in 2.7%. Following routine p-EGD, 11.2% of patients were placed on PPI and 8.3% were recommended to stop NSAIDs. CONCLUSION Gastroesophageal reflux disease and associated pathology are common in the bariatric population. Preoperative EGD in patients undergoing bariatric surgery frequently identifies clinically significant UGI pathology. This may have important implications for medical and surgical management. Given the rate of abnormal preoperative endoscopic findings in obese patients, the work-up for bariatric surgery should align with the current recommendations for foregut surgery.
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10
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Fecso AB, Di Palma A, Maeda A, Englesakis M, Jackson T, Okrainec A. Operative management of recalcitrant marginal ulcers following laparoscopic Roux-en-Y gastric bypass for morbid obesity: a systematic review. Surg Obes Relat Dis 2021; 17:2082-2090. [PMID: 34433513 DOI: 10.1016/j.soard.2021.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/18/2021] [Accepted: 07/17/2021] [Indexed: 10/20/2022]
Abstract
One of the short- and long-term complications following Roux-en-Y gastric bypass (RYGB) for morbid obesity is the development of marginal ulcers (MUs). Although chronic and recalcitrant/recurrent marginal ulcers (rMUs) are common, there is no consensus on their optimal management. The objective of this study was to perform a systematic review of the elective operative management of rMUs. A systematic search of the literature was conducted. Relevant databases were searched up to May 16, 2020. Articles were included if they met the following inclusion criteria: (1) bariatric patients were included as the study population, (2) laparoscopic RYGB was performed as the index operation, (3) study patients developed rMUs, and (4) MUs required elective operative (surgical, endoscopic) interventions. Quality of articles was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The search identified 3470 citations; of these, 16 observational studies were included. Elective management of rMUs consisted of endoscopic (oversewing ± stents) and surgical interventions (gastrojejunostomy revision, vagotomy, conversion to sleeve gastrectomy, subtotal/total gastrectomy, reversal to normal anatomy). Quality of the studies as assessed by the GRADE system was low to very low. Recalcitrant/recurrent MUs are challenging complications both for bariatric patients and for their treating surgeons. There are no established algorithms for the management of rMUs, and the currently available evidence in the literature is limited both in quantity and in quality. Future multicentre, multisurgeon, randomized, controlled trials are needed to address this issue.
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Affiliation(s)
- Andras B Fecso
- Division of General Surgery, University Health Network, Toronto, Ontario, Canada; Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Adam Di Palma
- Division of General Surgery, University Health Network, Toronto, Ontario, Canada; Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Azusa Maeda
- Division of General Surgery, University Health Network, Toronto, Ontario, Canada
| | - Marina Englesakis
- Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Timothy Jackson
- Division of General Surgery, University Health Network, Toronto, Ontario, Canada; Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Allan Okrainec
- Division of General Surgery, University Health Network, Toronto, Ontario, Canada; Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
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A Preclinical Animal Study of Combined Intragastric Balloon and Duodenal-Jejunal Bypass Liner for Obesity and Metabolic Disease. Clin Transl Gastroenterol 2021; 11:e00234. [PMID: 33094961 PMCID: PMC7508443 DOI: 10.14309/ctg.0000000000000234] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION: Endoscopic bariatric and metabolic therapies can potentially reproduce similar gastric and small intestinal anatomic and physiologic manipulations as Roux-en-Y gastric bypass. This proof of concept animal study was aimed to assess the feasibility, safety, efficacy, and impact on gastrointestinal physiology of combined intragastric balloons (IGB) and duodenal-jejunal bypass liner (DJBL) for the treatment of obesity. METHODS: Five Ossabaw pigs were fed a high-calorie diet to develop obesity and were randomly assigned to receive IGB or DJBL in sequence. The weight gain rate was calculated. Fasting and postprandial blood samples were drawn before any intervention (serving as the baseline group) and 1 month after second device insertion (serving as the combination group) to measure gut neurohormonal changes and metabolic parameters. RESULTS: Four pigs successfully received a sequential device insertion. One pig developed duodenal sleeve prolapse that was spontaneously resolved. One pig was early terminated because of developing a central line infection. The rate of weight gain in the combination group (0.63 ± 1.3 kg/wk) was significantly lower than the baseline group (1.96 ± 2.17 kg/wk) and numerically lower than after insertion of the IGB (1.00 ± 1.40 kg/wk) or the DJBL (0.75 ± 2.27 kg/wk) alone. A trend of higher postprandial glucagon-like peptide-1 was observed in the combination group compared with the baseline group. DISCUSSION: A combination of IGB and DJBL is feasible and well tolerated. A strategy of sequential use of these devices might offer a synergistic approach that can enhance weight loss and metabolic outcomes.
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Kumar P, Yau HCV, Trivedi A, Yong D, Mahawar K. Global Variations in Practices Concerning Roux-en-Y Gastric Bypass-an Online Survey of 651 Bariatric and Metabolic Surgeons with Cumulative Experience of 158,335 Procedures. Obes Surg 2021; 30:4339-4351. [PMID: 32592015 DOI: 10.1007/s11695-020-04796-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
INTRODUCTION There is significant variation in practices concerning Roux-en-Y gastric bypass (RYGB) among bariatric surgeons, but there is currently a lack of robust data on the nature and extent of these variations. The purpose of this study was to understand global variations in practices concerning RYGB. METHODS A questionnaire-based survey on Survey Monkey® was created, and the link was shared freely on various social media platforms. The link was also distributed through a personnel email network of authors. RESULTS A total of 657 surgeons from 65 countries completed the survey. Crohn's disease and liver cirrhosis were considered absolute contraindications for RYGB by 427 surgeons (64.98%) and 347 surgeons (53.30%), respectively. More than 68.5% of surgeons performed routine upper GI endoscopy while 64.17% performed routine ultrasound of abdomen preoperatively. The majority of surgeons (77.70%) used the perigastric technique for Gastric pouch creation. Approximately, 79.5% used orogastric bougie. More than 70% of the respondents did not use any staple line reinforcement routinely. Only 17.67% of surgeons measured the whole small bowel length, and the majority of surgeons (86.5%) used constant length of BP limb. Approximately, 89% used constant length of alimentary limb. Approximately, 95% of surgeons preferred antecolic bypass, and more than 86% routinely closed the Petersen defect. Marginal ulcer prophylaxis was used by the majority (91.17%). Almost 95% of surgeons recommended lifelong vitamin and mineral supplements. CONCLUSION This survey identifies global variations in practices concerning RYGB. It identifies several areas for future research and consensus building.
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Affiliation(s)
- Parveen Kumar
- Sir Charles Gairdner Hospital, Nedlands, Western Australia.
| | | | | | - David Yong
- Joondalup Health Campus, Joondalup, Western Australia
| | - Kamal Mahawar
- Bariatric Unit, Sunderland Royal Hospital, Sunderland, UK
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13
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Komaei I, Currò G, Mento F, Cassaro G, Lazzara C, Barbera A, Ammendola M, Alibrandi A, Navarra G. Gastric Histopathologic Findings in South Italian Morbidly Obese Patients Undergoing Laparoscopic Sleeve Gastrectomy: Is Histopathologic Examination of All Resected Gastric Specimens Necessary? Obes Surg 2021; 30:1339-1346. [PMID: 31713151 DOI: 10.1007/s11695-019-04272-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The value of the routine histopathologic examination of resected gastric remnants following laparoscopic sleeve gastrectomy (LSG) remains to be controversial. This study aimed to determine whether the routine histopathologic examination of gastric specimens is necessary for all patients undergoing LSG if upper gastrointestinal endoscopy (UGIE) plus multiple biopsies are performed routinely during the preoperative work-up. MATERIALS AND METHODS Clinicopathologic data of 474 patients who underwent LSG were analysed. Types of histopathologic findings in LSG specimens and the prevalence of these and Helicobacter pylori (HP) infection were estimated. Comparisons were conducted to assess the association of risk factors with the most frequent abnormal and premalignant histopathologic findings. RESULTS Chronic gastritis was the most common gastric pathology (63.5%) and premalignant lesions were present in 7.8% of the specimens. The prevalence of HP infection was 36.9%. A statistically significant association was observed between HP infection and chronic gastritis (P = .000), and premalignant lesions (P = .000). Similarly, a statistically significant association was noted between age and premalignant gastric lesions (P = .000). CONCLUSION Histopathologic examination of LSG specimens may not be routinely needed and can be performed on selected patients. While we recommend routine preoperative UGIE in all LSG-treated patients, we suggest that histopathologic assessment of the LSG specimens should be mandatory when UGIE biopsies demonstrate HP infection and/or premalignant lesions, in all patients older than 42 years, and in cases of intraoperative detection of incidental tumours or suspicious lesions.
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Affiliation(s)
- Iman Komaei
- Department of Human Pathology of Adult and Evolutive Age, General Surgery Unit, University Hospital of Messina, Via Consolare Valeria 1, 98125, Messina, ME, Italy
| | - Giuseppe Currò
- Department of Human Pathology of Adult and Evolutive Age, General Surgery Unit, University Hospital of Messina, Via Consolare Valeria 1, 98125, Messina, ME, Italy. .,Department of Health Sciences, General Surgery Unit, Magna Graecia University of Catanzaro, Catanzaro, Italy.
| | - Federica Mento
- Department of Human Pathology of Adult and Evolutive Age, General Surgery Unit, University Hospital of Messina, Via Consolare Valeria 1, 98125, Messina, ME, Italy
| | - Gabriele Cassaro
- Department of Human Pathology of Adult and Evolutive Age, General Surgery Unit, University Hospital of Messina, Via Consolare Valeria 1, 98125, Messina, ME, Italy
| | - Claudio Lazzara
- Department of Human Pathology of Adult and Evolutive Age, General Surgery Unit, University Hospital of Messina, Via Consolare Valeria 1, 98125, Messina, ME, Italy
| | - Adalberto Barbera
- Department of Human Pathology of Adult and Evolutive Age, General Surgery Unit, University Hospital of Messina, Via Consolare Valeria 1, 98125, Messina, ME, Italy
| | - Michele Ammendola
- Department of Health Sciences, General Surgery Unit, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | | | - Giuseppe Navarra
- Department of Human Pathology of Adult and Evolutive Age, General Surgery Unit, University Hospital of Messina, Via Consolare Valeria 1, 98125, Messina, ME, Italy
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14
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Iron Deficiency - Not Only a Premenopausal Topic After Bariatric Surgery? Obes Surg 2021; 31:3242-3250. [PMID: 33821393 PMCID: PMC8175328 DOI: 10.1007/s11695-021-05380-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/24/2021] [Accepted: 03/24/2021] [Indexed: 11/11/2022]
Abstract
Purpose In our centre, specialized high dose multivitamin supplementation designed to meet the needs of patients after gastric bypass surgery is routinely recommended in the early postoperative period. The aim of the present study was to analyse whether iron supplementation prescribed in clinical practice is sufficient in both sexes and whether multivitamin supplementation standardized for women might potentially lead to iron overload in men. Materials/Methods This was a retrospective study covering the period up to 36 months after bariatric surgery. Three groups were compared (men, premenopausal and postmenopausal women). The iron status was evaluated employing serum ferritin concentrations. Results A total of 283 patients who had at least one follow-up visit between January 2015 and April 2018 at a specialized academic outpatient centre were included (71 men, 130 premenopausal women, 82 postmenopausal women). Thirty-six months after surgery, 33.3%, 68.4% and 54.5% of the men, pre- and postmenopausal women, respectively, were iron deficient. The preoperative prevalence of excess ferritin levels was 13.7% in premenopausal, 3.0% in postmenopausal women, 5.7% in men and declined in the following months. Conclusion Iron deficiency is very common after gastric bypass surgery, and even high dosages of multivitamin and mineral supplements might not be sufficient to prevent the development of iron deficiency. Men, pre- and postmenopausal women differ in their prevalence of iron deficiency which demands adapted iron dosage regimens based on the sex and the age. Iron overload is rare in all observed groups and highest in premenopausal women. Graphical abstract ![]()
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15
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Bariatric Embolization in the Treatment of Patients with a Body Mass Index Between 30 and 39.9 kg/m 2 (Obesity Class I and II) and Metabolic Syndrome, a Pilot Study. Cardiovasc Intervent Radiol 2021; 44:598-606. [PMID: 33527186 DOI: 10.1007/s00270-021-02776-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 01/15/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION To evaluate the efficacy and clinical safety of bariatric arterial embolization (BAE) in adults with body mass index (BMI) between 30 and 39.9 kg/m2 and metabolic syndrome (MS). MATERIALS AND METHODS Between March and August 2018, ten female participants between 21 and 48-years-old, median BMI of 36.37 ± 2.58 kg/m2 and MS were enrolled in this prospective trial. We embolized the fundal branches from the left gastric and other artery sources, which resulted in embolization of at least two arteries in 9 out 10 participants. Six months after bariatric embolization, efficacy was assessed by changes in total body weight (TBW), ghrelin and Homeostatic Model Assessment-Insulin Resistance (HOMA-IR) levels and by changes in quality of life (QOL) and in binge eating scale (BES) scores. Safety was assessed by the identification of any related complications, including gastric ulcers, screened by gastrointestinal endoscopy, performed before and one week and one month after BAE. RESULTS Six months after embolization, TBW decreased by 6.8% (6.22 kg ± 3.6;p = .01), serum ghrelin dropped from 25.39 pg/ml ± 10.63 to 17.1 ± 8.07 (p = 0.01), and HOMA-IR decreased from 7.29 ± 5.66 to 3.73 ± 1.99 (p = 0.01). The QOL scores improved from 59.64 ± 5.59 to 69.02 ± 11.97 (p < 0.05) and in the BES from 21.50 ± 8.89 to 9.60 ± 4.40 (p = 0.01). Endoscopy revealed symptomatic gastric ulcers in two participants, which had healed without sequelae. In one participant, ultrasound revealed an asymptomatic focal arterial thrombus at the left distal radial artery puncture site. CONCLUSION BAE is effective in reducing weight, insulin resistance and ghrelin levels and improving BES and QOL scores in patients with class I and II obesity and MS, with no major complications.
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16
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Lazzarin G, Di Furia M, Romano L, Di Sibio A, Di Giacomo C, Lombardi L, Giuliani A, Schietroma M, Pessia B, Carlei F, Marchese M. Endoscopic Double-Pigtail Catheter (EDPC) Internal Drainage as First-Line Treatment of Gastric Leak: A Case Series during Laparoscopic Sleeve Gastrectomy Learning Curve for Morbid Obesity. Minim Invasive Surg 2020; 2020:8250904. [PMID: 33425388 PMCID: PMC7775182 DOI: 10.1155/2020/8250904] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 12/08/2020] [Accepted: 12/15/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The prevalence of morbid obesity has dramatically increased over the last several decades worldwide, currently reaching epidemic proportions. Gastric leak (GL) remains the potentially fatal main complication after sleeve gastrectomy (SG) for morbid obesity. To our knowledge, there are no standardized guidelines for GL treatment after laparoscopic sleeve gastrectomy (LSG) yet. The aim of this study was to represent our institutional preliminary experience using the endoscopic double-pigtail catheter (EDPC) as the method of internal drainage and propose it as first-line treatment in case of GL after LSG. METHODS One hundred and seventeen patients were admitted to our surgical department and underwent laparoscopic sleeve gastrectomy (LSG) for morbid obesity from March 2014 to June 2019. In 5 patients (4.3%) of our series, GL occurred as a complication of LSG. EPDC was the stand-alone procedure of internal drainage and GL first-line treatment. The internal pig tail was endoscopically removed from 30th to 40th POD in all cases. RESULTS Present data (clinical, biochemical, and instrumental tests) showed a complete resolution of GL, with promotion of a pseudodiverticula and complete re-epithelialization of leak. Follow-up was more strict than usual (clinical visit and biochemical test on 7th, 14th, and 21st day after discharge; a CT scan with gastrografin on 30th day from discharge if clinical visit and exams were normal). CONCLUSION This was a preliminary retrospective observational study, conducted on 5 patients affected by GL as a complication of LSG for morbid obesity. EDPC maintains the safety, efficacy, and nonexpensive characteristic and may be proposed as better first-line treatment in case of GL after bariatric surgery.
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Affiliation(s)
- Gianni Lazzarin
- Department of Biotechnological and Applied Clinical Sciences, ASL1 Abruzzo, San Salvatore Hospital, L'Aquila, Italy
| | - Marino Di Furia
- Department of Biotechnological and Applied Clinical Sciences, ASL1 Abruzzo, San Salvatore Hospital, L'Aquila, Italy
| | - Lucia Romano
- Department of Biotechnological and Applied Clinical Sciences, ASL1 Abruzzo, San Salvatore Hospital, L'Aquila, Italy
| | - Alessandra Di Sibio
- Department of Radiology, ASL1 Abruzzo, San Salvatore Hospital, L'Aquila, Italy
| | - Carla Di Giacomo
- Surgical Endoscopy Unit, ASL1 Abruzzo, San Salvatore Hospital, L'Aquila, Italy
| | - Loreto Lombardi
- Surgical Endoscopy Unit, ASL1 Abruzzo, San Salvatore Hospital, L'Aquila, Italy
| | - Antonio Giuliani
- Department of Biotechnological and Applied Clinical Sciences, ASL1 Abruzzo, San Salvatore Hospital, L'Aquila, Italy
| | - Mario Schietroma
- Department of Biotechnological and Applied Clinical Sciences, ASL1 Abruzzo, San Salvatore Hospital, L'Aquila, Italy
| | - Beatrice Pessia
- Department of Biotechnological and Applied Clinical Sciences, ASL1 Abruzzo, San Salvatore Hospital, L'Aquila, Italy
| | - Francesco Carlei
- Department of Biotechnological and Applied Clinical Sciences, ASL1 Abruzzo, San Salvatore Hospital, L'Aquila, Italy
| | - Michele Marchese
- Surgical Endoscopy Unit, ASL1 Abruzzo, San Salvatore Hospital, L'Aquila, Italy
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Faustino AVM, Rama TF, Andrade MPC, Carneiro VMD, Leite MIGP. A rare tumour, a singular indication: sleeve gastrectomy in a morbidly obese septuagenarian with gastric schwannoma. J Surg Case Rep 2020; 2020:rjaa421. [PMID: 33154810 PMCID: PMC7603400 DOI: 10.1093/jscr/rjaa421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/15/2020] [Indexed: 11/30/2022] Open
Abstract
Gastric schwannoma is an extremely rare mesenchymal tumour, representing only 0.2% of all gastric tumours. Obesity is an alarming worldwide disease whose only effective and sustained treatment seems to be surgical. We present a case of a 73-year-old female with epigastric pain and unspecific dyspeptic symptoms, whose diagnostic endoscopic procedures raised suspicion of a gastrointestinal stromal tumour. Given her good performance status, and since grade 2 obesity with high-risk comorbid conditions was present, she was considered a suitable candidate for laparoscopic sleeve gastrectomy. Both surgery and immediate postoperative period were uneventful. Histological and immunocytochemical analysis classified the tumour as benign gastric schwannoma. After 24 months, besides being disease-free, she presented an excess weight loss of 90.2%, with improvements in metabolic profile allowing withdrawal from chronic medication. The patient is healthier, satisfied and living an active life, showing that age by itself should not be a deterrent to bariatric surgery.
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Affiliation(s)
- Ana V M Faustino
- Department of General Surgery, Hospital do Divino Espírito Santo, São Miguel - Azores, Portugal
| | - Tiago F Rama
- Department of General Surgery, Hospital do Divino Espírito Santo, São Miguel - Azores, Portugal
| | - Margarida P C Andrade
- Department of General Surgery, Hospital do Divino Espírito Santo, São Miguel - Azores, Portugal
| | - Vítor M D Carneiro
- Department of Pathology, Hospital do Divino Espírito Santo, São Miguel - Azores, Portugal
| | - Maria I G P Leite
- Department of General Surgery, Hospital do Divino Espírito Santo, São Miguel - Azores, Portugal
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18
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Ilyas S, Al-Refai R, Maharjan R, Diaz Bustamante L, Ghattas KN, Khan S. Bariatric Surgery and Type 2 Diabetes Mellitus: Assessing Factors Leading to Remission. A Systematic Review. Cureus 2020; 12:e9973. [PMID: 32983676 PMCID: PMC7510520 DOI: 10.7759/cureus.9973] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 08/23/2020] [Indexed: 12/05/2022] Open
Abstract
Type 2 Diabetes Mellitus (T2DM) is a health problem of paramount proportions and is associated with significant morbidity and mortality. Our study aims to review data published on the effects of different types of bariatric surgeries on T2DM remission, compared to lifestyle and medical intervention (LMI) exclusively, along with a comprehensive finding of numerous preoperative factors that lead to remission. We used PubMed, PubMed Central (PMC), and MEDLINE to search for literature. Our criteria included peer-reviewed, English language articles published in 2010 and onwards, consisting of adults with T2DM and a body mass index (BMI) of >30 kg/m2 as the population of interest. Twenty-four articles with 5,411 patients were selected for this systematic review, which included nine randomized controlled trials (RCTs) and 15 observational studies. The primary endpoint was T2DM remission. Based on the review, bariatric surgery is superior to LMI in inducing remission in T2DM, especially when employing the Roux-en-Y Gastric Bypass (RYGB) technique. Lower age of onset and shorter duration of T2DM, along with a high BMI are some of the factors that can lead to greater remission rates. Further research in RCTs is needed by incorporating double/triple-blind protocols, a standard definition of T2DM remission, long follow-up periods to evaluate for relapses in remission and any side effects, with a focus on inflammatory markers (eg, osteopontin), scoring systems (eg, DiaRem), and benefits of One-Anastomosis Gastric Bypass (OAGB) over other modalities, to advance our understanding of T2DM remission.
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Affiliation(s)
- Shahbakht Ilyas
- Surgery, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Medicine and Surgery, CMH Lahore Medical College and Institute of Dentistry, Lahore, PAK
| | - Reham Al-Refai
- Pathology, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Reeju Maharjan
- Neurology, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Liliana Diaz Bustamante
- Family Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Kyrillos N Ghattas
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
- Internal Medicine, Assiut University, Assiut, EGY
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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19
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Iossa A, Carrano FM, DE Angelis F, Boru C, DI Lorenzo N, Silecchia G. Updates in bariatric surgery guidelines: what's new? Minerva Surg 2020; 76:5-7. [PMID: 32773755 DOI: 10.23736/s2724-5691.20.08447-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Angelo Iossa
- Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University, Rome, Italy -
| | - Francesco M Carrano
- Department of Medico-Surgical Sciences and Biotechnologies, Tor Vergata University, Rome, Italy
| | - Francesco DE Angelis
- Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University, Rome, Italy
| | - Cristian Boru
- Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University, Rome, Italy
| | - Nicola DI Lorenzo
- Department of Medico-Surgical Sciences and Biotechnologies, Tor Vergata University, Rome, Italy
| | - Gianfranco Silecchia
- Department of Medico-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, Sapienza University, Rome, Italy
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20
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El Ansari W, El-Menyar A, Sathian B, Al-Thani H, Al-Kuwari M, Al-Ansari A. Is Routine Preoperative Esophagogastroduodenoscopy Prior to Bariatric Surgery Mandatory? Systematic Review and Meta-analysis of 10,685 Patients. Obes Surg 2020; 30:3073-3083. [PMID: 32468339 PMCID: PMC7305097 DOI: 10.1007/s11695-020-04672-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND This systematic review and meta-analysis searched, retrieved and synthesized the evidence as to whether preoperative esophagogastroduodenoscopy (p-EGD) should be routine before bariatric surgery (BS). METHODS Databases searched for retrospective, prospective, and randomized (RCT) or quasi-RCT studies (01 January 2000-30 April 2019) of outcomes of routine p-EGD before BS. STROBE checklist assessed the quality of the studies. P-EGD findings were categorized: Group 0 (no abnormal findings); Group 1 (abnormal findings that do not necessitate changing the surgical approach or postponing surgery); Group 2 (abnormal findings that change the surgical approach or postpone surgery); and Group 3 (findings that signify absolute contraindications to surgery). We assessed data heterogeneity and publication bias. Random effect model was used. RESULTS Twenty-five eligible studies were included (10,685 patients). Studies were heterogeneous, and there was publication bias. Group 0 comprised 5424 patients (56%, 95% CI: 45-67%); Group 1, 2064 patients (26%, 95% CI: 23-50%); Group 2, 1351 patients (16%, 95% CI: 11-21%); and Group 3 included 31 patients (0.4%, 95% CI: 0-1%). CONCLUSION For 82% of patients, routine p-EGD did not change surgical plan/ postpone surgery. For 16% of patients, p-EGD findings necessitated changing the surgical approach/ postponing surgery, but the proportion of postponements due to medical treatment of H Pylori as opposed to "necessary" substantial change in surgical approach is unclear. For 0.4% patients, p-EGD findings signified absolute contraindication to surgery. These findings invite a revisit to whether p-EGD should be routine before BS, and whether it is judicious to expose many obese patients to an invasive procedure that has potential risk and insufficient evidence of effectiveness. Further justification is required.
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Affiliation(s)
- Walid El Ansari
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, Qatar University, Doha, Qatar
- Schools of Health and Education, University of Skovde, Skövde, Sweden
| | - Ayman El-Menyar
- Department of Surgery, Trauma and Vascular Surgery, Clinical Research, Hamad General Hospital, Doha, Qatar
- Clinical Medicine, Weill Cornell Medical School, Doha, Qatar
| | - Brijesh Sathian
- Department of Surgery, Trauma and Vascular Surgery, Clinical Research, Hamad General Hospital, Doha, Qatar
| | - Hassan Al-Thani
- Department of Surgery, Trauma and Vascular Surgery Section, Hamad Medical Corporation, Doha, Qatar
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Singh A, Koenen B, Kirby DF. Bariatric Surgery and Its Complications in Inflammatory Bowel Disease Patients. Inflamm Bowel Dis 2020; 26:1155-1165. [PMID: 31626698 DOI: 10.1093/ibd/izz246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Indexed: 12/14/2022]
Abstract
Recent data have suggested that bariatric procedures, especially laparoscopic sleeve gastrectomy (SG), are safe and effective weight loss measures in patients with inflammatory bowel disease (IBD). But most of the studies have looked at short-term outcomes, and there is a general lack of awareness of underlying disease processes and baseline comorbidities in IBD patients undergoing bariatric procedures. Postbariatric issues in IBD patients including diarrhea from dumping syndrome, choleretic diarrhea, a high prevalence of small intestinal bacterial overgrowth, gastroesophageal reflux disease, Barrett's esophagus, stomal ulcerations, stenosis, and renal and gallstones can complicate the natural history of IBD. This could lead to unnecessary hospitalizations, change of medical therapy, and poor surgical and quality of life outcomes. In this review, we will discuss major complications after common bariatric procedures (SG, Roux-en-Y gastric bypass, and gastric banding) and suggest possible management strategies.
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Affiliation(s)
- Amandeep Singh
- Department of Gastroenterology, Hepatology & Nutrition, Center for Human Nutrition, Center for Gut Rehabilitation and Intestinal Transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian Koenen
- Department of Gastroenterology, Hepatology & Nutrition, Center for Human Nutrition, Center for Gut Rehabilitation and Intestinal Transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Donald F Kirby
- Department of Gastroenterology, Hepatology & Nutrition, Center for Human Nutrition, Center for Gut Rehabilitation and Intestinal Transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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22
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Prevalence of Endoscopic Findings Before Bariatric Surgery and Their Influence on the Selection of the Surgical Technique. Obes Surg 2020; 30:4375-4380. [PMID: 32588172 DOI: 10.1007/s11695-020-04800-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/16/2020] [Accepted: 06/17/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the two most popular procedures performed. The decision of which technique is most appropriate depends on the surgeon's preferences and experience. However, several factors strongly influence the decision of the procedure performed, including gastrointestinal disorders or asymptomatic upper gastrointestinal endoscopy (UGE) findings. This study aimed to describe the pathological endoscopic findings in morbidly obese patients undergoing preoperative routine UGE. MATERIALS AND METHODS A retrospective review of a prospectively collected database of all UGEs performed before bariatric surgery was performed. UGE was routinely performed to all the patients as part of the preoperative evaluation protocol. RESULTS A total of 790 patients were included. Surgical technique included 610 (77.2%) RYGB and 180 (22.8%) SG. Twenty-one asymptomatic patients presented esophagitis at UGE. In only seven patients (0.89%), the endoscopic findings of esophagitis had changed the initial surgical decision. The presence of ulcers or adenomatous or incompletely resected polyps was an indication for SG, to assure future endoscopic access in case it is needed. In 25 patients (3.17%), the initial operation would have been changed based on UGE findings. CONCLUSION Preoperative UGE allows the diagnosis of asymptomatic esophagitis related to gastroesophageal reflux disease and the identification of asymptomatic polyps and ulcers, with the potential ability for malignant transformation. In up to 3.17% of the cases, the endoscopic findings changed the operative strategy. As the complication rate associated with the procedure is low, we recommend the routine performance of preoperative UGE before bariatric surgery.
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The role of preoperative upper endoscopy in adolescents undergoing laparoscopic vertical sleeve gastrectomy. Surg Obes Relat Dis 2020; 16:1212-1217. [PMID: 32576512 DOI: 10.1016/j.soard.2020.04.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/17/2020] [Accepted: 04/21/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Vertical sleeve gastrectomy (VSG) has been associated with gastroesophageal reflux symptoms and, in adults, with a development of Barrett's esophagus. Adults with Barrett's esophagus identified at baseline before bariatric operation are generally advised against VSG operations. The role of preoperative esophagogastroduodenoscopy (EGD) in adolescents preparing for bariatric surgery is not clearly defined. OBJECTIVE The goal of this study was to report the frequency of abnormalities identified on EGD performed at baseline in adolescents undergoing VSG for severe obesity. SETTING Free-standing academic children's hospital. United States. METHODS A retrospective chart review was conducted to describe findings of EGD performed just before VSG in a cohort of 40 adolescents and young adults (age range 14-25 yr) immediately before VSG. Review of findings from gross and histopathological evaluation of the esophagus, resected stomach, and duodenum was performed. RESULTS Five individuals reported preoperative symptoms of gastroesophageal reflux. Anatomic findings at EGD were normal in 98% of individuals. Histopathology of the esophagus, stomach, and duodenum was normal in 88%, 70%, and 95%, respectively. Abnormal findings of gastritis (18%), esophagitis (13%), and/or Helicobacter pylori (10%) infection were most common. Those with evidence of H. pylori in gastric resection specimens were treated appropriately with eradication therapy postoperatively. With the exception of 2 patients with incidentally detected esophageal mucosal eosinophilia, EGD findings did not lead to additional changes in medical or surgical management. There were no complications of the EGD procedure. CONCLUSIONS Routine EGD at the time of VSG was safe but resulted in low yield of abnormal findings requiring a change in clinical management.
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Garg R, Mohan BP, Ponnada S, Singh A, Aminian A, Regueiro M, Click B. Safety and Efficacy of Bariatric Surgery in Inflammatory Bowel Disease Patients: a Systematic Review and Meta-analysis. Obes Surg 2020; 30:3872-3883. [PMID: 32578179 DOI: 10.1007/s11695-020-04729-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/16/2020] [Accepted: 05/19/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND The safety and efficacy of bariatric surgery in inflammatory bowel disease (IBD) patients is poorly understood. We conducted a systematic review and meta-analysis studying safety and efficacy of bariatric surgery in IBD patients as well as the impact of bariatric surgery on IBD course. METHODS We conducted a comprehensive search of multiple databases (through September 2019) to identify studies that reported outcome of bariatric surgery in IBD patients. Outcomes assessed included the pooled rate of adverse events, change in medications after bariatric surgery, and 12-month excess weight loss (EWL) and body mass index (BMI) reduction after bariatric surgery. RESULTS A total of 10 studies were included in final analysis. The pooled rate of early and late adverse events was 15.9% (95% CI, 9.3-25.9) and 16.9% (95% CI, 12.1-23.1), respectively. The rate of adverse events in Roux-en-Y gastric bypass was 45.6% (95% CI, 21.9-71.4) compared with 21.6% (95% CI, 11.1-38) in sleeve gastrectomy (p = 0.11). The pooled rate of 12-month EWL and BMI reduction after surgery was 66.1% (95% CI, 59.8-72.3%) and 13.7 kg/m2 (95% CI, 12.5-14.9), respectively. The pooled rate of decrease, increase, and no change of IBD medications were 45.6% (95% CI, 23.8-69.2), 11% (95% CI, 6.3-18.4), and 57.6% (95% CI, 39.2-74.1), respectively. CONCLUSIONS Bariatric surgery has acceptable safety and efficacy profile in IBD patients. Nearly half of patients had decrease in their IBD medications after bariatric surgery, and only 10% experienced therapeutic escalation following bariatric surgery. Sleeve gastrectomy may be the preferred procedure in this population.
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Affiliation(s)
- Rajat Garg
- Department of Internal Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
| | - Babu P Mohan
- Department of Internal Medicine, Banner University Medical Center/University of Arizona, Tucson, AZ, USA
| | - Suresh Ponnada
- Department of Internal Medicine, Carilion Roanoke Medical Center, Roanoke, VA, USA
| | - Amandeep Singh
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ali Aminian
- Department of Laparoscopic and Bariatric Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Miguel Regueiro
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Benjamin Click
- Department of Gastroenterology and Hepatology, Cleveland Clinic Foundation, Cleveland, OH, USA
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Yang S, Zhou L, Chen Y, Krewski D, Xie RH, Wen SW. The impact of pregnancy on postoperative outcomes among obese women who underwent bariatric surgery: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2020; 252:239-245. [PMID: 32623256 DOI: 10.1016/j.ejogrb.2020.06.044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/20/2020] [Accepted: 06/22/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Women who had a history of bariatric surgery are increasingly becoming pregnant. There is growing evidence showing that increased risk of postoperative complications may be associated with the gestation after bariatric surgery.The objective of this systematic review was to evaluate the potential impact of pregnancy on weight loss and postoperative complications in obese women after bariatric surgery. STUDY DESIGN PubMed, Embase, Medline and Cochrane Central Register of Controlled Trails were searched from inception through October 2018. Selection criteria included observational or randomized trial examining weight loss and medical complications in pregnant compared to non-pregnant women after bariatric surgery. Two reviewers extracted information and performed quality appraisal of eligible articles. Meta-analysis was performed to ascertain the certainty of the evidence when possible. RESULTS Seven observational cohort studies with a total of 27,369 obese women were included in the final analysis. The mean difference (95 % confidence interval) in percent excess weight loss between pregnant and non-pregnant subjects was -9.5 (-19.9, 0.9). The odds ratio (95 % confidence interval) for postoperative complications in pregnant relative to non-pregnant subjects was 0.85 (0.33, 2.18). CONCLUSIONS Pregnancy may have little or no effect on weight loss or postoperative complications in women who have undergone bariatric surgery.
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Affiliation(s)
- Siyu Yang
- Nursing School of Central South University, Changsha, Hunan, PR China.
| | - Leshan Zhou
- Nursing School of Central South University, Changsha, Hunan, PR China.
| | - Yijing Chen
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, PR China; Wuhan Mental Health Center affiliated Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Daniel Krewski
- McLaughlin Centre for Population Health Risk Assessment, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Ri-Hua Xie
- Department of Nursing, General Practice Center Nanhai Hospital, Southern Medical University, Guangzhou, PR China.
| | - Shi Wu Wen
- School of Epidemiology and Public Health, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada; OMNI Research Group, Department of Obstetrics and Gynecology, University of Ottawa Faculty of Medicine, Ottawa, Canada.
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Di Lorenzo N, Antoniou SA, Batterham RL, Busetto L, Godoroja D, Iossa A, Carrano FM, Agresta F, Alarçon I, Azran C, Bouvy N, Balaguè Ponz C, Buza M, Copaescu C, De Luca M, Dicker D, Di Vincenzo A, Felsenreich DM, Francis NK, Fried M, Gonzalo Prats B, Goitein D, Halford JCG, Herlesova J, Kalogridaki M, Ket H, Morales-Conde S, Piatto G, Prager G, Pruijssers S, Pucci A, Rayman S, Romano E, Sanchez-Cordero S, Vilallonga R, Silecchia G. Clinical practice guidelines of the European Association for Endoscopic Surgery (EAES) on bariatric surgery: update 2020 endorsed by IFSO-EC, EASO and ESPCOP. Surg Endosc 2020; 34:2332-2358. [PMID: 32328827 PMCID: PMC7214495 DOI: 10.1007/s00464-020-07555-y] [Citation(s) in RCA: 221] [Impact Index Per Article: 55.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/07/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgery for obesity and metabolic diseases has been evolved in the light of new scientific evidence, long-term outcomes and accumulated experience. EAES has sponsored an update of previous guidelines on bariatric surgery. METHODS A multidisciplinary group of bariatric surgeons, obesity physicians, nutritional experts, psychologists, anesthetists and a patient representative comprised the guideline development panel. Development and reporting conformed to GRADE guidelines and AGREE II standards. RESULTS Systematic review of databases, record selection, data extraction and synthesis, evidence appraisal and evidence-to-decision frameworks were developed for 42 key questions in the domains Indication; Preoperative work-up; Perioperative management; Non-bypass, bypass and one-anastomosis procedures; Revisional surgery; Postoperative care; and Investigational procedures. A total of 36 recommendations and position statements were formed through a modified Delphi procedure. CONCLUSION This document summarizes the latest evidence on bariatric surgery through state-of-the art guideline development, aiming to facilitate evidence-based clinical decisions.
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Affiliation(s)
- Nicola Di Lorenzo
- Department of Surgical Sciences, University of Rome "Tor Vergata", Rome, Italy
| | - Stavros A Antoniou
- Department of Surgery, European University of Cyprus, Nicosia, Cyprus
- Department of Surgery, Mediterranean Hospital of Cyprus, Limassol, Cyprus
| | - Rachel L Batterham
- Centre for Obesity Research, University College London, London, UK
- Biomedical Research Centre, National Institute of Health Research, London, UK
| | - Luca Busetto
- Internal Medicine 3, Department of Medicine, DIMED, Center for the Study and the Integrated Treatment of Obesity, University Hospital of Padua, Padua, Italy
| | - Daniela Godoroja
- Department of Anesthesiology, Ponderas Academic Hospital Regina Maria, Bucharest, Romania
| | - Angelo Iossa
- Department of Medical-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, "La Sapienza" University of Rome-Polo Pontino, Bariatric Centre of Excellence IFSO-EC, Via F. Faggiana 1668, 04100, Latina, Italy
| | - Francesco M Carrano
- Department of Endocrine and Metabolic Surgery, University of Insubria, Ospedale di Circolo and Fondazione Macchi, ASST Sette Laghi, Varese, Italy
| | | | - Isaias Alarçon
- Unit of Innovation in Minimally Invasive Surgery, Department of General and Digestive Surgery, University Hospital "Virgen del Rocío", 41010, Sevilla, Spain
| | | | - Nicole Bouvy
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Maura Buza
- Department of General Surgery, Ponderas Academic Hospital Regina Maria, Bucharest, Romania
| | - Catalin Copaescu
- Department of General Surgery, Ponderas Academic Hospital Regina Maria, Bucharest, Romania
| | - Maurizio De Luca
- Division of General Surgery, Castelfranco and Montebelluna Hospitals, Treviso, Italy
| | - Dror Dicker
- Department of Internal Medicine D, Hasharon Hospital, Rabin Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Angelo Di Vincenzo
- Internal Medicine 3, Department of Medicine, DIMED, Center for the Study and the Integrated Treatment of Obesity, University Hospital of Padua, Padua, Italy
| | - Daniel M Felsenreich
- Division of General Surgery, Department of Surgery, Vienna Medical University, Vienna, Austria
| | - Nader K Francis
- Department of General Surgery, Yeovil District Hospital NHS Foundation Trust, Yeovil, UK
| | - Martin Fried
- Center for Treatment of Obesity and Metabolic Disorders, OB Klinika, Prague, Czech Republic
| | | | - David Goitein
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Surgery C, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Jason C G Halford
- Department of Psychological Sciences, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Jitka Herlesova
- Center for Treatment of Obesity and Metabolic Disorders, OB Klinika, Prague, Czech Republic
| | | | - Hans Ket
- VU Amsterdam, Amsterdam, Netherlands
| | - Salvador Morales-Conde
- Unit of Innovation in Minimally Invasive Surgery, Department of General and Digestive Surgery, University Hospital "Virgen del Rocío", 41010, Sevilla, Spain
| | - Giacomo Piatto
- Division of General Surgery, Castelfranco and Montebelluna Hospitals, Treviso, Italy
| | - Gerhard Prager
- Division of General Surgery, Department of Surgery, Vienna Medical University, Vienna, Austria
| | - Suzanne Pruijssers
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Andrea Pucci
- Centre for Obesity Research, University College London, London, UK
- Biomedical Research Centre, National Institute of Health Research, London, UK
| | - Shlomi Rayman
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Surgery C, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - Eugenia Romano
- Department of Psychological Sciences, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | | | - Ramon Vilallonga
- Endocrine, Metabolic and Bariatric Unit, General Surgery Department, Vall D'Hebron University Hospital, Center of Excellence for the EAC-BC, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gianfranco Silecchia
- Department of Medical-Surgical Sciences and Biotechnologies, Faculty of Pharmacy and Medicine, "La Sapienza" University of Rome-Polo Pontino, Bariatric Centre of Excellence IFSO-EC, Via F. Faggiana 1668, 04100, Latina, Italy.
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El Ansari W, El-Menyar A. Is routine preoperative esophagogastroduodenscopy prior to bariatric surgery mandatory? protocol for a systematic review and meta-analysis. Int J Surg Protoc 2020; 22:1-5. [PMID: 32405604 PMCID: PMC7210597 DOI: 10.1016/j.isjp.2020.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/15/2020] [Accepted: 04/16/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Routine preoperative esophagogastroduodenscopy (p-EGD) prior to bariatric surgery (BS) is currently widely undertaken, and hence an important issue with many clinical and financial repercussions. Yet, the true extent of why p-EGD is routinely undertaken for all bariatric patients remains not well understood. METHODS AND ANALYSIS To address this, we will undertake a systematic review and meta-analysis of routine p-EGD prior to BS from around the world. This protocol describes the methodological approach to be adopted and outlines the search strategies and eligibility criteria that will be employed to identify and select studies, and the way by which data from the selected studies will be extracted for analysis. PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), WHO International Clinical Trials Registry Platform, Cochrane Library, MEDLINE, Scopus, clinicaltrials.gov and Google scholar will be searched from 01 January 2000 to 30 April 2019 for original studies written in English that provided prevalence estimates of the outcomes of routine p-EGD prior to BS. STROBE criteria will assess the methodological quality of the selected studies. The use of fixed or random effects model will depend on the results of statistical tests for heterogeneity. Publication bias will be visually estimated by assessing funnel plots. Pooled estimates will be calculated. This protocol conforms to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines and has been submitted for registration at the PROSPERO International Prospective Register of systematic reviews. No ethical clearance is required for this study. This review will be published in a peer- reviewed journal and will be presented at various national and international conferences.
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Affiliation(s)
- Walid El Ansari
- Department of Surgery, Hamad General Hospital, Hamad Medical Corporation, Doha 3050, Qatar
- College of Medicine, Qatar University, Doha 2713, Qatar
- Schools of Health and Education, University of Skovde, 541 28 Skövde, Sweden
| | - Ayman El-Menyar
- Department of Surgery, Trauma and Vascular Surgery, Clinical Research, Hamad General Hospital, Doha 3050, Qatar
- Clinical Medicine, Weill Cornell Medical School, Doha 24144, Qatar
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Preoperative Endoscopic and Radiologic Evaluation of Bariatric Patients: What Do They Add? J Gastrointest Surg 2020; 24:764-771. [PMID: 31073799 DOI: 10.1007/s11605-019-04219-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 03/27/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Preoperative esophagogastroduodenoscopy (EGD) and barium swallow (BS) are commonly performed for evaluation in bariatric surgery patients. The routine use of these modalities has been controversial. METHODS A retrospective review of a prospectively maintained database was performed to include primary bariatric surgery patients between March 2013 and August 2016. RESULTS Two hundred nine patients were included. All the patients underwent preoperative EGD and BS. The mean age was 43.12 years and BMI 46.4 kg/m2. Reflux symptoms were present in 58.5% of patients. Preoperative EGD revealed abnormalities in 87.5% of patients: esophagitis (54.5%), Barrett's esophagus (5.3%), dysplasia (1%), and gastritis (51%). Endoscopic evidence of HH was documented in 52.2% of patients while only 34% of patients had evidence of HH in their BS. Of the asymptomatic patients, 80.2% had abnormal EGD. Helicobacter pylori on biopsy was found in 17.2% patients, out of which 47.2% were asymptomatic. Based on EGD findings, the choice of surgical procedure was changed in 3.34% of patients. Repair of HH was performed in 107 patients, with 68.2% (n = 73) symptomatic patients and 31.8% (n = 34) asymptomatic patients. On ROC analysis, EGD was better predictive of the presence of HH (AUC = 0.802, OR 5.20, p = < 0.0001) and symptoms were a poor indicator for GERD. CONCLUSIONS Preoperative EGD is abnormal in the majority of patients regardless of their symptoms. EGD is the only modality that can provide tissue sample, which can potentially determine the type of bariatric surgery. Given the low diagnostic accuracy of BS, its routine use can be eliminated.
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Ates D, Cebeci F. Adaptation and Validation of Turkish Version of the Moorehead–Ardelt Quality of Life Questionnaire II in Bariatric Patients. Bariatr Surg Pract Patient Care 2019. [DOI: 10.1089/bari.2019.0004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Damla Ates
- Cerrahi Hastalıkları Hemşireliěi, Hemsirelik Fakultesi, Akdeniz Universitesi, Antalya, Türkiye
| | - Fatma Cebeci
- Cerrahi Hastalıkları Hemşireliěi, Hemsirelik Fakultesi, Akdeniz Universitesi, Antalya, Türkiye
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Abstract
BACKGROUND Inflammatory bowel diseases (IBD) are listed as a contraindication for bariatric surgery in various guidelines due to a theoretical higher complication risk. Therefore, little is known about safety and efficacy of bariatric surgery in IBD patients. AIM We assessed the safety and efficacy of bariatric surgery and postoperative quality of life (QoL) in IBD patients. SETTING The study was conducted in a large peripheral hospital in the Netherlands. METHODS All IBD patients who underwent bariatric surgery in our facility were included. Complications, mortality, reoperations, and micronutrient deficiencies were analyzed. Weight loss was assessed 6, 12, and 24 months after surgery. Postoperative QoL was assessed using a disease-specific Inflammatory Bowel Disease Questionnaire (IBDQ). RESULTS Forty-five patients were included in this study, all diagnosed with IBD (16 ulcerative colitis (UC) and 29 Crohn's disease (CD)) prior to bariatric surgery. Bariatric procedures included Roux-en-Y gastric bypass, sleeve gastrectomy, gastric banding, and revisional surgery. There was no mortality in the entire follow-up period and there were no major perioperative complications. Two major complications in two CD patients occurred during follow-up, gastro-enterostomy bleeding and pyelonephritis with secondary pancreatitis. Mean percentage (± SD) of overall excess weight loss (%EWL) and total body weight loss (%TBWL), 12 months after surgery, were 62.9 ± 27.1 and 26.2 ± 10.6%, respectively. Twenty-four months postoperatively, mean overall %EWL and %TBWL were similar for both UC and CD patients and were 62.9 ± 31.0 and 26.6 ± 12.2, respectively. Mean Bariatric Analysis and Reporting Outcome System (BAROS) score was 3.34 ± 2.42. Median total IBDQ score was 170.8 (min. 77; max. 218). Both scores did not differ significantly between UC and CD patients. CONCLUSION As bariatric procedures appear safe and effective in this CU and CD population, one could question why bariatric surgery is contraindicated in the patients. Nevertheless, close lifelong monitoring to assure safety and a favorable outcome remains essential.
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Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) has gained popularity in the last 10 years for its good results in weight loss and comorbidity control. However, guidelines on the pathological examination of the specimen are lacking. The aim of this retrospective study was to determine the usefulness of the routine specimen examination when presurgery endoscopy (upper gastrointestinal endoscopy, UGIE) and multiple gastric biopsies are part of the preoperative work-up. METHODS A retrospective review of records of the patients submitted to LSG between January 2012 and August 2017 was carried out. Sex, age, histopathology findings in the presurgery endoscopy biopsies and surgical specimen, and the prevalence of Helicobacter pylori infection were analyzed. RESULTS A total of 925 patients entered the study group (mean age = 44.1 years, Females = 80.3%, BMI = 44.58 kg/m2). The most common histopathology pattern in the endoscopy biopsies and in the surgical specimens was inactive chronic gastritis (64.4 and 55.6%, respectively). Helicobacter pylori infection was 24.6 and 2.48%, respectively. Ninety-nine percent (n 796) of patients with non-significant endoscopy biopsy findings showed the same patterns in specimen analysis. Only three patients (0.3%) who had intestinal presurgery metaplasia were positive in the specimen analysis, and two cases of gastric stromal neoplasms (gastrointestinal stromal tumor and gastric leiomyoma) were found intraoperatively. CONCLUSION Most of the findings are non-significant and can be predicted if UGIE plus multiple biopsies is routinely included in the bariatric work-up with significant cost reduction. In those patients who had a significant finding prior to the surgery or intraoperatively, the pathological examination of the specimen is recommended.
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Nickel F, de la Garza JR, Werthmann FS, Benner L, Tapking C, Karadza E, Wekerle AL, Billeter AT, Kenngott HG, Fischer L, Müller-Stich BP. Predictors of Risk and Success of Obesity Surgery. Obes Facts 2019; 12:427-439. [PMID: 31416073 PMCID: PMC6758709 DOI: 10.1159/000496939] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 01/14/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Obesity surgery has proven successful for weight loss and the resolution of comorbidities. There is, however, little evidence on its success and the risk of complications when considering age of onset of obesity (AOO), years of obesity (YOO), preoperative body mass index (BMI), Edmonton obesity staging system (EOSS) score, and age as possible predictors of weight loss, the resolution of comorbidities, and the risk of complications. METHODS Patients who underwent Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) from a prospective database were analyzed. Multiple regression analyses were used to predict comorbidities and their resolution, percentage excess weight loss (%EWL) and total weight loss (%TWL) 12 months after surgery, and the risk of complications using the predictors AOO, YOO, age, EOSS, and BMI. RESULTS 180 patients aged 46.8 ± 11.1 years with a preoperative BMI 49.5 ± 7.5 were included. The number of preoperative comorbidities was higher with older age (β = 0.054; p = 0.023) and a greater BMI (β = 0.040; p = 0.036) but was not related to AOO and YOO. Patients with AOO as a child or adolescent were more likely to have an EOSS score of ≥2. Greater preoperative BMI was negatively associated with %EWL (β = -1.236; p < 0.001) and older age was negatively associated with %TWL (β = -0.344; p = 0.020). Postoperative complications were positively associated with EOSS score (odds ratio [OR] 1.147; p = 0.042) and BMI (OR 1.010; p = 0.020), but not with age. AOO and YOO were not related to postoperative outcome. CONCLUSION Greater BMI was associated with a lower %EWL and age was associated with a low %TWL. YOO and AOO did not influence outcome. Age, BMI, and EOSS score were the most important predictors for risk and success after obesity surgery. Surgery should be performed early enough for optimal outcomes.
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Affiliation(s)
- Felix Nickel
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Javier R de la Garza
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Fabian S Werthmann
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Laura Benner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Christian Tapking
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Emir Karadza
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Anna-Laura Wekerle
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Adrian T Billeter
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Hannes G Kenngott
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Lars Fischer
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | - Beat Peter Müller-Stich
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany,
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Hudson JL, Barnes EL, Herfarth HH, Isaacs KL, Jain A. Bariatric Surgery Is a Safe and Effective Option for Patients with Inflammatory Bowel Diseases: A Case Series and Systematic Review of the Literature. Inflamm Intest Dis 2019; 3:173-179. [PMID: 31111033 DOI: 10.1159/000496925] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 01/14/2019] [Indexed: 01/04/2023] Open
Abstract
Background Questions remain regarding both the safety and efficacy of bariatric surgery in patients with inflammatory bowel diseases (IBD), including the effects of bariatric surgery on the course of disease. We report a case series from a tertiary care IBD referral center and review the existing literature regarding the safety and efficacy of bariatric surgery in IBD patients. Objectives Examine the safety and efficacy of bariatric surgery in IBD patients. Explore possible effects of weight loss on postoperative IBD course. Method We performed a retrospective review of patients at our center undergoing bariatric surgery with a concurrent IBD diagnosis, collecting baseline characteristics, surgery type, and postoperative course (including IBD outcomes and weight loss). Data from these patients were combined with available data from the existing literature to calculate standardized means with standard error, variance, and confidence intervals (CI). Results Data from 13 patients who had undergone bariatric surgery at our facility were combined with data from 8 other studies to create a study population of 101 patients. Of these, 61 had Crohn's disease, 37 ulcerative colitis, and 3 IBD-unspecified, with a mean preoperative BMI of 44.2 (95% CI 42.9-45.7). Following surgery, a mean excess weight loss of 68.4% was demonstrated (95% CI, 65.7-71.2). Of the 101 patients, 22 experienced early and 20 experienced late postoperative complications. Postoperatively, 10 patients experienced a flare of IBD, 20 remained in remission, and 7 patients were able to discontinue immunosuppressive therapy. Conclusions Based on available studies, bariatric surgery appears to be both an effective and safe option for weight loss in patients with IBD.
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Affiliation(s)
- Joshua L Hudson
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Hans H Herfarth
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Kim L Isaacs
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Animesh Jain
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Pathologic findings of the removed stomach during sleeve gastrectomy. Surg Endosc 2019; 33:4003-4007. [PMID: 30771070 DOI: 10.1007/s00464-019-06689-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 01/25/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is the preferred surgical intervention to treat morbid obesity. Despite the rising popularity of LSG, little is known on the histopathologic findings of the resected partial stomach specimens. Our study aims to identify prevalent pathologic findings of the removed stomach and explore the association between patient characteristics and abnormal findings. METHODS A retrospective analysis was conducted using a prospectively maintained database of 649 patients who underwent LSG between November 1, 2013 and December 31, 2015 at our institution. Patient characteristics included age, body mass index, gender, and preoperative comorbidities (diabetes, hyperlipidemia, depression, gastroesophageal reflux, hypertension, and sleep apnea). Statistical analysis was performed using descriptive analysis and logistic regression models. RESULTS Abnormal pathologic findings were identified in approximately one-fifth (n = 142, 21.9%) of the patients. The most common find is non-specific chronic gastritis (9.7%), followed by Helicobacter pylori gastritis (4.9%). Approximately 15% of patients had significant histopathological alterations that might require further investigation, treatment, or follow-up, including non-specific chronic gastritis, H. pylori gastritis, autoimmune atrophic gastritis, and gastrointestinal stromal tumor. The odds of abnormal findings in patients without hyperlipidemia was 0.09 times the corresponding odds in those with hyperlipidemia (95% CI 0.03-0.29), controlling for factors including age, body mass index, gender, and other preoperative comorbidities. CONCLUSION Patients with gastroesophageal reflux and hyperlipidemia might suggest higher incidence rate of gastric histopathologic abnormalities. Routine preoperative screening may not be beneficial for patients undergoing sleeve gastrectomy.
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Leeds IL, Meyers PM, Enumah ZO, He J, Burkhart RA, Haut ER, Efron JE, Johnston FM. Psychosocial Risks are Independently Associated with Cancer Surgery Outcomes in Medically Comorbid Patients. Ann Surg Oncol 2019; 26:936-944. [DOI: 10.1245/s10434-018-07136-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Indexed: 11/18/2022]
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Magouliotis DE, Tasiopoulou VS, Svokos KA, Svokos AA, Sioka E, Tzovaras G, Zacharoulis D. Banded vs. non-banded Roux-en-Y gastric bypass for morbid obesity: a systematic review and meta-analysis. Clin Obes 2018; 8:424-433. [PMID: 30144284 DOI: 10.1111/cob.12274] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 06/11/2018] [Accepted: 06/21/2018] [Indexed: 01/05/2023]
Abstract
We aim to review the available literature on patients with morbid obesity treated with banded (BRYGB) or non-banded Roux-en-Y gastric bypass (NBRYGB), in order to compare the clinical outcomes and intraoperative parameters of the two methods. A systematic literature search was performed in PubMed, Cochrane library and Scopus databases, in accordance with the PRISMA guidelines. Eight studies met the inclusion criteria incorporating 3899 patients. This study reveals similar rates of complications, mortality, remission of type 2 diabetes, hypertension, dyslipidaemia, gastroesophageal reflux and obstructive sleep apnoea, along with similar % excess weight loss (%EWL) at 1 and 2 years postoperatively. In contrast, according to an analysis of two eligible studies the BRYGB procedure was associated with increased %EWL at 5 years postoperatively. These results should be interpreted with caution due to the small number of statistical arms and randomized controlled studies. However, the present article represents the best available evidence in the field. Well-designed, randomized controlled studies, comparing BRYGB to NBRYGB, are necessary to further assess their clinical outcomes.
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Affiliation(s)
- D E Magouliotis
- Department of Surgery, University Hospital of Larissa, Larissa, Greece
| | - V S Tasiopoulou
- School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - K A Svokos
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - A A Svokos
- Department of Obstetrics and Gynecology, Riverside Regional Medical Center, Newport News, VA, USA
| | - E Sioka
- Department of Surgery, University Hospital of Larissa, Larissa, Greece
| | - G Tzovaras
- Department of Surgery, University Hospital of Larissa, Larissa, Greece
| | - D Zacharoulis
- Department of Surgery, University Hospital of Larissa, Larissa, Greece
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Schlottmann F, Buxhoeveden R. Laparoscopic Roux-en-Y Gastric Bypass: Surgical Technique and Tips for Success. J Laparoendosc Adv Surg Tech A 2018; 28:938-943. [DOI: 10.1089/lap.2018.0393] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Francisco Schlottmann
- Department of Surgery, University of North Carolina, Chapel Hill, North Carolina
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
| | - Rudolf Buxhoeveden
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
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Schlottmann F, Nayyar A, Herbella FAM, Patti MG. Preoperative Evaluation in Bariatric Surgery. J Laparoendosc Adv Surg Tech A 2018; 28:925-929. [PMID: 30004270 DOI: 10.1089/lap.2018.0391] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
An adequate preoperative workup is critical for the success of bariatric surgery. A key component of the preoperative evaluation involves a comprehensive patient education about surgical outcomes and the postoperative behavioral regimen required. A complete medical evaluation should include the study of the cardiovascular, pulmonary, and gastrointestinal systems as well as a metabolic status assessment. The nutrition professional should be in charge of the nutritional assessment, preoperative weight loss efforts, and diet education regarding postoperative eating behaviors. A psychological evaluation is also needed because psychosocial factors have a significant impact on the long-term outcomes of bariatric surgery, including adherence to recommended postoperative lifestyle regimen, emotional adjustment, and weight loss outcomes. We recommend preoperative abdominal ultrasound to assess for biliary tract pathology, steatosis, fibrosis, and presence of nonalcoholic steatohepatitis. A routine preoperative esophagogastroduodenoscopy is also recommended to evaluate common gastrointestinal disorders associated with obesity. Preoperative weight loss should be strongly encouraged.
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Affiliation(s)
- Francisco Schlottmann
- 1 Department of Surgery, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina.,2 Department of Surgery, Hospital Alemán of Buenos Aires , Buenos Aires, Argentina
| | - Apoorve Nayyar
- 1 Department of Surgery, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | - Fernando A M Herbella
- 3 Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo , Sao Paulo, Brazil
| | - Marco G Patti
- 1 Department of Surgery, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina.,4 Department of Medicine, University of North Carolina , Chapel Hill, North Carolina
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Mingrone G, Bornstein S, Le Roux CW. Optimisation of follow-up after metabolic surgery. Lancet Diabetes Endocrinol 2018; 6:487-499. [PMID: 29396249 DOI: 10.1016/s2213-8587(17)30434-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 10/18/2017] [Accepted: 10/19/2017] [Indexed: 02/06/2023]
Abstract
Bariatric surgery has many benefits beyond weight loss, including improved control of glycaemia, blood pressure, and dyslipidaemia; hence, such surgery has been rebranded as metabolic surgery. The operations are, unfortunately, also associated with major surgical and medical complications. The medical complications include gastro-oesophageal reflux disease, malnutrition, and metabolic complications deriving from vitamin and mineral malabsorption. The benefits of surgery can be optimised by implementing specific protocols before and after surgery. In this Review, we discuss the assessment of the risk of major cardiac complications and severe obstructive sleep apnoea before surgery, and the provision of adequate lifelong postsurgery nutritional, vitamin, and mineral supplementation to reduce complications. Additionally, we examine the best antidiabetic medications to reduce the risk of hypoglycaemia after gastric bypass and sleeve gastrectomy, and the strategies to improve weight loss or reduce weight regain. Although optimising clinical pathways is possible to maximise metabolic benefits and reduce the risks of complications and micronutrient deficiencies, evolution of these strategies can further improve the risk-to-benefit ratio of metabolic surgery.
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Affiliation(s)
- Geltrude Mingrone
- Department of Internal Medicine, Catholic University, Rome, Italy; Diabetes and Nutritional Sciences, Hodgkin Building, Guy's Campus, King's College London, London, UK.
| | - Stefan Bornstein
- Diabetes and Nutritional Sciences, Hodgkin Building, Guy's Campus, King's College London, London, UK; Department of Medicine III, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Carel W Le Roux
- Diabetes Complications Research Centre, Conway Institute, University College Dublin, Dublin, Ireland; Division of Investigative Science, Imperial College London, London, UK
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Cheng J, Gao J, Shuai X, Wang G, Tao K. The comprehensive summary of surgical versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomized controlled trials. Oncotarget 2018; 7:39216-39230. [PMID: 27233078 PMCID: PMC5129927 DOI: 10.18632/oncotarget.9581] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 05/20/2016] [Indexed: 12/18/2022] Open
Abstract
Background Bariatric surgery has emerged as a competitive strategy for obese patients. However, its comparative efficacy against non-surgical treatments remains ill-defined, especially among nonseverely obese crowds. Therefore, we implemented a systematic review and meta-analysis in order for an academic addition to current literatures. Methods Literatures were retrieved from databases of PubMed, Web of Science, EMBASE and Cochrane Library. Randomized trials comparing surgical with non-surgical therapies for obesity were included. A Revised Jadad's Scale and Risk of Bias Summary were employed for methodological assessment. Subgroups analysis, sensitivity analysis and publication bias assessment were respectively performed in order to find out the source of heterogeneity, detect the outcome stability and potential publication bias. Results 25 randomized trials were eligibly included, totally comprising of 1194 participants. Both groups displayed well comparability concerning baseline parameters (P > 0.05). The pooled results of primary endpoints (weight loss and diabetic remission) revealed a significant advantage among surgical patients rather than those receiving non-surgical treatments (P < 0.05). Furthermore, except for certain cardiovascular indicators, bariatric surgery was superior to conventional arms in terms of metabolic secondary parameters (P < 0.05). Additionally, the pooled outcomes were confirmed to be stable by sensitivity analysis. Although Egger's test (P < 0.01) and Begg's test (P<0.05) had reported the presence of publication bias among included studies, “Trim-and-Fill” method verified that the pooled outcomes remained stable. Conclusion Bariatric surgery is a better therapeutic option for weight loss, irrespective of follow-up duration, surgical techniques and obesity levels.
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Affiliation(s)
- Ji Cheng
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jinbo Gao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaoming Shuai
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Guobin Wang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Kaixiong Tao
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Validity and Reproducibility of the Glittre ADL-Test in Obese and Post-Bariatric Surgery Patients. Obes Surg 2017; 27:110-114. [PMID: 27317008 DOI: 10.1007/s11695-016-2244-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Obese and post-bariatric surgery (BS) subjects often present limitations in physical functioning (PF). The Glittre ADL-test is a simple and useful way to evaluate this outcome. It includes functional activities such as rising from a chair, lifting, carrying weights, and bending over and was never studied in the obese population. This study aimed to determine the validity and reproducibility of the Glittre ADL-test to evaluate PF in obese, post-BS, and healthy control subjects. METHODS Twenty-one post-BS patients (3-4 years post-surgery) (16 women, 41 ± 11 years, BMI = 28 ± 4 kg m-2) (group PO); 21 obese individuals (16 women, 44 ± 9 years, BMI = 44 ± 6 kg.m-2) (group OB) and 21 control individuals matched to PO (16 women, 42 ± 12 years old, BMI = 27 ± 6 kg m-2) (group MC) were included. For the reproducibility analysis, the Glittre ADL-test was performed twice, with a 30-min interval. As criterion methods for the validation, subjects performed two walking tests and answered a health status questionnaire (SF-36). RESULTS High intraclass correlation (OB: r = 0.91 and PO: r = 0.89; MC: r = 0.86; P < 0.0001 for all) and good Bland-Altman agreement between the two tests were found in all groups. However, learning effect ranged between 8.8 and 11.8 % and significant test-retest differences occurred. The test was valid for all groups (moderate-to-high significant correlations with the criterion methods). CONCLUSIONS Glittre ADL-test is valid and reproducible to evaluate PF of obese, post-BS, and healthy control subjects. However, due to the large learning effect, two tests are required for accurate assessment.
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Yan Y, Zhou Z, Kong F, Feng S, Li X, Sha Y, Zhang G, Liu H, Zhang H, Wang S, Hu C, Zhang X. Roux-en-Y Gastric Bypass Surgery Suppresses Hepatic Gluconeogenesis and Increases Intestinal Gluconeogenesis in a T2DM Rat Model. Obes Surg 2017; 26:2683-2690. [PMID: 27038047 DOI: 10.1007/s11695-016-2157-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) is an effective surgical treatment for type 2 diabetes mellitus (T2DM). The present study aimed to investigate the effects of RYGB on glucose homeostasis, lipid metabolism, and intestinal morphological adaption, as well as hepatic and intestinal gluconeogenesis. METHODS Twenty adult male T2DM rats induced by high-fat diet and low dose of streptozotocin were randomly divided into sham and RYGB groups. The parameters of body weight, food intake, glucose tolerance, insulin sensitivity, and serum lipid profiles were assessed to evaluate metabolic changes. Intestinal sections were stained with hematoxylin and eosin (H&E) for light microscopy examination. The messenger RNA (mRNA) and protein expression levels of key regulatory enzymes of gluconeogenesis [phosphoenolpyruvate carboxykinase (PEPCK), glucose-6-phosphatase (G6Pase)] were determined through reverse-transcription PCR (RT-PCR) and Western blotting, respectively. RESULTS RYGB induced significant improvements in glucose tolerance and insulin sensitivity, along with weight loss and decreased food intake. RYGB also decreased serum triglyceride (TG) and free fatty acid (FFA) levels. The jejunum and ileum exhibited a marked increase in the length and number of intestinal villi after RYGB. The RYGB group exhibited downregulated mRNA and protein expression levels of PEPCK and G6Pase in the liver and upregulated expression of these enzymes in the jejunum and ileum tissues. CONCLUSIONS RYGB ameliorates glucose and lipid metabolism accompanied by weight loss and calorie restriction. The small intestine shows hyperplasia and hypertrophy after RYGB. Meanwhile, our study demonstrated that the reduced hepatic gluconeogenesis and increased intestinal gluconeogenesis may contribute to improved glucose homeostasis after RYGB.
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Affiliation(s)
- Yong Yan
- Department of General Surgery, Central Hospital of Fengxian District, Southern Medical University, No.6600, Nan Feng Road, Shanghai, 201499, China
| | - Zhou Zhou
- Department of Endocrinology and Metabolism, Shanghai Diabetes Institute, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China
| | - Fanzhi Kong
- Department of General Surgery, Central Hospital of Fengxian District, Southern Medical University, No.6600, Nan Feng Road, Shanghai, 201499, China
| | - Suibin Feng
- Department of General Surgery, Central Hospital of Fengxian District, Southern Medical University, No.6600, Nan Feng Road, Shanghai, 201499, China
| | - Xuzhong Li
- Department of General Surgery, Central Hospital of Fengxian District, Southern Medical University, No.6600, Nan Feng Road, Shanghai, 201499, China
| | - Yanhua Sha
- Laboratory Medicine Center, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, China
| | - Guangjun Zhang
- Department of General Surgery, Central Hospital of Fengxian District, Southern Medical University, No.6600, Nan Feng Road, Shanghai, 201499, China
| | - Haijun Liu
- Department of General Surgery, Central Hospital of Fengxian District, Southern Medical University, No.6600, Nan Feng Road, Shanghai, 201499, China
| | - Haiqing Zhang
- Department of General Surgery, Central Hospital of Fengxian District, Southern Medical University, No.6600, Nan Feng Road, Shanghai, 201499, China
| | - Shiguang Wang
- Department of General Surgery, Central Hospital of Fengxian District, Southern Medical University, No.6600, Nan Feng Road, Shanghai, 201499, China
| | - Cheng Hu
- Department of Endocrinology and Metabolism, Shanghai Diabetes Institute, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, 200233, China.
| | - Xueli Zhang
- Department of General Surgery, Central Hospital of Fengxian District, Southern Medical University, No.6600, Nan Feng Road, Shanghai, 201499, China.
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Comparison of Banded Versus Non-banded Roux-en-Y Gastric Bypass: a Series of 1150 Patients at a Single Institution. Obes Surg 2017; 28:212-217. [DOI: 10.1007/s11695-017-2832-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Monteiro F, Ponce DAN, Silva H, Pitta F, Carrilho AJF. Physical Function, Quality of Life, and Energy Expenditure During Activities of Daily Living in Obese, Post-Bariatric Surgery, and Healthy Subjects. Obes Surg 2017; 27:2138-2144. [DOI: 10.1007/s11695-017-2619-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
BACKGROUND Banded-gastric bypass is a highly effective bariatric procedure, yet the possibility of band erosion remains a significant drawback. Surgical removal of eroded bands may be associated with significant morbidity. In this study, we assess the efficacy and safety of a solely peroral endoscopic approach for the management of eroded bands in patients with a banded-gastric bypass. MATERIALS AND METHODS Starting January 2012, all patients with banded-gastric bypass and an eroded band were subjected to an attempt at peroral endoscopic removal using endoscopic scissors and/or argon plasma coagulation (APC), regardless of the circumference of band eroding inside the lumen. RESULTS Sixteen patients presented with eroded bands, 2 were deemed not amenable to endoscopic removal as only part of the thickness was eroded. Of the 14 patients where endoscopic attempts were performed, 12 (86%) were completely removed successfully, while 2 (14%) were cut but could not be extracted and only the intraluminal portion was trimmed. Complete resolution of symptoms occurred in 13 (93%) while in 1 patient (7%) there was partial improvement. Only one endoscopic session was performed per patient with a median time of 37.5 min per session (22-55 min). No complications were encountered. CONCLUSION Endoscopic removal of eroded gastric bands in patients with banded-gastric bypass is effective and safe in the majority of patients. When bands are adherent to the gastric wall, removal of the intraluminal portion of the band may lead to full or partial improvement of symptoms. Endoscopic band removal can be attempted even when a small part of band circumference has eroded.
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Zhao L, Zhu L, Su Z, Liu Y, Li P, Yang X, Li W, Tan L, Sun X, Zhu S. Using the hyperinsulinemic euglycemic clamp to assess insulin sensitivity at 3 months following Roux-en-Y gastric bypass surgery in type 2 diabetes patients with BMI <35 kg/m 2 in China. Int J Surg 2016; 38:90-94. [PMID: 28043929 DOI: 10.1016/j.ijsu.2016.12.120] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 12/14/2016] [Accepted: 12/26/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND The aim of this study was to describe short-time effect of Roux-en-Y gastric bypass (RYGB) on insulin sensitivity (IS) of Chinese diabetes patients with body mass index (BMI) <35 kg/m2 by hyperinsulinemic euglycemic clamp. MATERIALS AND METHODS We studied 15 type 2 diabete mellitus (T2DM) patients with BMI <35 kg/m2, who underwent laparoscopical Roux-en-Y gastric bypass (LRYGB). Hyperinsulinemic-euglycemic clamp were performed at baseline and at 3 months after LRYGB. RESULTS The glucose disposal rate (M value) increased significantly at 3 months after RYGB (from 3.36 ± 1.26 mg kg-1 min-1 to 6.30 ± 1.3 mg kg-1 min-1, p < 0.001). The time to reach euglycemia at the hyperinsulinemic euglycemic clamp reduced remarkably from baseline to 3 months after RYGB (from 114.40 ± 6.11 min to 97.93 ± 8.57 min, p < 0.001). There was a marked reduction in value of HOMA-IR (from 4.47 ± 2.20 mg kg-1 min-1 to 2.10 ± 0.75 mg kg-1 min-1, p < 0.001). The parameters of body fat distribution (body weight, BMI, waist circumference, waist to hip radio) changed obviously after surgery. RYGB caused a significant improvement in fasting and postprandial plasma glucose and insulin, HbAc1. Preoperative M value and the time to reach steady-state correlated with changes of M and the time to reach steady-state at 3 months after RYGB. CONCLUSION Peripheral and hepatic IS improved remarkably at 3 months following RYGB, as an important mechanism for early improvement in T2DM patients with low BMI. And the time to reach euglycemia at the hyperinsulinemic euglycemic clamp may be an useful index of assessing insulin sensitivity. It is more reasonal to combine the time to reach euglycemia with M value for assessing IS.
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Affiliation(s)
- Lei Zhao
- Department of General Surgery, Third Xiangya Hospital, Central South University, Changsha, 410013 Hunan, People's Republic of China
| | - Liyong Zhu
- Department of General Surgery, Third Xiangya Hospital, Central South University, Changsha, 410013 Hunan, People's Republic of China
| | - Zhihong Su
- Department of General Surgery, Third Xiangya Hospital, Central South University, Changsha, 410013 Hunan, People's Republic of China
| | - Yong Liu
- Department of General Surgery, Third Xiangya Hospital, Central South University, Changsha, 410013 Hunan, People's Republic of China
| | - Pengzhou Li
- Department of General Surgery, Third Xiangya Hospital, Central South University, Changsha, 410013 Hunan, People's Republic of China
| | - Xiangwu Yang
- Department of General Surgery, Third Xiangya Hospital, Central South University, Changsha, 410013 Hunan, People's Republic of China
| | - Weizheng Li
- Department of General Surgery, Third Xiangya Hospital, Central South University, Changsha, 410013 Hunan, People's Republic of China
| | - Lingjie Tan
- Department of General Surgery, Third Xiangya Hospital, Central South University, Changsha, 410013 Hunan, People's Republic of China
| | - Xulong Sun
- Department of General Surgery, Third Xiangya Hospital, Central South University, Changsha, 410013 Hunan, People's Republic of China
| | - Shaihong Zhu
- Department of General Surgery, Third Xiangya Hospital, Central South University, Changsha, 410013 Hunan, People's Republic of China.
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Yan Y, Sha Y, Yao G, Wang S, Kong F, Liu H, Zhang G, Zhang H, Hu C, Zhang X. Roux-en-Y Gastric Bypass Versus Medical Treatment for Type 2 Diabetes Mellitus in Obese Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Medicine (Baltimore) 2016; 95:e3462. [PMID: 27124041 PMCID: PMC4998704 DOI: 10.1097/md.0000000000003462] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The aim of the study is to compare Roux-en-Y gastric bypass (RYGB) surgery versus medical treatment for type 2 diabetes mellitus (T2DM) in obese patients.Bariatric surgery can achieve remission of T2DM in obese patients. RYGB surgery has been performed as one of the most common surgical treatment options for obese patients with T2DM, but the efficacy of RYGB surgery comparing with medical treatment alone has not been conclusively determined.A systematic literature search identified randomized controlled trials (RCTs) evaluating RYGB surgery versus medical treatment for T2DM in obese patients was conducted in PubMed, Embase, Cochrane Database, and Cochrane Clinical Trials Registry. This systematic review and meta-analysis were performed according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. The primary outcome was T2DM remission. Additional analyses comprised hemoglobin A1c (HbA1c), fasting plasma glucose (FPG), body mass index (BMI), waist circumference, serum lipid level, blood pressure, medication use, and adverse events. Random-effects meta-analyses were calculated and presented as weighted odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CI).Six RCTs concerning 410 total obese T2DM patients were included. Follow-up ranged from 12 to 60 months. RYGB surgery was associated with a higher T2DM remission rate (OR: 76.37, 95% CI: 20.70-281.73, P < 0.001) and serum level of high-density lipoprotein cholesterol (MD: 0.24 mmol/L, 95% CI 0.18-0.30 mmol/L, P < 0.001) than medical treatment alone. HbA1c (MD: -1.25%, 95% CI: -1.88% to -0.63%, P < 0.001), BMI (MD: -6.54 kg/m, 95% CI: -9.28 to -3.80 kg/m, P < 0.001), waist circumference (MD: -15.60 cm, 95% CI: -18.21 to -13.00 cm, P < 0.001), triglyceride (MD: -0.87 mmol/L, 95% CI: -1.17 to -0.57 mmol/L, P < 0.001), low-density lipoprotein cholesterol (MD: -0.32 mmol/L, 95% CI: -0.62 to -0.02 mmol/L, P = 0.04), systolic blood pressure (MD: -2.83 mm Hg, 95% CI: -4.88 to -0.78 mm Hg, P < 0.01) were lower after RYGB surgery. However, FPG (MD: -1.58 mmol/L, 95% CI: -3.58 to 0.41 mmol/L, P = 0.12), total cholesterol (MD: -0.40 mmol/L, 95% CI: -0.92 to 0.12 mmol/L, P = 0.13), and diastolic blood pressure (MD: 0.28 mm Hg, 95% CI: -1.89 to 2.45 mm Hg, P = 0.80) were not significantly different between the 2 treatment groups. The medicine use and quality of life were solely improved in the surgical group. Nutritional deficiencies and anemia were noted more frequently in the RYGB group.RYGB surgery is superior to medical treatment for short- to medium-term remission of T2DM, improvement of metabolic condition, and cardiovascular risk factors. Further RCTs should address the safety and long-term benefits of RYGB surgery on obese patients with T2DM.
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Affiliation(s)
- Yong Yan
- From the Department of General Surgery (YY, GY, SW, FK, HL, GZ, HZ, XZ), Fengxian Central Hospital, Affiliated Hospital of Southern Medical University, Shanghai; Laboratory Medicine Center (YS), Nanfang Hospital, Southern Medical University, Guangzhou; and Department of Endocrinology and Metabolism (CH), Shanghai Diabetes Institute, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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48
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Sheetz KH, Norton EC, Birkmeyer JD, Dimick JB. Provider Experience and the Comparative Safety of Laparoscopic and Open Colectomy. Health Serv Res 2016; 52:56-73. [PMID: 26990210 DOI: 10.1111/1475-6773.12482] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To evaluate the comparative safety of laparoscopic and open colectomy across surgeons varying in experience with laparoscopy. DATA SOURCES National Medicare data (2008-2010) for beneficiaries undergoing laparoscopic or open colectomy. STUDY DESIGN Using instrumental variable methods to address selection bias, we evaluated outcomes of laparoscopic and open colectomy. Our instrument was the regional use of laparoscopy in the year prior to a patient's operation. We then evaluated outcomes stratified by surgeons' annual volume of laparoscopic colectomy. PRINCIPAL FINDINGS Laparoscopic colectomy was associated with lower mortality (OR: 0.75, 95 percent CI: 0.70-0.78) and fewer complications than open surgery (OR: 0.82, 95 percent CI: 0.79-0.85). Increasing surgeon volume was associated with better outcomes for both procedures, but the relationship was stronger for laparoscopy. The comparative safety depended on surgeon volume. High-volume surgeons had 40 percent lower mortality (OR: 0.60, 95 percent CI: 0.55-0.65) and 30 percent fewer complications (OR: 0.70, 95 percent CI: 0.67-0.74) with laparoscopy. Conversely, low-volume surgeons had 7 percent higher mortality (OR: 1.07, 95 percent CI: 1.02-1.13) and 18 percent more complications (OR: 1.18, 95 percent CI: 1.12-1.24) with laparoscopy. CONCLUSIONS This population-based study demonstrates that the comparative safety of laparoscopic and open colectomy is influenced by surgeon volume. Laparoscopic colectomy is only safer for patients whose surgeons have sufficient experience.
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Affiliation(s)
- Kyle H Sheetz
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Edward C Norton
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI.,Department of Health Management and Policy, Department of Economics, University of Michigan, Ann Arbor, MI.,National Bureau of Economic Research, Cambridge, MA
| | | | - Justin B Dimick
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.,Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI
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McLawhorn AS, Southren D, Wang YC, Marx RG, Dodwell ER. Cost-Effectiveness of Bariatric Surgery Prior to Total Knee Arthroplasty in the Morbidly Obese: A Computer Model-Based Evaluation. J Bone Joint Surg Am 2016; 98:e6. [PMID: 26791039 DOI: 10.2106/jbjs.n.00416] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Obesity is associated with adverse outcomes and increased costs after total knee arthroplasty. Bariatric surgery is an effective treatment for morbid obesity, but its cost-effectiveness for weight loss prior to total knee arthroplasty is unknown. The purpose of this study was to evaluate the cost-effectiveness of bariatric surgery prior to total knee arthroplasty for patients in whom medical treatment of obesity and knee osteoarthritis had failed. METHODS A state-transition Markov model was constructed to compare the cost-utility of two treatment protocols for patients with morbid obesity and end-stage knee osteoarthritis: (1) immediate total knee arthroplasty and (2) bariatric surgery two years prior to the total knee arthroplasty. The probability of transition for each health state and its utility were derived from the literature. Costs, expressed in 2012 United States dollars, were estimated with use of administrative and claims data. Costs and utilities were discounted at 3% annually, and effectiveness was expressed in quality-adjusted life-years (QALYs). The principal outcome measure was the incremental cost-effectiveness ratio (ICER). One-way, two-way, and probabilistic sensitivity analyses were performed, using $100,000 per QALY as the threshold willingness to pay. RESULTS Morbidly obese patients undergoing total knee arthroplasty alone had lower QALYs gained than patients who underwent bariatric surgery two years prior to the total knee arthroplasty. The ICER between these two procedures was approximately $13,910 per QALY, well below the threshold willingness to pay. Results were stable across broad value ranges for independent variables. Probabilistic sensitivity analysis found that the median ICER was $14,023 per QALY (95% confidence interval, $4875 to $51,210 per QALY). CONCLUSIONS This model supports bariatric surgery prior to total knee arthroplasty as a cost-effective option for improving outcomes in morbidly obese patients with end-stage knee osteoarthritis who are indicated for total knee arthroplasty. LEVEL OF EVIDENCE Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander S McLawhorn
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for A.S. McLawhorn:
| | - Daniel Southren
- Columbia University College of Physicians & Surgeons, 630 West 168th Street, New York, NY 10032
| | - Y Claire Wang
- Department of Health Policy and Management, Columbia Mailman School of Public Health, 600 West 168th Street, 6th Floor, New York, NY 10032
| | - Robert G Marx
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for A.S. McLawhorn:
| | - Emily R Dodwell
- Department of Orthopedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for A.S. McLawhorn:
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50
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Controversies in perioperative anesthetic management of the morbidly obese: I am a surgeon, why should I care? Obes Surg 2015; 25:879-87. [PMID: 25726320 DOI: 10.1007/s11695-015-1635-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Over the last four decades, as the rates of obesity have increased, so have the challenges associated with its anesthetic management. In the present review, we discuss perioperative anesthesia management issues that are modifiable by the early involvement of the surgical team. We sum up available evidence or expert opinion on issues like patient positioning, postoperative analgesia, and the effect of continuous positive airway pressure (CPAP) ventilation on surgical anastomosis. We also address established predictors of higher perioperative risk and suggest possible management strategies and concerns of obese patients undergoing same day procedures. Finally, a generalized pharmacological model relevant to altered pharmacokinetics in these patients is presented.
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