Midterm outcomes of laparoscopic sleeve gastrectomy as a stand-alone procedure in super-obese patients

Analysis of the 1-year efficacy of four different surgical methods for treating Chinese super obese (BMI ≥ 50 kg/m2) patients

This study aimed to retrospectively analyze the perioperative and postoperative follow-up data of patients with super obesity who had undergone RYGB, SG, BPD/DS, and SADI-S. A retrospective observational study was conducted to analyze the perioperative and postoperative follow-up data of 60 patients with super obesity who had undergone bariatric surgery. A total of 34 men and 26 women were included in this study. The participants had an average preoperative BMI of 53.81 ± 3.25 kg/m2. The body weight and BMI of all four patient groups decreased significantly at 3, 6, and 12 months postoperatively compared with the preoperative values. Additionally, the TWL (%) and EWL (%) of all four groups increased gradually over the same period. Compared with the preoperative values, the systolic and diastolic blood pressure, glycosylated hemoglobin, uric acid, triglycerides, and total cholesterol decreased to varying degrees in the four groups 1 year postoperatively. RYGB, SG, BPD/DS, and SADI-S are all safe and effective in treating super obese patients and improving their metabolic diseases to a certain extent.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

The first survey addressing patients with BMI over 50: a survey of 789 bariatric surgeons

Background

Bariatric surgery in patients with BMI over 50 kg/m² is a challenging task. The aim of this study was to address main issues regarding perioperative management of these patients by using a worldwide survey.

Methods

An online 48-item questionnaire-based survey on perioperative management of patients with a BMI superior to 50 kg/m² was ideated by 15 bariatric surgeons from 9 different countries. The questionnaire was emailed to all members of the International Federation of Surgery for Obesity (IFSO). Responses were collected and analyzed by the authors.

Results

789 bariatric surgeons from 73 countries participated in the survey. Most surgeons (89.9%) believed that metabolic/bariatric surgery (MBS) on patients with BMI over 50 kg/m² should only be performed by expert bariatric surgeons. Half of the participants (55.3%) believed that weight loss must be encouraged before surgery and 42.6% of surgeons recommended an excess weight loss of at least 10%. However, only 3.6% of surgeons recommended the insertion of an Intragastric Balloon as bridge therapy before surgery. Sleeve Gastrectomy (SG) was considered the best choice for patients younger than 18 or older than 65 years old. SG and One Anastomosis Gastric Bypass were the most common procedures for individuals between 18 and 65 years. Half of the surgeons believed that a 2-stage approach should be offered to patients with BMI > 50 kg/m², with SG being the first step. Postoperative thromboprophylaxis was recommended for 2 and 4 weeks by 37.8% and 37.7% of participants, respectively.

Conclusion

This survey demonstrated worldwide variations in bariatric surgery practice regarding patients with a BMI superior to 50 kg/m². Careful analysis of these results is useful for identifying several areas for future research and consensus building.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08979-w.

Roux-en-Y Gastric Bypass Vs Sleeve Gastrectomy in Super Obesity: a Systematic Review and Meta-Analysis

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are safe procedures that may present sub-optimal results in superobesity (SO). A meta-analysis was performed aiming to summarize the available evidence on weight loss (primary outcome) and comorbidities resolution of LRYGB and LSG in patients with SO (BMI ≥ 50 kg/m2). From the 16 included studies, 7 integrated the meta-analysis. LRYGB showed a significantly higher weight loss at 6 to 12-months, but not after 24 months and a higher dyslipidemia resolution at 12 months. When compared with LSG, LRYGB achieved better weight loss after 6 and 12 months and higher dyslipidemia resolution after 1 year. There were no significant differences for resolution of the other co-morbidities studied.

Is One Anastomosis Gastric Bypass with a Biliopancreatic Limb of 150 cm Effective in the Treatment of People with Severe Obesity with BMI > 50?

Purpose

The treatment of people with severe obesity and BMI > 50 kg/m² is challenging. The present study aims to evaluate the short and mid-term outcomes of one anastomosis gastric bypass (OAGB) with a biliopancreatic limb of 150 cm as a primary bariatric procedure to treat those people in a referral center for bariatric surgery.

Material and Methods

Data of patients who underwent OAGB for severe obesity with BMI > 50 kg/m² between 2010 and 2017 were collected prospectively and analyzed retrospectively. Follow-up comprised clinical and biochemical assessment at 1, 3, 6, 12, 18, and 24 months postoperatively, and once a year thereafter.

Results

Overall, 245 patients underwent OAGB. Postoperative mortality was null, and early morbidity was observed in 14 (5.7%) patients. At 24 months, the percentage total weight loss (%TWL) was 43.2 ± 9, and percentage excess weight loss (%EWL) was 80 ± 15.7 (184 patients). At 60 months, %TWL was 41.9 ± 10.2, and %EWL was 78.1 ± 18.3 (79 patients). Conversion to Roux-en-Y gastric bypass was needed in three (1.2%) patients for reflux resistant to medical treatment. Six patients (2.4%) had reoperation for an internal hernia during follow-up. Anastomotic ulcers occurred in three (1.2%) patients. Only two patients (0.8%) underwent a second bariatric surgery for insufficient weight loss.

Conclusion

OAGB with a biliopancreatic limb of 150 cm is feasible and associated with sustained weight loss in the treatment of severe obesity with BMI > 50 kg/m². Further randomized studies are needed to compare OAGB with other bariatric procedures in this setting.

Graphical abstract

Factors influencing the choice between laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass

BACKGROUND

While laparoscopic sleeve gastrectomy (LSG) continues to be the most commonly performed bariatric operation, several variables influence surgeons' practice patterns and patients' decision-making in the type of bariatric procedure to perform. The aim of this study was to evaluate patient factors that influence the decision between laparoscopic Roux-en-Y gastric bypass (LRYGB) versus LSG.

METHODS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried for patients undergoing LSG and LRYGB between 2015 and 2017. Univariate analysis and multivariate logistic regression were used to evaluate factors associated with performing LRYGB compared to LSG.

RESULTS

A total of 252,117 (72.3%) LSG and 96,677 (27.7%) LRYGB cases were identified. Patients undergoing LSG were younger (44.3 ± 12.0 vs 45.2 ± 11.8 years; p < 0.01) and had a lower body mass index (BMI; 45.1 ± 7.8 vs 46.2 ± 8.1 kg/m²; p < 0.01). Most of the patients were females (79.4%), white (73.0%), with an American Society of Anesthesiology (ASA) class ≤ 3 (96.4%). The factors associated with undergoing LRYGB compared to LSG were diabetes mellitus, gastroesophageal reflux disease, BMI ≥ 50 kg/m², ASA class > 3, obstructive sleep apnea, hypertension, and hyperlipidemia. However, patients with kidney disease, black race, chronic steroid use, age ≥ 60 years, recent smoking history, chronic obstructive pulmonary disease, and coronary artery disease were more likely to undergo LSG.

CONCLUSIONS

The decision to perform LRYGB is primarily driven by obesity-associated comorbidities and higher BMI, whereas LSG is more likely to be performed in higher risk patients.

Remission of Type 2 Diabetes and Sleeve Gastrectomy in Morbid Obesity: a Comparative Systematic Review and Meta-analysis

BACKGROUND

The sleeve gastrectomy (SG) has gained popularity which has resulted in a rising number of patients with T2DM to undergo this procedure. This systematic review and meta-analysis aimed to compare the long-term effects of SG on T2DM remission with remission seen after Roux-en-Y gastric bypass (RYGB) or gastric banding (GB).

METHODS

A literature search was performed in PubMed and Cochrane Library using the following search terms: 'sleeve gastrectomy', 'diabetes', 'gastric bypass' and 'gastric banding'. Studies published between January 2000 and April 2018, and with following inclusion criteria were selected for this review: BMI ≥ 35 kg/m2, age ≥ 18 years, follow-up ≥ 1 year, T2DM. Data was statistically analysed using a random-effects model and results were expressed as odds ratio with 95% confidence interval.

RESULTS

After exclusion, 35 out of an initial 748 studies, consisting of 18 138 T2DM patients, remained for inclusion. Of these patients, 2480 underwent a SG. The remaining patients underwent a RYGB (n = 10,597) or GB (n = 5061). One year postoperatively, SG patients reached significantly (OR 0.71, p = 0.003) less T2DM remission than RYGB. After stratifying for different criteria for remission, RYGB still tended to result in higher remission rates, but the difference was not statistically significant. Beyond 1 year of follow-up, the difference between RYGB and SG in terms of T2DM remission decreased. SG was superior to the GB (OR 2.17, p = 0.001) after 1 year of follow-up.

CONCLUSION

This review demonstrates important remission of T2DM following SG. Nevertheless, as remission was significantly more often observed following RYGB surgery, the latter procedure remains the gold standard for reaching T2DM remission in patients with concurrent obesity.

Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy for Super Super Obese and Super Obese: Systematic Review and Meta-analysis of Weight Results, Comorbidity Resolution

BACKGROUND

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) used for super obesity (SO) and super super obesity (SSO) remain controversial. The meta-analysis was to summarize the evidence.

METHODS

We searched in MEDLINE and PubMed for studies concerning RYGB and SG for SO or SSO and pooled complication, percentage excess weight loss (%EWL), and resolution of comorbidities.

RESULTS

Twelve studies were identified. RYGB achieved higher %EWL at 12 months, but no significant difference at 24 months. Resolution of diabetes mellitus and dyslipidemia reached a statistical significance; however, there was no significant difference in hypertension.

CONCLUSIONS

RYGB was superior in %EWL for SSO and SO at 12 months. However, regarding at 24 months, RYGB was equal to SG, which is from a meta-analysis and cannot be seen as a definitive conclusion.

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

Introduction:

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

Objective and Methodology:

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

Results:

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

Conclusion:

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

Comparative Effectiveness of Different Bariatric Procedures in Super Morbid Obesity

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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