Superior weight loss and lower HbA1c 3 years after duodenal switch compared with Roux-en-Y gastric bypass—a randomized controlled trial

SICOB Italian clinical practice guidelines for the surgical treatment of obesity and associated diseases using GRADE methodology on bariatric and metabolic surgery

Obesity is a chronic disease associated with increased morbidity and mortality and reduced quality of life. Pharmacotherapy can be associated with life style changes in increasing and maintaining weight loss and ameliorating obesity-related complications and comorbidities. In patients affected by obesity and uncontrolled obesity-associated complications or high degrees of BMI (> 40 Kg/m2), metabolic bariatric surgery can be a valid therapeutic option. Many different types of surgical procedures have been developed in last decades, mainly performed via laparoscopic approaches. However, clinical indications for metabolic and bariatric surgery (MBS) and the choice of the most appropriate type of procedure have not been clarified so far.The Italian Society of Bariatric and Metabolic Surgery for Obesity (Società Italiana di Chirurgia dell'Obesità e delle Malattie Metaboliche-SICOB) decided to design and develop the updated version of the Italian guidelines aimed at assisting healthcare professionals in the choice of the surgical option for the treatment of obesity and related conditions. Between June and October 2022, a panel of 24 experts and an evidence review team (ERT, 10 members), participated in the definition of clinical questions, outcomes, and recommendations and collected and analyzed all the available evidence on the basis of pre-specified search strategies. GRADE methodology and PICO (Patient, Intervention, Comparison, Outcome) conceptual framework have been adopted for the development of the present guidelines. Aim of the present guideline is to verify indications to surgery with respect to the presence of comorbid conditions, evaluate the different types of surgical approaches and endoscopic bariatric procedure and revise indication to revision surgery and postoperative procedures.

Roux-en-Y gastric bypass versus duodenal switch in patients with body mass index ≥50 kg/m2: a systematic review and meta-analysis

Currently, there is no consensus on the best bariatric surgery type for patients with body mass index (BMI) ≥50 kg/m2. This systematic review and meta-analysis aimed to compare outcomes of duodenal switch (DS) and Roux-en-Y gastric bypass (RYGB) in terms of weight loss, resolution of obesity-related comorbidities, and complications among patients with a BMI ≥50 kg/m2. A systematic search was conducted across databases including PubMed, Embase, Scopus, and Web of Science to include studies that compared outcomes of DS and RYGB in patients with BMI ≥50 kg/m2. A meta-analysis was carried out, alongside subgroup analyses based on the type of study and duration of follow-up. Twelve articles were included in this study (2678 patients, follow-up: 1-15 years). Patients with DS had 7.31 kg/m2 higher BMI loss (95% CI: 5.59-9.03, P < .001) and 9.9% more total weight loss (95% CI: 4.47-15.28%, P < .001) compared with RYGB. The rate of complications, reoperation, mortality, and remission of comorbidities including diabetes, hypertension, dyslipidemia, and obstructive sleep apnea was not significantly different between DS and RYGB. Rate of malnutrition was 8.3% in the DS group compared with 1.2% in RYGB (OR: 5.53, 95% CI: 1.35-22.44, P = .02). In addition, 5.4% DS patients needed revisional surgery for malnutrition versus none in RYGB (OR: 6.1, 95% CI: 1.03-36.33, P = .05), and 24.6% of DS patients developed gallbladder disease needed cholecystectomy versus 4.5% after RYGB (OR: 6.36, 95% CI: 1.70-23.82, P = .01). DS leads to significantly higher BMI and total weight loss in patients with BMI ≥50 kg/m2 but may be associated with a higher rate of major malnutrition and needed revisional surgery. These should be considered in surgical planning.

The role of metabolic and bariatric surgery on the obesity pandemic in Latin America: A review of current practices and future directions

Latin America faces a significant public health challenge due to the high prevalence of obesity and its associated diseases. Metabolic and bariatric surgery is effective and safe to treat obesity when other treatments fail; however, its implementation in Latin America remains unsatisfactory. This review explores the current status, challenges, and innovations of metabolic and bariatric surgery in Latin America. We searched peer-reviewed journals in English and Spanish for relevant articles published between 1998 and 2023. We found that more than 20% of the Latin American population is affected by obesity. Unfortunately, only a limited number of patients have access to metabolic and bariatric surgery due to high cost, limited availability, and shortage of specialists. The review found that ongoing clinical trials are being conducted in Brazil, Mexico, Chile, and Venezuela, indicating some regional progress. However, published studies remain low in number compared with other regions. Furthermore, we summarized the clinical outcomes, risks, and perioperative assessments associated with metabolic and bariatric surgery. We discussed potential strategies to enhance the availability and affordability of this intervention. This review emphasizes the significance of metabolic and bariatric surgery in addressing the obesity pandemic, specifically for Latin America, and proposes directions for future research and innovation.

Ten-Year Outcomes Following Roux-en-Y Gastric Bypass vs Duodenal Switch for High Body Mass Index: A Randomized Clinical Trial

Importance

Results from long-term follow-up after biliopancreatic diversion with duodenal switch (DS) are scarce.

Objective

To compare weight loss, health outcomes, and quality of life 10 years or more after Roux-en-Y-gastric bypass (RYGB) and DS surgery in patients with severe obesity-that is, a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 50 to 60.

Design, Setting, and Participants

This open-label randomized clinical trial was conducted at 2 academic bariatric centers in Sweden and Norway. Sixty patients with a BMI of 50 to 60 were included from March 1, 2006, to August 31, 2007. Data were analyzed from August 12, 2022, to January 25, 2023.

Interventions

Laparoscopic RYGB or laparoscopic DS.

Main Outcomes and Measures

The main outcome was change in BMI after 10 or more years. Secondary outcomes included anthropometric measures, lipid and glycemic profiles, bone mass density, adverse events, gastrointestinal tract symptoms, and health-related quality of life.

Results

Forty-eight of the original 60 patients (80%) were assessed after a median of 12 (range, 9-13) years (mean [SD] age, 48.0 [6.0] years; 35 women [73%]). At follow-up, the mean BMI reductions were 11.0 (95% CI, 8.3-13.7) for RYGB and 20.3 (95% CI, 17.6-23.0) for DS, with a mean between-group difference of 9.3 (95% CI, 5.4-13.1; P < .001). Total weight loss was 20.0% (95% CI, 15.3%-24.7%) for RYGB and 33.9% (95% CI, 27.8%-40.0%) for DS (P = .001). Mean serum lipid levels, except high-density lipoprotein cholesterol and hemoglobin A1c, improved more in the DS group during follow-up. Bone mass was reduced for both groups from 5 to 10 years, with lower bone mass after DS at 10 years. Quality-of-life scores (Obesity-Related Problem Scale and the 36-Item Short Form Health Survey) were comparable across groups at 10 years. The total number of adverse events was higher after DS (135 vs 97 for RYGB; P = .02). More patients in the DS group developed vitamin deficiencies (21 vs 11 for RYGB; P = .008) including 25-hydroxyvitamin D deficiency (19 for DS vs 9 for RYGB; P = .005). Four of 29 patients in the DS group (14%) developed severe protein-caloric malnutrition, of whom 3 (10%) underwent revisional surgery.

Conclusions and Relevance

In this randomized clinical trial, BMI reduction was greater after DS, but RYGB had a better risk profile over 10 years. Biliopancreatic diversion with DS may not be a better surgical strategy than RYGB for patients with a BMI of 50 to 60.

Trial Registration

ClinicalTrials.gov Identifier: NCT00327912.

Bariatric Surgery for Patients with Overweight/Obesity. A Comprehensive Grading Methodology and Network Metanalysis of Randomized Controlled Trials on Weight Loss Outcomes and Adverse Events

This study aims to compare different types of metabolic bariatric surgery (MBS) with lifestyle intervention/medical therapy (LSI/MT) for the treatment of overweight/obesity. The present and network meta-analysis (NMA) includes randomized trials. MBS was associated with a reduction of BMI, body weight, and percent weight loss, when compared to LSI/MT, and also with a significant reduction of HbA1c and a higher remission of diabetes. Meta-regression analyses revealed that BMI, a higher proportion of women, and a longer duration of trial were associated with greater effects of MBS. The NMA showed that all surgical procedures included (except greater curvature plication) were associated with a reduction of BMI. MBS is an effective option for the treatment of obesity. The choice of BMI thresholds for eligibility for surgery of patients with different complications should be performed making an evaluation of risks and benefits in each BMI category.

Long-term Follow-up 15 Years After Duodenal Switch or Gastric Bypass for Super Obesity: a Randomized Controlled Trial

BACKGROUND

In super obesity, Roux-en-Y gastric bypass (RYGB) may be insufficient why some surgeons advocate biliopancreatic diversion with duodenal switch (BPD/DS), a more malabsorptive procedure. There is a paucity of evidence regarding results beyond 10 years, especially after BPD/DS. The aim of this randomized controlled trial was to compare the long-term outcome of BPD/DS, and RYGB in patients with super obesity, i.e., body mass index (BMI) > 50 kg/m2.

METHODS

This is a 13- to 17-year follow-up study of a single-center, single-blinded randomized trial in which 47 patients (BMI > 48 and eligible for bariatric surgery) were randomized 1:1 to BPD/DS and RYGB (25 men, 24 BPD/DS, 39.1 ± 9.9 years, BMI 54.5 ± 6.1 kg/m2). The primary outcome was weight loss. The study was financed by Swedish governmental funding of clinical research (ALF).

TRIAL REGISTRATION NUMBER

ISRCTN10940791.

RESULTS

Thirty-four (18 BPD/DS) of the living 42 patients (81.0%) participated. BPD/DS resulted in higher BMI loss (20.4 ± 7.9 vs. 12.4 ± 8.6, p = .008) and higher percent of total body weight loss (37.5% ± 12.2 vs. 22.8% ± 14.8, p = .004). BPD/DS was associated with lower fasting glucose, glycated hemoglobin (HbA1c), and low-density lipoprotein (LDL) as well as lower hemoglobin. Adverse events were more common after BPD/DS (2.7 vs. 0.9 per patient, p = .004). The global assessment tool BAROS (Bariatric Analysis and Reporting Outcome System) demonstrated superior scores for BPD/DS (p = .047).

CONCLUSION

When compared to RYGB, BPD/DS results in superior weight loss and metabolic control as well as superior BAROS score, however, at the cost of more adverse events.

Impact of biliopancreatic diversion with duodenal switch on glucose homeostasis and gut hormones and their correlations with appetite

BACKGROUND

Biliopancreatic diversion with duodenal switch (BPD/DS) results in lifelong changes in gastrointestinal physiology with unclear associations with appetite perception.

OBJECTIVE

To explore mixed meal-induced changes in glucose homeostasis and gut hormones and their correlations with appetite perception.

SETTING

University hospital.

METHODS

Of 28 patients studied preoperatively (age: 38.4 ± 11.3 years; body mass index [BMI]: 56.5 ± 5.1 kg/m²; 14 women), 19 (68%) returned for postoperative follow-up. Plasma was sampled for 180 minutes during a 260-kcal standardized mixed meal. Concentrations of leptin, glucose, insulin, triglycerides, active acyl-ghrelin, motilin, total glucose-dependent insulinotropic polypeptide (GIP), active glucagon-like peptide 1 (GLP-1), and total peptide YY (PYY) were measured. Subjective appetite sensations were scored.

RESULTS

BPD/DS resulted in 66.1% ± 23.3% excess BMI loss. Leptin was halved. Glucose and insulin levels were reduced, blunting a preoperative peak at 30 minutes, giving a lower homeostasis model assessment for insulin resistance (HOMA-IR; 13.9 versus 4.8). In contrast, reduced ghrelin and motilin concentrations were accompanied by pronounced peaks 20-30 minutes prior to meal responses. GIP was reduced, whereas GLP-1 and PYY responses were markedly increased, with an early postprandial peak (P < .05, for all). HOMA-IR correlated with insulin (r = .72) and GIP (r = .57). Postoperatively, satiety correlated with GLP-1 (r = .56), whereas the gastric motility index correlated with the desire to eat (r = .60), percentage excess BMI loss (r = -.55), and percentage total weight loss (r = -.49). Delta insulin, GLP-1, and leptin correlated positively with percentage total weight loss (r = .51, r = .48, and r = .58, respectively).

CONCLUSIONS

BPD/DS reduces leptin, HOMA-IR, and GIP while markedly increasing GLP-1 and PYY. This study marks the magnitude change in GLP-1 with additional effects of PYY as important factors for weight loss.

Experience in biliopancreatic diversion with duodenal switch: Results at 2, 5 and 10 years

INTRODUCTION

Duodenal switch (DS) is considered one of the most effective techniques to achieve weight loss and reduce comorbidities in patients with morbidly obesity.

MATERIAL AND METHODS

Descriptive single-center study. 224 patients were analyzed who underwent direct laparoscopic DS in our center. The objective was to describe the results of weight, resolution of comorbidities, nutritional supplementation and postoperative complications at 2, 5 and 10 years.

RESULTS

The mean age of the cohort was 49.3 [23-65] years and the mean weight and BMI were 131.8 [20] kg and 49.8 [5] kg/m². The excess weight lost percentage at 2, 5 and 10 years was 80.6[15]%, 69.3[18]%, 67.4[18]%, respectively. Complete remission of diabetes was evidenced at 2 and 5 years in 35 (85.4%) and 27 (70.4%) patients. In the immediate postoperative period, the complication rate for Clavien-Dindo ≥ III was 15 patients (6.7%) and mortality at 30 and 90 days was 1 (0.4%) and 2 (0.9%) patients. Revisional surgery was performed in 2 patients (0.9%). 80% of the patients required an extra nutritional supplement up to 10 years after surgery.

CONCLUSIONS

Direct DS is a safe and effective technique in patients with a BMI between 45 and 55 kg/m². Weight loss is maintained with a low rate of revision surgery. It is a metabolically effective technique that entails the need for a close postoperative follow-up to assess nutritional supplementation.

No Uniformity in the References of Clinical Practice Guidelines for Bariatric Surgery: a Review of 3 Similar Guidelines Published in 2020

In 2020, updated versions of the clinical practice guidelines of the European Association for Endoscopic Surgery, the Canadian Adult Obesity Clinical Practice Guidelines and the Dutch Federation for Medical Specialist clinical practice guidelines on bariatric surgery were published. We systematically reviewed and compared them on recommendations and references. Although the authors would have had access to the same literature, only 5 out of 655 unique references were used by all 3 guidelines and just 49 references by any combination of 2 guidelines. These findings attest to the subjectivity involved in clinical practice guidelines development and could be the cause for the observed differences in recommendations. International cooperation in guideline development might be a conceivable solution.

Gastrointestinal Physiology Before and After Duodenal Switch with Comparisons to Unoperated Lean Controls: Novel Use of the SmartPill Wireless Motility Capsule

Purpose

Bariatric surgery alters gastrointestinal anatomy. In this exploratory study, the SmartPill® wireless motility capsule (WMC) was used to study changes in gastrointestinal physiology following biliopancreatic diversion with duodenal switch (BPD/DS).

Material and Methods

Twenty-eight BPD/DS patients (35 ± 11 years, 50% females, body mass index [BMI] 56 ± 5) were to be examined preoperatively and postoperatively. In addition to transit time, appetite control and gastrointestinal symptoms were studied by patient-scored questionnaires (visual analogue scale and Gastrointestinal Symptom Rating Scale (GSRS)). Data was compared to 41 lean unoperated controls.

Results

About 1.8 years postoperatively, 18 patients (BMI 35.8 ± 8.3) returned for a second WMC test. As expected, small bowel transit time was reduced, from 3.9 ± 1.6 h to 2.8 ± 2.0, p = 0.02, and at both these time points, it was shorter than in lean controls (5.4 ± 1.9 h, p = 0.001). Postoperatively, a trend towards reduced colon and whole gut transit times was seen in BPD/DS-patients, thus approaching those of lean controls. Surprisingly, BPD/DS patients scored higher satiety than controls preoperatively as well as increased hunger and desire to eat postoperatively. Compared to lean, BPD/DS patients reported a higher total GSRS score at both time points (1.2 ± 0.2 vs 1.7 ± 0.6 and 2.3 ± 0.5, p < 0.001). Postoperatively, the scores for diarrhea and indigestion increased.

Conclusions

The novel use of the SmartPill system in BPD/DS patients gave the expected readouts. Although small bowel transit time was further shortened after BPD/DS, whole gut transit time did not differ from controls. Typical gastrointestinal symptoms were reported postoperatively.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-021-05452-4.

Experience in biliopancreatic diversion with duodenal switch: results at 2, 5 and 10 years

INTRODUCTION

Duodenal switch (DS) is considered one of the most effective techniques to achieve weight loss and reduce comorbidities in patients with morbidly obesity.

MATERIAL AND METHODS

Descriptive single-center study. 224 patients were analyzed who underwent direct laparoscopic DS in our center. The objective was to describe the results of weight, resolution of comorbidities, nutritional supplementation and postoperative complications at 2, 5 and 10 years.

RESULTS

The mean age of the cohort was 49.3 [23-65] years and the mean weight and BMI were 131.8 [20]kg and 49.8 [5]kg/m2. The excess weight lost percentage at 2, 5 and 10 years was 80.6[15]%, 69.3[18]%, 67.4[18]%, respectively. Complete remission of diabetes was evidenced at 2 and 5 years in 35 (85.4%) and 27 (70.4%) patients. In the immediate postoperative period, the complication rate for Clavien-Dindo ≥ III was 15 patients (6.7%) and mortality at 30 and 90 days was 1 (0.4%) and 2 (0.9%) patients. Revisional surgery was performed in 2 patients (0.9%). 80% of the patients required an extra nutritional supplement up to 10 years after surgery.

CONCLUSIONS

Direct DS is a safe and effective technique in patients with a BMI between 45 and 55 kg/m2. Weight loss is maintained with a low rate of revision surgery. It is a metabolically effective technique that entails the need for a close postoperative follow-up to assess nutritional supplementation.

Laparoscopic Duodenal Switch Versus Roux-en-Y Gastric Bypass at a High-Volume Community Hospital: a Retrospective Cohort Study from a Rural Setting

BACKGROUND

The classic duodenal switch (DS) represents a minority of bariatric procedures due to its high complexity and potential for complications.

METHODS

A retrospective chart review was conducted on 100 laparoscopic DS cases from 2014 to 2018 at an accredited program in a rural community hospital and compared to 100 laparoscopic Roux-en-Y gastric bypasses (RYGB). Primary outcomes were 30-day morbidity and mortality. Secondary outcomes included anastomotic leak and remission of type 2 diabetes.

RESULTS

There were more demographic risk factors for DS. The 30-day morbidity was higher for DS compared to RYGB (31% vs 13%, respectively; p = 0.0037). There was one mortality for DS and none for RYGB. There were statistically significant longer intraoperative times, greater EBL, and greater decrease in BMI for DS. The DS had a lower incidence of anastomotic ulcers (4% vs 13%, respectively; p = 0.0289), with a higher incidence of subsequent surgery beyond 30 days (21% vs 8%, respectively; p = 0.0160). There were 3 anastomotic leaks for DS and none for RYGB, although not statistically significant (p = 0.2463). The DS was more likely to eradicate hypertension, but the RYGB was more likely to eradicate GERD. There were no statistically significant differences for type 2 diabetes remission (92.1% vs 89.5%, respectively; p = 0.7239).

CONCLUSION

Laparoscopic DS offers greater weight loss and hypertension remission, with lower incidence of anastomotic ulcers, but at the expense of greater morbidity and need for subsequent surgery, with no significant differences in type 2 diabetes remission when compared to RYGB in a rural community hospital program.

Clinical practice guidelines of the European Association for Endoscopic Surgery (EAES) on bariatric surgery: update 2020 endorsed by IFSO-EC, EASO and ESPCOP

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.

Ongoing Inconsistencies in Weight Loss Reporting Following Bariatric Surgery: a Systematic Review

Weight loss is the primary outcome following bariatric surgery; however, its documentation within current literature is heterogeneous and poorly defined, limiting meaningful comparison between studies. Randomized controlled trials from 2012 to 2016 were identified using the Medline database through "Gastric bypass OR sleeve gastrectomy AND weight" search terms. A total of 73 studies with 5948 patients were included. Reporting of preoperative weight was done primarily using mean body mass index (BMI) (87.7%) and mean weight (65.8%). Postoperative weight reporting was more variable, with the most frequently reported measure being mean postoperative BMI (71.2%). Overall, nearly one third of all bariatric literature contained discrepancies that precluded meaningful meta-analysis. Reporting of weight loss following bariatric surgery is becoming increasingly diverse for both pre- and post-operative outcomes. Ongoing heterogeneity will continue to act as a barrier to meaningful comparison of bariatric outcomes until standardized reporting practices become adopted.

Increased circulating magnesium concentrations after Roux-en-Y gastric bypass surgery in patients with type 2 diabetes

BACKGROUND

Low circulating magnesium concentrations predict cardiovascular and all-cause mortality in patients with type 2 diabetes (T2D). Epidemiologic and clinical studies have indicated lower extra- and intracellular magnesium concentrations in patients with diabetes.

OBJECTIVE

We aimed to describe alterations, if any, in circulating magnesium concentrations after laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) in patients with obesity and T2D.

SETTING

Outpatient clinic of obesity and central hospital.

METHODS

Retrospective analysis of 1-year outcome of plasma magnesium (p-Mg) and glucometabolic status in all consecutive patients who underwent primary LRYGBP and who completed the follow-up visits, including biochemical test panels 6 and 12 months after surgery.

RESULTS

LRYGBP and complete follow-up visits were performed in 51 patients with T2D and 86 patients without T2D. All patients were given similar dietary advice and multivitamin and mineral supplementation after surgery. Before RYGB, the patients with T2D showed lower p-Mg compared with patients without T2D (.79 ± .06 mM and .82 ± .05 mM, respectively, P<.01). P-Mg was inversely correlated to fasting blood glucose and glycosylated hemoglobin levels. After surgery, mean p-Mg increased by 5.2% in the group with T2D compared with 1.4% in the patients without T2D (P<.01), ending at an equal level of .83 mM. The alterations in p-Mg were inversely related to the changes in fasting glucose and glycosylated hemoglobin concentrations.

CONCLUSION

The lowered p-Mg associated with impaired glucometabolic status in patients with T2D was increased after LRYGBP, reaching similar concentrations as in patients without T2D.

Cirrhosis following single anastomosis duodeno-ileal switch: A case report

•

We report a rare case of a liver cirrhosis in a patient who underwent single anastomosis duodenal switch procedure.

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We describe the possible presentation of the patient with a liver cirrhosis.

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Management of single anastomosis duodenal switch patients should include close monitoring of liver function.

Introduction

Single anastomosis duodeno-ileal switch (SADI-S) involves a single, loop duodeno-ileal anastomosis with omission of the traditional Roux-en-Y distal ileo-ileal anastomosis. Not much has been published on the complications of SADI-S.

Presentation of case

The patient is a 40 year-old male who underwent robot-assisted SADI-S three years prior. At the time of surgery, his body mass index (BMI) was 69 kg/m². His BMI was 31 kg/m² at the time of presentation. Computed tomography of the abdomen and pelvis showed a liver with a nodular appearance and moderate ascites throughout the abdomen and above the liver. Liver function showed AST 73 U/L, ALT 63 U/L, alkaline phosphatase 128 U/L, bilirubin 1.0 mg/dL, and albumin 2.8 g/dL. He underwent diagnostic and therapeutic paracentesis with removal of 6L of fluid that was negative for infection or malignant cells. Esophagogastroduodenoscopy showed grade I esophageal varices and diffuse mild gastritis.

Discussion

Mild hepatic dysfunction is common after biliopancreatic diversion and usually manifests as a temporary rise in liver enzymes that peak several months after surgery and normalize by one year. Cirrhosis and liver failure are rare sequelae that may develop at any time after surgery. Potential mechanisms include the absorption of hepatotoxic compounds from the bypassed small intestine in the context of bacterial overgrowth, protein malnutrition, and excessive free fatty acid mobilization causing steatosis and oxidative damage to hepatocytes.

Conclusion

Close laboratory monitoring is important after SADI-S in order to detect worsening hepatic dysfunction, which may occur many years after the surgery in the absence of other etiologies for liver failure.

Changes in bowel habits and patient-scored symptoms after Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch

BACKGROUND

Bariatric procedures are increasingly being used, but data on bowel habits are scarce.

OBJECTIVES

To assess changes in gastrointestinal function and patient-scored symptoms after Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch (BPD/DS).

SETTING

University hospital in Sweden.

METHODS

We recruited 268 adult patients (mean age of 42.5 yr, body mass index 44.8, 67.9% female) listed for RYGB and BPD/DS. Patients answered validated questionnaires prospectively concerning bowel function, the Fecal Incontinence Quality of Life Scale, and the 36-Item Short Form Health Survey before and after their operation.

RESULTS

Postoperatively, 208 patients (78.2% of 266 eligible patients) answered the questionnaires. RYGB patients had fewer bowel motions per week (8 versus 10) and more abdominal pain postoperatively (P<.001). Postoperatively, the 35 BPD/DS patients (69% versus 23%) needed to empty their bowel twice or more than twice daily, reported more flatus and urgency, and increased need for keeping a diet (P<.001). Concerning Fecal Incontinence Quality of Life Scale, coping and behavior was slightly reduced while depression and self-perception scores were improved after RYGB. Lifestyle, coping and behavior, and embarrassment were reduced after BPD/DS (P<.05). In the 36-Item Short Form Health Survey, physical scores were markedly improved, while mental scores were largely unaffected.

CONCLUSION

RYGB resulted in a reduced number of bowel movements but increased problems with abdominal pain. In contrast, BPD/DS-patients reported higher frequency of bowel movements, more troubles with flatus and urgency, and increased need for keeping a diet. These symptoms affected quality of life negatively, however, general quality of life was markedly improved after both procedures. These results will be of great value for preoperative counseling.

A systematic review and narrative synthesis of interventions for uncomplicated obesity: weight loss, well-being and impact on eating disorders

OBJECTIVE

Most weight loss research focuses on weight as the primary outcome, often to the exclusion of other physiological or psychological measures. This study aims to provide a holistic evaluation of the effects from weight loss interventions for individuals with obesity by examining the physiological, psychological and eating disorders outcomes from these interventions.

METHODS

Databases Medline, PsycInfo and Cochrane Library (2011-2016) were searched for randomised controlled trials and systematic reviews of obesity treatments (dietary, exercise, behavioural, psychological, pharmacological or surgical). Data extracted included study features, risk of bias, study outcomes, and an assessment of treatment impacts on physical, psychological or eating disorder outcomes.

RESULTS

From 3628 novel records, 134 studies met all inclusion criteria and were evaluated in this review. Lifestyle interventions had the strongest evidence base as a first-line approach, with escalation to pharmacotherapy and bariatric surgery in more severe or complicated cases. Quality of life was the most common psychological outcome measure, and improved in all cases where it was assessed, across all intervention types. Behavioural, psychological and lifestyle interventions for weight loss led to improvements in cognitive restraint, control over eating and binge eating, while bariatric surgery led to improvements in eating behaviour and body image that were not sustained over the long-term.

DISCUSSION

Numerous treatment strategies have been trialled to assist people to lose weight and many of these are effective over the short-term. Quality of life, and to a lesser degree depression, anxiety and psychosocial function, often improve alongside weight loss. Weight loss is also associated with improvements in eating disorder psychopathology and related measures, although overall, eating disorder outcomes are rarely assessed. Further research and between-sector collaboration is required to address the significant overlap in risk factors, diagnoses and treatment outcomes between obesity and eating disorders.

Common Channel Length in Bypass Surgery Does Not Impact T2DM in Diabetic Zucker Rats

INTRODUCTION

Metabolic surgery is known to impact glucose tolerance but the exact mechanism is still unclear. Based on recently-published data, especially the role of the hindgut may require redefinition.

METHODS

Either a loop duodeno-jejunostomy (DJOS) with exclusion of one third of total intestinal length, a loop duodeno-ileostomy (DiOS, exclusion of two thirds), or SHAM operation was performed in 9-week-old Zucker diabetic fatty rats. One, 3, and 6 months after surgery, an oral glucose tolerance test (OGTT) and glucose-stimulated hormone analyses were conducted. Body weight was documented weekly.

RESULTS

DJOS and DiOS animals showed significantly better glucose control in all OGTTs than the SHAM group (two-way ANOVA p < 0.0001). Body weight developed largely parallel in both intervention groups; SHAM animals had gained significantly less weight after 6 months (Mann-Whitney DJOS/DiOS vs. SHAM p < 0.05, DJOS vs. DiOS p > 0.05). Operative interventions had no impact on GLP-1 and GIP levels at any time point (Mann-Whitney p > 0.05 for all). DJOS/DiOS operations could preserve insulin production up to 6 months, while there was already a sharp decline of insulin levels in the SHAM group (Mann-Whitney: DJOS/DiOS vs. SHAM p < 0.05 for all time points). Additionally, insulin sensitivity was improved significantly 1 month postoperative in both intervention groups compared to SHAM (Mann-Whitney DJOS/DiOS vs. SHAM p < 0.05).

CONCLUSION

The data of the current study demonstrate a sharp amelioration of glucose control after duodenal exclusion with unchanged levels of GLP-1 and GIP. Direct or delayed hindgut stimulation had no impact on glucose control in our model.

Laparoscopy in Duodenal Switch: Safe and Halves Length of Stay in a Nationwide Cohort from the Scandinavian Obesity Registry

BACKGROUND AND AIMS

Unsatisfactory weight loss after gastric bypass or sleeve gastrectomy in super-obese patients (body mass index > 50) is a growing concern. Biliopancreatic diversion with duodenal switch results in greater weight loss, but is technically challenging to perform, especially as a laparoscopic procedure (Lap-DS). The aim of this study was to compare perioperative outcomes of Lap-DS and the corresponding open procedure (O-DS) in Sweden.

MATERIAL AND METHODS

The data source was a nationwide cohort from the Scandinavian Obesity Surgery Registry and 317 biliopancreatic diversion with duodenal switch patients (mean body mass index = 56.7 ± 6.6 kg/m², 38.4 ± 10.2 years, and 57% females) were analyzed. Follow-up at 30 days was complete in 98% of patients.

RESULTS

The 53 Lap-DS patients were younger than the 264 patients undergoing O-DS (35.0 vs 39.1 years, p = 0.01). Operative time was 163 ± 38 min for lap-DS and 150 ± 31 min for O-DS, p = 0.01, with less bleeding in Lap-DS (94 vs 216 mL, p < 0.001). There was one conversion to open surgery. Patients undergoing Lap-DS had a shorter length of stay than O-DS, 3.3 versus 6.6 days, p = 0.02. No significant differences in overall complications within 30 days were seen (12% and 17%, respectively). Interestingly, the two leaks in Lap-DS were located at the entero-enteric anastomosis, while three out of four leaks in O-DS occurred at the top of the gastric tube.

CONCLUSION

Lap-DS can be performed by dedicated bariatric surgeons as a single-stage procedure. The use of laparoscopic approach halved the length of stay, without increasing the risk for complications significantly. Any difference in long-term weight result is pending.

The future of the Roux-en-Y gastric bypass

Archaic surgical procedures such as the jejunoileal bypass, vertical banded gastroplasty and duodenal switch have contributed to the current best practice of Roux-en-Y gastric bypass (RYGB) procedure for the treatment of obesity and its consequences. Despite this, RYGB has been blighted with late occurring adverse events such as severe malnutrition, marginal ulcer and reactive hypoglycemia. Despite this, RYGB has given us an opportunity to examine the effect of surgery on gut hormones and the impact on metabolic syndrome which in turn has allowed us to carry out a lower impact but equally, if not more effective, procedure - the vertical sleeve gastrectomy (VSG). We examine the benefits of sleeve gastrectomy from the less challenging technical aspect to the effect on obesity and its metabolic syndrome long-term and have concluded that sleeve gastrectomy is possibly the next current best practice.

Metabolic Surgery in Type 2 Diabetes: Roux-en-Y Gastric Bypass or Sleeve Gastrectomy as Procedure of Choice?

In recent years, a marked increase in the relative use of sleeve gastrectomy (SG) has occurred. However, long-term head-to-head comparison of the impact of this bariatric surgery (BS) procedure with the still considered "gold standard" Roux-en-Y gastric bypass (GBP) in subjects with type 2 diabetes mellitus (T2DM) is surprisingly low. The aim of this review manuscript is to appraise current evidence on the potential of GBP and SG as long-term therapeutic tool for subjects with T2DM. In our opinion, unfortunately, review of current literature does not allow to properly answer which of the two surgeries would be better as procedure of choice for subjects with T2DM. Arguably, the apparent superiority of GBP over SG could be overcome by the addition of a malabsortive component to SG in a staged approach restricted to those failing to achieve the desired metabolic outcomes. Nonetheless, whether this serves as basis for the election of SG as primary strategy for those with T2DM is questionable.

Hypoglycemia in everyday life after gastric bypass and duodenal switch

DESIGN

Gastric bypass (GBP) and duodenal switch (DS) in morbid obesity are accompanied by marked metabolic improvements, particularly in glucose control. In recent years, episodes of severe late postprandial hypoglycemia have been increasingly described in GBP patients; data in DS patients are scarce. We recruited three groups of subjects; 15 GBP, 15 DS, and 15 non-operated overweight controls to examine to what extent hypoglycemia occurs in daily life.

METHODS

Continuous glucose monitoring (CGM) was used during 3 days of normal activity. The glycemic variability was measured by mean amplitude of glycemic excursion and continuous overall net glycemic action. Fasting blood samples were drawn, and the patients kept a food and symptom log throughout the study.

RESULTS

The GBP group displayed highly variable CGM curves, and 2.9% of their time was spent in hypoglycemia (<3.3  mmol/l, or 60  mg/dl). The DS group had twice as much time in hypoglycemia (5.9%) and displayed CGM curves with little variation as well as lower HbA1c levels (29.3 vs 35.9 mmol/mol, P<0.05). Out of a total of 72 hypoglycemic episodes registered over the 3-day period, 70 (97%) occurred in the postprandial state and only about one-fifth of the hypoglycemic episodes in the GBP and DS groups were accompanied by symptoms. No hypoglycemias were seen in controls during the 3-day period.

CONCLUSION

Both types of bariatric surgery induce marked, but different, changes in glucose balance accompanied by frequent, but mainly unnoticed, hypoglycemic episodes. The impact and mechanism of hypoglycemic unawareness after weight-reduction surgery deserves to be clarified.

Novel therapeutics for type 2 diabetes: insulin resistance

Insulin resistance (IR) plays an important role in the pathogenesis of type 2 diabetes (T2D) and cardiovascular disease. Hence improving IR is a major target of treatment in patients with T2D. Obesity and lack of exercise are major causes of IR. However, recent evidence implicates sleep disorders and disorders of the circadian rhythm in the pathogenesis of IR. Weight loss and lifestyle changes are the cornerstone and most effective treatments of IR, but adherence and patient's acceptability are poor. Bariatric surgery results in significant and sustainable long-term weight loss associated with beneficial impact on IR and glucose metabolism, making this an attractive treatment option for patients with T2D. Currently available pharmacological options targeting IR (such as metformin and thiazolidinediones) do not maintain glycaemic measures within targets long term and can be associated with significant side effects. Over the last two decades, many pharmacological agents targeting different aspects of the insulin signalling pathway were developed to improve IR, but only a minority reached clinical trials. Such treatments need to be specific and reversible as many of the components of the insulin signalling pathway are involved in other cellular functions such as apoptosis. Recent evidence highlighted the role of circadian rhythm and sleep-related disorders in the pathogenesis of IR. In this article, we review the latest developments in the pharmacological and non-pharmacological interventions targeting IR including bariatric surgery. We will also review the role of circadian rhythm and sleep-related disorders in the development and treatment of IR.

Predictors of metabolic syndrome persistence 1 year after laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is effective in reversing the metabolic syndrome (MS) in up to 90% of patients.

OBJECTIVES

The aim of this study was to determine predictors of MS persistence 1 year after LRYGB.

SETTING

University Hospital, France.

METHODS

Ninety-one patients with a mean age of 44.4 years and a mean body mass index (BMI) of 43.1 kg/m² meeting the criteria for MS were enrolled in this prospective study. Anthropometric, metabolic, and inflammatory biological parameters were assessed before and 1 year after LRYGB. Patients were divided into 2 groups according to the persistence (MS nonresponders) or resolution of MS (MS responders) 1 year after LRYGB and a comparison was performed at baseline and 1 year after surgery.

RESULTS

Sixty-nine patients (75.8%) underwent remission, while 22 (24.2%) showed persistence of MS 1 year after LRYGB. At baseline the MS nonresponders group presented significantly higher values of fasting plasma glucose (7.8 versus 5.3 mmol/L, P = .004), glycosylated hemoglobin (HbA1c, 7.3% versus 5.9%, P = .0004), triglycerides (TG, 2.37 versus 1.33 mmol/L, P = .006), and homeostasis model assessment of insulin resistance (HOMA-IR, 442.5 versus 256, P = .006). The rate of diabetes was significantly higher in this group (68.2% versus 36.8%, P = .0086), as well as the number of MS components per patient. One year after LRYGB, the MS nonresponders showed a significantly lower excess BMI lost (EBMIL) (56.1% versus 82.4%, P = .00008). On multivariate analysis, baseline levels of TG, glucose metabolism markers and EBMIL were associated with the persistence of MS.

CONCLUSION

Baseline levels of TG, plasma fasting glucose, and HbA1c, as well as history of type 2 diabetes and EBMIL, represent predictors of MS persistence 1 year after LRYGB.

Surgery for weight loss in adults

BACKGROUND

Bariatric (weight loss) surgery for obesity is considered when other treatments have failed. The effects of the available bariatric procedures compared with medical management and with each other are uncertain. This is an update of a Cochrane review first published in 2003 and most recently updated in 2009.

OBJECTIVES

To assess the effects of bariatric surgery for overweight and obesity, including the control of comorbidities.

SEARCH METHODS

Studies were obtained from searches of numerous databases, supplemented with searches of reference lists and consultation with experts in obesity research. Date of last search was November 2013.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing surgical interventions with non-surgical management of obesity or overweight or comparing different surgical procedures.

DATA COLLECTION AND ANALYSIS

Data were extracted by one review author and checked by a second review author. Two review authors independently assessed risk of bias and evaluated overall study quality utilising the GRADE instrument.

MAIN RESULTS

Twenty-two trials with 1798 participants were included; sample sizes ranged from 15 to 250. Most studies followed participants for 12, 24 or 36 months; the longest follow-up was 10 years. The risk of bias across all domains of most trials was uncertain; just one was judged to have adequate allocation concealment.All seven RCTs comparing surgery with non-surgical interventions found benefits of surgery on measures of weight change at one to two years follow-up. Improvements for some aspects of health-related quality of life (QoL) (two RCTs) and diabetes (five RCTs) were also found. The overall quality of the evidence was moderate. Five studies reported data on mortality, no deaths occurred. Serious adverse events (SAEs) were reported in four studies and ranged from 0% to 37% in the surgery groups and 0% to 25% in the no surgery groups. Between 2% and 13% of participants required reoperations in the five studies that reported these data.Three RCTs found that laparoscopic Roux-en-Y gastric bypass (L)(RYGB) achieved significantly greater weight loss and body mass index (BMI) reduction up to five years after surgery compared with laparoscopic adjustable gastric banding (LAGB). Mean end-of-study BMI was lower following LRYGB compared with LAGB: mean difference (MD) -5.2 kg/m² (95% confidence interval (CI) -6.4 to -4.0; P < 0.00001; 265 participants; 3 trials; moderate quality evidence). Evidence for QoL and comorbidities was very low quality. The LRGYB procedure resulted in greater duration of hospitalisation in two RCTs (4/3.1 versus 2/1.5 days) and a greater number of late major complications (26.1% versus 11.6%) in one RCT. In one RCT the LAGB required high rates of reoperation for band removal (9 patients, 40.9%).Open RYGB, LRYGB and laparoscopic sleeve gastrectomy (LSG) led to losses of weight and/or BMI but there was no consistent picture as to which procedure was better or worse in the seven included trials. MD was -0.2 kg/m² (95% CI -1.8 to 1.3); 353 participants; 6 trials; low quality evidence) in favour of LRYGB.  No statistically significant differences in QoL were found (one RCT). Six RCTs reported mortality; one death occurred following LRYGB. SAEs were reported by one RCT and were higher in the LRYGB group (4.5%) than the LSG group (0.9%). Reoperations ranged from 6.7% to 24% in the LRYGB group and 3.3% to 34% in the LSG group. Effects on comorbidities, complications and additional surgical procedures were neutral, except gastro-oesophageal reflux disease improved following LRYGB (one RCT). One RCT of people with a BMI 25 to 35 and type 2 diabetes found laparoscopic mini-gastric bypass resulted in greater weight loss and improvement of diabetes compared with LSG, and had similar levels of complications.Two RCTs found that biliopancreatic diversion with duodenal switch (BDDS) resulted in greater weight loss than RYGB in morbidly obese patients. End-of-study mean BMI loss was greater following BDDS: MD -7.3 kg/m² (95% CI -9.3 to -5.4); P < 0.00001; 107 participants; 2 trials; moderate quality evidence). QoL was similar on most domains. In one study between 82% to 100% of participants with diabetes had a HbA1c of less than 5% three years after surgery. Reoperations were higher in the BDDS group (16.1% to 27.6%) than the LRYGB group (4.3% to 8.3%). One death occurred in the BDDS group.One RCT comparing laparoscopic duodenojejunal bypass with sleeve gastrectomy versus LRYGB found BMI, excess weight loss, and rates of remission of diabetes and hypertension were similar at 12 months follow-up (very low quality evidence). QoL, SAEs and reoperation rates were not reported. No deaths occurred in either group.One RCT comparing laparoscopic isolated sleeve gastrectomy (LISG) versus LAGB found greater improvement in weight-loss outcomes following LISG at three years follow-up (very low quality evidence). QoL, mortality and SAEs were not reported. Reoperations occurred in 20% of the LAGB group and in 10% of the LISG group.One RCT (unpublished) comparing laparoscopic gastric imbrication with LSG found no statistically significant difference in weight loss between groups (very low quality evidence).  QoL and comorbidities were not reported. No deaths occurred. Two participants in the gastric imbrication group required reoperation.

AUTHORS' CONCLUSIONS

Surgery results in greater improvement in weight loss outcomes and weight associated comorbidities compared with non-surgical interventions, regardless of the type of procedures used. When compared with each other, certain procedures resulted in greater weight loss and improvements in comorbidities than others. Outcomes were similar between RYGB and sleeve gastrectomy, and both of these procedures had better outcomes than adjustable gastric banding. For people with very high BMI, biliopancreatic diversion with duodenal switch resulted in greater weight loss than RYGB. Duodenojejunal bypass with sleeve gastrectomy and laparoscopic RYGB had similar outcomes, however this is based on one small trial. Isolated sleeve gastrectomy led to better weight-loss outcomes than adjustable gastric banding after three years follow-up. This was based on one trial only.  Weight-related outcomes were similar between laparoscopic gastric imbrication and laparoscopic sleeve gastrectomy in one trial. Across all studies adverse event rates and reoperation rates were generally poorly reported. Most trials followed participants for only one or two years, therefore the long-term effects of surgery remain unclear.

Duodenal switch versus Roux-en-Y gastric bypass for morbid obesity: systematic review and meta-analysis of weight results, diabetes resolution and early complications in single-centre comparisons

Long-term weight loss after Roux-en-Y gastric bypass (RYGB) in super-obese patients has not been ideal. Biliopancreatic diversion with duodenal switch (DS) is argued to be better; however, additional side effects are feared. The aim of the present study was to determine differences in results after DS and RYGB in publications from single-centre comparisons. A systematic review of studies containing DS and RYGB performed at the same centre was performed. Outcome data were weight results, resolution of comorbid conditions, perioperative results and complications. Main outcome was difference in weight loss after DS and RYGB. Secondary outcomes were difference in resolution of comorbidities, perioperative results and complications. The final analysis included 16 studies with in total 874 DS and 1,149 RYGB operations. When comparing weight results at the longest follow-up of each study, DS yielded 6.2 (95% confidence interval 5.0-7.5) body mass index units additional weight loss compared with RYGB, P < 0.001. Operative time and length of stay were significantly longer after DS, as well as the risk for post-operative leaks, P < 0.05. DS is more effective than RYGB as a weight-reducing procedure. However, this comes at the price of more early complications and might also yield slightly higher perioperative mortality.

Older adults fighting obesity with bariatric surgery: Benefits, side effects, and outcomes

The aging population is growing exponentially worldwide. Associated with this greater life expectancy is the increased burden of chronic health conditions, many of which are exacerbated by the continued rise in obesity. In the US, the prevalence of obesity in adults aged 60 years and older increased from 23.6% to 37% in 2010.

Increased plasma magnesium concentrations 3 years after biliopancreatic diversion with duodenal switch

BACKGROUND

Biliopancreatic diversion with duodenal switch, BPD-DS, is a surgical procedure for treatment of super obese patients. It renders very good weight results and it strongly reduces the incidence of type 2 diabetes. One important mechanism of weight reduction after BPD-DS is malabsorption. Hypomagnesemia is an established cardiovascular risk factor. While it is well-known that magnesium levels decline after jejuno-ileal bypass and increase after gastric bypass surgery, information on how magnesium status is affected by BPD-DS is scant. The aim of the present study was to evaluate plasma magnesium concentrations (P-Mg) after BPD-DS.

METHODS

Thirty-one patients, all Caucasians (9 diabetics, 12 men, age 38 ± 8 years, weight 159 ± 22 kg, body mass index (BMI) 53.9 ± 5.2 kg/m(2)) underwent BPD-DS. We evaluated weight, glycated hemoglobin levels (HbA1c) and P-Mg preoperatively as well as at 1 and 3 years after surgery. All subjects were treated with vitamin and mineral substitution after surgery, including 100 mg of magnesium salt. P-Mg was analyzed with respect to changes over time, correlation to BMI and HbA1c levels before and 3 years after surgery.

RESULTS

The plasma magnesium concentrations increased by 15 % from 0.77 ± 0.07 to 0.88 ± 0.09 mmol/l over 3 years (p < 0.001). The weight loss was 71 ± 25 kg. No patient had diabetes at follow-up. No correlations between P-Mg and BMI or HbA1c were seen.

CONCLUSIONS

Although exerting much of its weight-reducing effect by a malabsorptive mechanism, BPD-DS yields a rise in P-Mg 3 years postoperatively, possibly contributing to the improved metabolic state after this operation.

Satiety signals and obesity

PURPOSE OF REVIEW

The obesity epidemic over the world has called to attention different ways to manage this development. As bariatric surgery today is the only manner by which rapid and sustained weight control can be achieved, new ways of treating obesity are under investigation. This review focuses on today's knowledge on satiety signaling as a means to combat obesity.

RECENT FINDINGS

The combined knowledge achieved from obesity surgery with gastric bypass and duodenal switch together with the pharmacological treatment of type 2 diabetes have given us some clues of how to manage obesity. The basis for our understanding is the present research focusing on the gut peptide hormones that are released in response to food intake, and the paucity of satiety signaling seems to prevail in obesity. This means that obese patients experience less activation of higher brain centers in association with a meal and therefore compensate with increased meal size or frequent food intake.

SUMMARY

Altered satiety signaling primarily emanating from the gastrointestinal tract seems to lead to the development of obesity and type 2 diabetes. Pharmacological tools that enhance the gut hormone signaling are in focus for the upcoming venues of treatment.

Bariatric surgery: the challenges with candidate selection, individualizing treatment and clinical outcomes

Obesity is recognized as a global health crisis. Bariatric surgery offers a treatment that can reduce weight, induce remission of obesity-related diseases, and improve the quality of life. In this article, we outline the different options in bariatric surgery and summarize the recommendations for selecting and assessing potential candidates before proceeding to surgery. We present current data on post-surgical outcomes and evaluate the psychosocial and economic effects of bariatric surgery. Finally, we evaluate the complication rates and present recommendations for post-operative care.