Trends in revisional bariatric surgery using the MBSAQIP database 2015-2017

Bariatric surgery: trends in utilization, complications, conversions and revisions

BACKGROUND

Sleeve gastrectomy (SG) increased in popularity after 2010 but recent data suggest it has concerning rates of gastroesophageal reflux and need for conversions. This study aims to evaluate recent trends in the utilization of bariatric procedures, associated complications, and conversions using an administrative claims database in the United States.

METHODS

We included adults who had bariatric procedures from 2000 to 2020 with continuous enrollment for at least 6 months in the MarketScan Commercial Claims and Encounters database. Index bariatric procedures and subsequent revisions or conversions were identified using CPT codes. Baseline comorbidities and postoperative complications were identified with ICD-9-CM and ICD-10 codes. Cumulative incidences of complications were estimated at 30-days, 6-months, and 1-year and compared with stabilized inverse probability of treatment weighted Kaplan-Meier analysis.

RESULTS

We identified 349,411 bariatric procedures and 5521 conversions or revisions. The sampled SG volume appeared to begin declining in 2018 while Roux-en-Y gastric bypass (RYGB) remained steady. Compared to RYGB, SG was associated with lower 1-year incidence [aHR, (95% CIs)] for 30-days readmission [0.65, (0.64-0.68)], dehydration [0.75, (0.73-0.78)], nausea or vomiting [0.70, (0.69-0.72)], dysphagia [0.55, (0.53-0.57)], and gastrointestinal hemorrhage [0.43, (0.40-0.46)]. Compared to RYGB, SG was associated with higher 1-year incidence [aHR, (95% CIs)] of esophagogastroduodenoscopy [1.13, (1.11-1.15)], heartburn [1.38, (1.28-1.49)], gastritis [4.28, (4.14-4.44)], portal vein thrombosis [3.93, (2.82-5.48)], and hernias of all types [1.36, (1.34-1.39)]. There were more conversions from SG to RYGB than re-sleeving procedures. SG had a significantly lower 1-year incidence of other non-revisional surgical interventions when compared to RYGB.

CONCLUSIONS

The overall volume of bariatric procedures within the claims database appeared to be declining over the last 10 years. The decreasing proportion of SG and the increasing proportion of RYGB suggest the specific complications of SG may be driving this trend. Clearly, RYGB should remain an important tool in the bariatric surgeon's armamentarium.

Decision-making Considerations in Revisional Bariatric Surgery

OBJECTIVE

With drastic variations in bariatric practices, consensus is lacking on an optimal approach for revisional bariatric surgeries.

MATERIALS AND METHODS

The authors reviewed and consolidated bariatric surgery literature to provide specific revision suggestions based on each index surgery, including adjustable gastric band (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS), single anastomosis duodenal-ileal bypass with sleeve (SADI-S), one anastomosis gastric bypass (OAGB), and vertical banded gastroplasty (VBG).

RESULTS

AGB has the highest weight recurrence rate and can be converted to RYGB, SG, and BPD-DS. After index SG, common surgical options include a resleeve or RYGB. The RYGB roux limb can be distalized and pouch resized in context of reflux, and the entire anatomy can be revised into BPD-DS. Data analyzing revisional surgery after a single anastomosis duodenal-ileal bypass with sleeve was limited. In patients with one anastomosis gastric bypass and vertical banded gastroplasty anatomy, most revisions were the conversion to RYGB.

CONCLUSIONS

As revisional bariatric surgery becomes more common, the best approach depends on the patient's indication for surgery and preexisting anatomy.

Update on comparison of laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass: a systematic review and meta-analysis of weight loss, comorbidities, and quality of life at 5 years

BACKGROUND

Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) are the two most commonly performed bariatric surgeries for the treatment of obesity. This meta-analysis was performed with the aim of summarizing the available evidence on weight loss, remission of comorbidities, and quality of life in LRYGB and LSG, complementing the current literature.

METHODS

We searched PubMed, EMBASE and the Cochrane Library from January 2012 to June 2023 for randomized controlled trials and non-randomized interventional studies. We finally selected 18 eligible studies.

RESULTS

LRYGB resulted in greater weight loss compared with LSG at 5 years [WMD= -7.65 kg/m², 95% confidence interval (CI) -11.54 to -3.76, P = 0.0001], but there exists high heterogeneity with I²=84%. Resolution rate of type 2 diabetes mellitus (T2D) (OR = 0.60, 95%Cl 0.41-0.87, p = 0.007) and dyslipidemia (OR = 0.44, 95%Cl 0.23-0.84, p = 0.01) was higher in the LRYGB group than that in the LSG group at 5 years. There was no difference between LRYGB and LSG for remission of hypertension, and obstructive sleep apnea. No differences were observed in the QoL after LRYGB or LSG. Morbidity was lower in the LSG group (WMD = -0.07, 95% CI: -0.13, -0.02, P = 0.01) than in the LRYGB group. No statistically significant difference was found in mortality between the two procedures.

CONCLUSION

At 5 years after surgery, LRYGB resulted in greater weight loss and achieved better remission rate of T2D and dyslipidemia than LSG. However, LSG has a lower morbidity rate than that of LRYGB.

Safety of redo sleeve gastrectomy as a primary revisional procedure

BACKGROUND

Insufficient weight loss after primary laparoscopic sleeve gastrectomy (LSG) occasionally requires revisional surgery. A few single-institution studies have examined the safety of redo LSG (RSG) and have shown mixed results.

OBJECTIVES

The aim of this study was to evaluate the safety of RSG compared with LSG over a period of 30 days.

SETTING

University of Southern California, United States; Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.

METHODS

The 2020-2021 MBSAQIP registry was used to evaluate patients who underwent RSG. Thirty-day outcomes were evaluated using univariable analysis and multivariable logistic and linear regression.

RESULTS

A total of 226,029 patients were reviewed, of whom 1454 (.7%) underwent RSG and 224,575 (99.3%) underwent initial LSG. Patients who underwent RSG were older (45 versus 42 yr), predominantly female (86.2% versus 81.3%), had a lower body mass index (40.0 versus 43.4), fewer co-morbidities, and greater rates of gastroesophageal reflux (38.7% versus 25.1%). They demonstrated increased overall complications (3.6% versus 2.1%, P < .001) and a longer operative time (81 versus 62 min, P < .001), but there was no difference in mortality. On multivariable analysis, patients who underwent RSG were independently associated with an increased risk of overall postoperative complications (odds ratio [OR]: 1.493, P = .018), organ space infection (OR: 6.231, P < .001), staple line leak (OR: 12.838, P < .001), pneumonia (OR: 3.85, P = .013), ventilator requirement over 48 hours (OR: 6.404, P = .035), sepsis (OR: 4.397, P = .010), septic shock (OR: 8.669, P < .001), reoperation (OR: 1.808, P = .013), readmission (OR: 2.104, P < .001), reintervention (OR: 4.435, P < .001), and longer operative times (β = 12.790, P < .001).

CONCLUSIONS

In this national database study, RSG was associated with increased rates of postoperative complications and a longer operative time. Although these results are concerning, further studies are required to examine long-term outcomes.

30-day morbidity and mortality of revisional bariatric surgery - An international multi-centre collaborative (BROAD) study

INTRODUCTION

Revisional bariatric surgery (RBS) for insufficient weight loss/weight regain or metabolic relapse is increasing worldwide. There is currently no large multinational, prospective data on 30-day morbidity and mortality of RBS. In this study, we aimed to evaluate the 30-day morbidity and mortality of RBS at participating centres.

METHODS

An international steering group was formed to oversee the study. The steering group members invited bariatric surgeons worldwide to participate in this study. Ethical approval was obtained at the lead centre. Data were collected prospectively on all consecutive RBS patients operated between 15th May 2021 to 31st December 2021. Revisions for complications were excluded.

RESULTS

A total of 65 global centres submitted data on 750 patients. Sleeve gastrectomy (n = 369, 49.2 %) was the most common primary surgery for which revision was performed. Revisional procedures performed included Roux-en-Y gastric bypass (RYGB) in 41.1 % (n = 308) patients, One anastomosis gastric bypass (OAGB) in 19.3 % (n = 145), Sleeve Gastrectomy (SG) in 16.7 % (n = 125) and other procedures in 22.9 % (n = 172) patients. Indications for revision included weight regain in 615(81.8 %) patients, inadequate weight loss in 127(16.9 %), inadequate diabetes control in 47(6.3 %) and diabetes relapse in 27(3.6 %). 30-day complications were seen in 80(10.7 %) patients. Forty-nine (6.5 %) complications were Clavien Dindo grade 3 or higher. Two patients (0.3 %) died within 30 days of RBS.

CONCLUSION

RBS for insufficient weight loss/weight regain or metabolic relapse is associated with 10.7 % morbidity and 0.3 % mortality. Sleeve gastrectomy is the most common primary procedure to undergo revisional bariatric surgery, while Roux-en-Y gastric bypass is the most commonly performed revision.

American Society for Metabolic and Bariatric Surgery 2022 estimate of metabolic and bariatric procedures performed in the United States

BACKGROUND

Metabolic and bariatric surgery (MBS), despite being the most effective durable treatment for obesity, remains underused as approximately 1% of all qualified patients undergo surgery. The American Society for Metabolic and Bariatric Surgery established a Numbers Taskforce to specify the annual rate of obesity treatment interventions utilization and to determine if patients in need are receiving appropriate treatment.

OBJECTIVE

To provide the best estimated number of metabolic and bariatric procedures being performed in the United States in 2022.

SETTING

United States.

METHODS

We reviewed data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program and National Surgical Quality Improvement Program. In addition, data from industry and state databases were used to estimate activity at non-accredited centers. Data from 2022 were compared mainly with data from the previous 2 years.

RESULTS

Compared with 2021, the total number of MBS performed in 2022 increased from approximately 262,893 to 280,000. The sleeve gastrectomy (SG) continues to be the most commonly performed procedure. The gastric bypass procedure trend remained relatively stable. The percentage of revision procedures and biliopancreatic diversion with duodenal switch procedures increased slightly. Intragastric balloon placement increased from the previous year. Endoscopic sleeve gastroplasty increased in numbers.

CONCLUSIONS

There was a 6.5% increase in MBS volume from 2021 to 2022 and a 41% increase from 2020, which demonstrates a recovery from the COVID-19 pandemic. SG continues to be the most dominant MBS procedure.

Outcomes of Endoscopic Sleeve Gastroplasty Following Laparoscopic Adjustable Gastric Band: A Propensity Score-matched Analysis

BACKGROUND

The performance of endoscopic sleeve gastroplasty (ESG) in patients with prior laparoscopic adjustable gastric band (LAGB) has not been characterized.

MATERIALS AND METHODS

This is a retrospective propensity score-matched study of ESG after LAGB at 2 centers with expertise in bariatric endoscopy. The primary outcome was total weight loss (TWL) at 12 months. Secondary outcomes included TWL at 3 and 6 months, 12-month excess weight loss (EWL), procedural characteristics, predictors of TWL, and serious adverse events.

RESULTS

Twenty-six adults (88.5% female, age 50.8 y, BMI 36.5 kg/m 2 ) with prior LAGB (median duration 8 y) underwent ESG at a median of 3 years after LAGB removal. A 2:1 age-matched, sex-matched, and BMI-matched comparator group was created, comprising ESG patients from the same organization and time frame but without prior LAGB. TWL for the LAGB-to-ESG cohort versus the ESG-only cohort was 10.1±5.5% versus 13.0±4.4% at 3 months ( P =0.0256), 12.4±7.2% versus 16.0±5.4% at 6 months ( P =0.0375), and 12.7±8.2% versus 18.4±6.5% at 12 months ( P =0.0149). At 12 months, the LAGB-to-ESG cohort had an EWL of 52.5±50.0%, and 75% achieved TWL ≥10%. There was no association between TWL at 3, 6, or 12 months and the following traits: age or BMI at the time of ESG, patient sex, and time from LAGB removal to ESG. No serious adverse events occurred in either cohort.

CONCLUSION

ESG after LAGB facilitates safe and clinically meaningful weight loss but is attenuated compared to primary ESG.

The Trajectory of Revisional Bariatric Surgery: Open to Laparoscopic to Robotic

Metabolic and bariatric surgery (MBS) is the most effective therapeutic intervention for patients with obesity, with sleeve gastrectomy (SG) being the most commonly performed primary MBS procedure. Long-term studies have demonstrated that 15-20% of patients require revisional bariatric surgery (RBS) due to weight-related issues or surgical complications. Despite the gold standard being laparoscopic revision, there are other available approaches such as open or robotic-assisted. An extensive literature review was performed for articles from their inception to February 2024. A descriptive review of MBS procedures (SG, Roux-en-Y gastric bypass (RYGB), single anastomosis duodeno-ileostomy (SADI) and biliopancreatic diversion-duodenal switch (BPD-DS)) was carried out to report and compare outcomes between primary and revisional bariatric surgery. A similar review was conducted to compare outcomes of revisional approaches (open, laparoscopic, robotic). RYGB remains the dominant RBS with a similar safety profile compared to revisional SADI and BPD-DS. In terms of the RBS surgical approach, all three options showed comparable short and long-term outcomes, with robotic RBS being associated with longer operative time and variable length of stay. Additional long-term studies are required to further validate our conclusions.

Limitations of the 2015-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database for emergency bariatric operations

BACKGROUND

The Metabolic and Bariatric Surgery Quality Improvement Project (MBSAQIP) is the largest bariatric surgery-specific clinical data set.

OBJECTIVES

In 2020, the definition of emergency cases was altered to include only revisional or conversion cases and not primary cases. The aim of this study was to examine how this change affects the utility of the data set for emergency case tracking.

SETTING

MBSAQIP database.

METHODS

Emergency cases were extracted from available MBSAQIP data (2015-2021). A comparison of co-morbidity profiles was done, specifically before and after the recent change to how "emergency" is defined in the data set.

RESULTS

Eleven thousand and twenty-nine of the 1,048,575 total cases were coded as "emergency cases." From 2015 to 2019, 10,574 emergency cases were performed (∼2115 cases/yr), markedly decreasing in 2020 and 2021 to 455 cases (∼228 cases/yr). Before 2020, the most common procedures were the unlisted procedure of the stomach (45.14%, n = 3101), gastric band removal (25.3%, n = 2676), and reduction of internal hernia (11.8%, n = 1244). Between 2020 and 2021, this distribution changed with Roux-en-Y gastric bypass (RYGB), the most common emergency procedure (29.23%, n = 133). As expected from the change that captured only revisional cases, the average operative length was greater between 2020 and 2021 (127.6 versus 86.5 min).

CONCLUSIONS

Capturable emergency cases declined in 2020, a trend related to changing the definition of emergency as part of MBSAQIP standards. This change excludes data on internal hernia reduction and does not likely reflect a real change in the prevalence of emergency bariatric cases. Because capture for emergency cases has diminished, so has any prior utility of using MBSAQIP data for studying emergency cases.

Third time's a charm: band to sleeve to bypass

BACKGROUND

Adjustable gastric bands (AGB) are frequently converted to sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) due to weight recurrence or band complications. Such conversions carry a higher-risk than primary procedures. Some patients undergo two conversions-from AGB to SG, and subsequently from SG to RYGB. This presents a unique situation with limited literature on indications and complication rates associated with these double conversions.

METHODS

We examined the 2020-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use File to evaluate conversions from AGB to SG and then to RYGB. Patient and operative characteristics, along with outcomes, were evaluated. Descriptive statistics were applied.

RESULTS

We identified 276 patients who underwent a conversion from AGB to SG and then to RYGB. The primary reason for the second conversion (SG to RYGB) was gastroesophageal reflux disease (GERD) at 55.1%, followed by inadequate weight loss or weight regain (IWL/WR) at 36.9%. The remaining reasons included dysphagia, nausea, vomiting, or others. Patients converted for IWL/WR demonstrated a higher baseline body mass index and prevalence of sleep apnea compared to other cohorts (both p < 0.001). Meanwhile, patients in the "other reasons" group had the highest rate of open surgical approaches (9.1%) and concurrent lysis of adhesions (p = 0.001 and p = 0.022), with correspondingly higher rates of anastomotic leak, reoperations, serious complications, and mortality.

CONCLUSIONS

Patients undergoing double conversions (AGB to SG to RYGB) do so primarily for GERD or IWL/WR. Further research is required to better define the optimal primary operation for each patient, aiming to reduce the necessity for multiple conversions.

Efficacy of endoscopic resuturing versus pharmacotherapy to treat weight recidivism after endoscopic sleeve gastroplasty

BACKGROUND AND AIMS

A subset of patients experience weight recidivism after primary endoscopic sleeve gastroplasty (P-ESG). Available options for management of weight regain include initiation of antiobesity medications (AOMs) or redo ESG (R-ESG). The comparative effectiveness of these options is not clear.

METHODS

This was a retrospective analysis of a prospectively maintained database of patients undergoing ESG. From 2013 to 2021, 79 patients who were started on AOM or underwent R-ESG for management of weight recidivism after P-ESG were included. The primary outcome of this study was final total body weight loss (TBWL) at the end of follow-up.

RESULTS

Fifty-five patients were started on AOM and 24 patients underwent R-ESG. Age, gender distribution, and baseline body mass index did not differ significantly between groups. The proportion of noncompliant patients (defined as patients who missed their first post-ESG follow-up visit) was significantly higher in the AOM group compared with the R-ESG group (67% vs 35%, P = .012). The additional TBWL after R-ESG was significantly (both clinically and statistically) better than after initiation of AOM (9.5% ± 7.2% vs 2.1% ± 8.6%, respectively; P = .001). Final TBWL clearly favored R-ESG over AOM for treatment of weight recidivism (19.9% ± 10.4% vs 13.6% ± 9.2%, P = .028).

CONCLUSIONS

R-ESG is an effective treatment to induce weight loss after experiencing weight recidivism. These results highlight an important advantage of ESG as a repeatable minimally invasive procedure.

Roux-en-Y gastric bypass and sleeve gastrectomy as revisional bariatric procedures after adjustable gastric banding: a retrospective cohort study

INTRODUCTION

The frequency of revisional bariatric surgery is increasing, but its effectiveness and safety are not yet fully established. The aim of our study was to compare short-term outcomes of primary (pRYGB and pSG) and revisional bariatric surgeries (rRYGB and rSG).

METHODS

We performed a retrospective cohort study assessing all patients submitted to primary and revisional (after a failed AGB) RYGB and SG in 2019. Each patient was followed-up at 6 months and 12 months after surgery. We compared pRYGB vs. rRYGB, pSG vs. rSG and rRYGB vs. rSG on weight loss, surgical complications, and resolution of comorbidities.

RESULTS

We assessed 494 patients, of which 18.8% had undergone a revisional procedure. Higher weight loss at 6 and 12 months was observed in patients undergoing primary vs. revisional procedures. Patients submitted to rRYGB lost more weight than those with rSG (%EWL 12 months = 82.6% vs. 69.0%, p < 0.001). Regarding the resolution of obesity-related comorbidities, diabetes resolution was more frequent in pRYGB than rRYGB (54.2% vs. 25.0%; p = 0.038). Also, 41.7% of the patients who underwent rRYGB had dyslipidemia resolution vs. 0% from the rSG group (p = 0.035). Dyslipidemia resolution was also more common in pSG vs. rSG (68.6% vs. 0.0%; p = 0.001). No significant differences in surgical complications were found.

CONCLUSION

Revisional bariatric surgery is effective and safe treating obesity and related comorbidities after AGB. Primary procedures appear to be associated with better weight loss outcomes. Further prospective studies are needed to better understand the role of revisional bariatric surgery.

Bariatric surgery provision in response to the COVID-19 pandemic: retrospective cohort study of a national registry

BACKGROUND

When surgery resumed following the outbreak of the COVID-19 pandemic, guidelines recommended the prioritization of patients with greater obesity-related co-morbidities and/or higher body mass index.

OBJECTIVE

The aim of this study was to record the effect of the pandemic on total number, patient demographics, and perioperative outcomes of elective bariatric surgery patients in the United Kingdom.

SETTING AND METHODS

The United Kingdom National Bariatric Surgical Registry was used to identify patients who underwent elective bariatric surgery during the pandemic (1 yr from April 1, 2020). Characteristics of this group were compared with those of a pre-pandemic cohort. Primary outcomes were case volume, case mix, and providers. National Health Service cases were analyzed for baseline health status and perioperative outcomes. Fisher exact, χ2, and Student t tests were used as appropriate.

RESULTS

The total number of cases decreased to one third of pre-pandemic volume (8615 to 2930). The decrease in operating volume varied, with 36 hospitals (45%) experiencing a 75%-100% reduction. Cases performed in the National Health Service fell from 74% to 53% (P < .0001). There was no change in baseline body mass index (45.2 ± 8.3 kg/m2 from 45.5 ± 8.3 kg/m2; P = .23) or prevalence of type 2 diabetes (26% from 26%; P = .99). Length of stay (median 2 d) and surgical complication rate (1.4% from 2.0%; relative risk = .71; 95% CI .45-1.12; P = .13) were unchanged.

CONCLUSIONS

In the context of a dramatic reduction in elective bariatric surgery due to the COVID-19 pandemic, patients with more severe co-morbidities were not prioritized for surgery. These findings should inform preparation for future crises.

Revisional Bariatric Surgery due to Complications: Indications and Outcomes

BACKGROUND

The increasing prevalence of bariatric procedures has led to a surge in revisional surgeries. Failure of bariatric surgery can be attributed to inadequate weight loss or complications necessitating revisional surgery. In this study, we investigated the indications and outcomes of revisional surgery due to complications following primary bariatric surgery.

MATERIALS AND METHODS

A retrospective study was conducted using data from the Tehran Obesity Treatment Study, which included patients who underwent revisional bariatric surgery between March 2013 and September 2021 due to complications following primary bariatric surgery.

RESULTS

Of the 5382 patients who underwent primary bariatric surgery (sleeve gastrectomy, one-anastomosis gastric bypass, and Roux-en-Y gastric bypass), 203 (3.70%) required revisional surgery, with 37 cases performed due to surgical complications. The indications of revisional operations were gastroesophageal reflux disease (GERD) (n=17, 45.9%), protein-calorie malnutrition (PCM) (n=14, 37.8%), unexplained abdominal pain (n=5, 13.5%), and phytobezoar (n=1, 0.03%). In the postoperative follow-up, most patients exhibited improvement in signs and symptoms related to underlying causes. However, eight patients experienced early or late complications of grade III or higher according to the Clavien-Dindo classification, with one death resulting from liver failure.

CONCLUSION

Revisional bariatric surgery may effectively address complications from primary bariatric surgery, with the majority of patients experiencing improvements in symptoms. While the overall incidence of revisional surgery due to complications is relatively low, our findings suggest that GERD and PCM are the most common indications for revisional surgery.

Revisional surgery after restrictive surgery: midterm outcomes of a tertiary center

INTRODUCTION

Revisional bariatric surgery (RBS) is a challenging type of procedure for the surgeons due to its specific morbidity and efficiency. The RBS has a higher prevalence nowadays and this study may help to improve scarce data upon this specific topic.

METHODS

Data from 252 patients undergoing RBS after laparoscopic adjustable gastric banding (LAGB) or laparoscopic sleeve gastrectomy (LSG) between 2005 and 2019, were analyzed at 2 years of follow up. A subgroup analysis of third procedure was also performed.

RESULTS

Overall morbidity occurred in 35 patients (37%) in the LSG group and 40 patients (25%) in the LAGB group (p = 0.045). At 2 years of RBS, mean weight was 92.8 ± 26.7 kg, BMI was 33.1 ± 8.56 kg/m2 for patients who had RBS after LSG. When RBS was performed after LAGB, mean weight at 2 years was 90.1 ± 20.7 kg and BMI was 32.5 ± 6.45 kg/m2. TWL for RBS performed after LSG was 12.7 ± 16.4% versus 25.5 ± 10.3% after LAGB (p < 0.001).

CONCLUSION

RBS after LSG seems to lead to higher overall morbidity whereas RBS after LAGB lead to more perioperative issues.

The analysis of factors increasing the odds for type 2 diabetes mellitus remission following re-do bariatric surgery after laparoscopic sleeve gastrectomy- cohort study

INTRODUCTION

Metabolic/bariatric surgery is the only proven treatment for type 2 diabetes mellitus (T2D) with curative intent. However, in a number of patients, the surgery is not effective or they may experience a relapse. Those patients can be offered re-do bariatric surgery (RBS).

PURPOSE

The study aimed to determine factors increasing the odds for T2D remission one year after RBS following primary laparoscopic sleeve gastrectomy.

METHODS

A multicenter retrospective cohort study was conducted between January 2010 and January 2020, which included 12 bariatric centers in Poland. The study population was divided into groups: Group 1- patients with T2D remission after RBS (n = 28) and Group 2- patients without T2D remission after RBS (n = 49). T2D remission was defined as HBA1c < 6.0% without glucose-lowering pharmacotherapy and glycemia within normal range at time of follow-up that was completed 12 months after RBS.

RESULTS

Fifty seven females and 20 males were included in the study. Patients who achieved BMI < 33 kg/m2 after RBS and those with %EBMIL > 60.7% had an increased chance of T2D remission (OR = 3.39, 95%CI = 1.28-8.95, p = 0.014 and OR = 12.48, 95%CI 2.67-58.42, p = 0.001, respectively). Time interval between primary LSG and RBS was significantly shorter in Group 1 than in Group 2 [1 (1-4) vs. 3 (2-4) years, p = 0.023].

CONCLUSIONS

Shorter time interval between LSG and RBS may ease remission of T2D in case of lack of remission after primary procedure. Significant excess weight loss seems to be the most crucial factor for T2D remission.

BRAZILIAN MULTI-SOCIETY POSITION STATEMENT ON EMERGING BARIATRIC AND METABOLIC SURGICAL PROCEDURES

This Brazilian multi-society position statement on emerging bariatric and metabolic surgical procedures was issued by the Brazilian Society of Bariatric and Metabolic Surgery (SBCBM), the Brazilian College of Digestive Surgery (CBCD), and the Brazilian College of Surgeons (CBC). This document is the result of a Brazilian Emerging Surgeries Forum aimed at evaluating the results of surgeries that are not yet listed in the Federal Council of Medicine (CFM), the regulatory agency that oversees and regulates medical practice in Brazil. The Forum integrated more than 400 specialists and academics with extensive knowledge about bariatric and metabolic surgery, representing the three surgical societies: SBCBM, CBC, and CBCD. International speakers participated online and presented their experiences with the techniques under discussion, emphasizing the regulatory policies in their countries. The indications for surgery and the subsequent procedures were carefully reviewed, including one anastomosis gastric bypass (OAGB), single anastomosis duodeno-ileal with sleeve gastrectomy (SADI-S or OADS), sleeve gastrectomy with transit bipartition (SGTB), and sleeve gastrectomy with ileal interposition (SGII). The recommendations of this document are based on an extensive literature review and discussions among bariatric surgery specialists from the three surgical societies. We concluded that patients with a body mass index over 30 kg/m2 may be candidates for metabolic surgery in the presence of comorbidities (arterial hypertension and type 2 diabetes) with no response to clinical treatment of obesity or in the control of other associated diseases. Regarding the surgical procedures, we concluded that OAGB, OADS, and SGTB are associated with low morbidity rates, satisfactory weight loss, and resolution of obesity-related comorbidities such as diabetes and arterial hypertension. SGII was considered a good and viable promising surgical alternative technique. The recommendations of this statement aim to synchronize our societies with the sentiments and understandings of most of our members and also serve as a guide for future decisions regarding bariatric surgical procedures in our country and worldwide.

One- versus two-stage conversions of adjustable gastric bands: an analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database

BACKGROUND

Laparoscopic adjustable gastric bands (AGB) are converted at high rates to secondary bariatric procedures. The available literature on the safety of converting in 1- versus 2-stage processes has not included large databases.

OBJECTIVE

To evaluate the safety of a 1- versus 2-stage conversion of AGB.

SETTING

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), United States.

METHODS

The MBSAQIP database for the years 2020 and 2021 was evaluated. One-stage AGB conversions were identified using Current Procedural Terminology codes and database variables. Multivariable analysis was performed to determine whether 1- or 2-stage conversions were associated with 30-day serious complications.

RESULTS

There were 12,085 patients who underwent conversion from previous AGB to sleeve gastrectomy (SG) (63.0%) or Roux-en-Y gastric bypass (RYGB) (37.0%), of whom 41.0% underwent conversion in 1 stage and 59.0% in 2 stages. Patients who underwent 2-stage conversions had higher body mass indexes. Rates of serious complications were higher for patients undergoing RYGB compared with SG (5.2% versus 3.3%, P < .001) but were similar between 1-stage and 2-stage conversions in both cohorts. In both cohorts, there were similar rates of anastomotic leaks, postoperative bleeding, reoperation, and readmissions. Mortality was rare and similar between conversion groups.

CONCLUSIONS

There was no difference in outcomes or complications in 30 days between 1- and 2-stage conversions of AGB to RYGB or SG. Conversions to RYGB have higher complication and mortality rates than to SG, but there was no statistically significant difference between staged procedures. One- and 2-stage conversions from AGB are equivalent in safety.

Weight loss and clinical outcomes following primary versus secondary Roux-en-Y gastric bypass: a multi-institutional experience

BACKGROUND

Revisional bariatric surgeries are increasing for weight recurrence and return of co-morbidities. Herein, we compare weight loss and clinical outcomes following primary Roux-en-Y Gastric Bypass (P-RYGB), adjustable gastric banding to RYGB (B-RYGB), and sleeve gastrectomy to RYGB (S-RYGB) to determine if primary versus secondary RYGB offer comparable benefits.

METHODS

Participating institutions' EMRs and MBSAQIP databases were used to identify adult patients who underwent P-/B-/S-RYGB from 2013 to 2019 with a minimum one-year follow-up. Weight loss and clinical outcomes were assessed at 30 days, 1 year, and 5 years. Our multivariable model controlled for year, institution, patient and procedure characteristics, and excess body weight (EBW).

RESULTS

768 patients underwent RYGB: P-RYGB n = 581 [75.7%]; B-RYGB n = 106 [13.7%]; S-RYGB n = 81 [10.5%]. The number of secondary RYGB procedures increased in recent years. The most common indications for B-RYGB and S-RYGB were weight recurrence/nonresponse (59.8%) and GERD (65.4%), respectively. Mean time from index operation to B-RYGB or S-RYGB was 8.9 and 3.9 years, respectively. After adjusting for EBW, 1 year %TWL (total weight loss) and %EWL (excess weight loss) were greater after P-RYGB (30.4%, 56.7%) versus B-RYGB (26.2%, 49.4%) or S-RYGB (15.6%, 37%). Overall comorbidity resolution was comparable. Secondary RYGB patients had a longer adjusted mean length of stay (OR 1.17, p = 0.071) and a higher risk of pre-discharge complications or 30-day reoperation.

CONCLUSION

Primary RYGB offers superior short-term weight loss outcomes compared to secondary RYGB, with decreased risk of 30-day reoperation.

Contemporary medical, device, and surgical therapies for obesity in adults

The goal of obesity management is to improve health. Sustained weight loss of more than 10% overall bodyweight improves many of the complications associated with obesity (eg, prevention and control of type 2 diabetes, hypertension, fatty liver disease, and obstructive sleep apnoea), as well as quality of life. Maintenance of weight loss is the major challenge of obesity management. Like all chronic diseases, managing obesity requires a long-term, multimodal approach, taking into account each individual's treatment goals, and the benefit and risk of different therapies. In conjunction with lifestyle interventions, anti-obesity medications and bariatric surgery improve the maintenance of weight loss and associated health gains. Most available anti-obesity medications act on central appetite pathways to reduce hunger and food reward. In the past 5 years, therapeutic advances have seen the development of targeted treatments for monogenic obesities and a new generation of anti-obesity medications. These highly effective anti-obesity medications are associated with weight losses of more than 10% of overall bodyweight in more than two-thirds of clinical trial participants. Long-term data on safety, efficacy, and cardiovascular outcomes are awaited. Long-term studies have shown that bariatric surgical procedures typically lead to a durable weight loss of 25% and rapid, sustained improvements in complications of obesity, although they have not yet been compared with new-generation highly effective anti-obesity medications. Further work is required to determine optimal patient-specific treatment strategies, including combinations of lifestyle interventions, anti-obesity medications, endoscopic and bariatric surgical procedures, and to ensure equitable access to effective treatments.

Comparison of early post-operative complications in primary and revisional laparoscopic sleeve gastrectomy, gastric bypass, and duodenal switch MBSAQIP-reported cases from 2015 to 2019

BACKGROUND

Sleeve gastrectomy (SG) is now the most performed bariatric surgery, though gastric bypass (GB) and duodenal switch (DS) remain common, especially as conversion/revision (C/R) procedures. This analysis compared early postoperative outcomes of primary and C/R laparoscopic SG to DS and GB; and primary procedures of each vs C/R counterparts.

METHODS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) dataset was queried for SG, GB, and DS cases from 2015 to 2019. Multivariable logistic regression calculated crude and adjusted odds ratios for surgical site infection (SSI), reoperation, and readmission at 30 days in two initial comparisons: (1) primary SG vs DS or GB and (2) C/R SG vs DS or GB. A secondary analysis compared primary GS, GB, or DS with C/R counterparts. Models were adjusted for confounding demographics and comorbidities.

RESULTS

Of 755,968 primary cases, most were SG (72.8%), followed by GB (26.3%), then DS (0.9%). Compared to SG, GB and DS demonstrated higher odds of SSI (aOR 3.02 [2.84, 3.2]), readmission (aOR 1.97 [1.92, 2.03]), and reoperation (aOR 2.74 [2.62, 2.86]), respectively. Of 68,716 C/R cases, SG was most common (43.2%), followed by GB (37.5%), then DS (19.2%). C/R GB and DS demonstrated greater risk of SSI (aOR 2.28 [1.98, 2.62]), readmission (aOR 2.10 [1.94, 2.27]), and reoperation (aOR 2.3 [2.04, 2.59]) vs SG, respectively. C/R SG and DS demonstrated greater risk of SSI (OR 2.09 [1.66, 2.63]; 1.63 [1.24, 2.14), readmission (OR 1.13 [1.02, 1.26]), and reoperation (OR 1.27 [1.06, 1.52]; 1.58 [1.24, 2.0]), vs primary procedures. C/R DS demonstrated greater risk of SSI (OR 1.23 [1.66, 2.63]).

CONCLUSIONS

Early complications are comparable between GB and DS, and greater than SG. In C/R procedures, GB and DS demonstrate greater risk than SG. Overall, C/R procedures demonstrate greater risk of most, but not all, early postoperative complications.

Analysis of the risk factors for perioperative morbidity after laparoscopic revisional bariatric procedures: results from the multicenter Polish Revision Obesity Surgery Study

BACKGROUND

The growing number of primary bariatric operations has led to an increase in demand for revision surgeries. Higher numbers of revisional operations are also observed in Poland, yet their safety and efficacy remain controversial because of a lack of current recommendations and guidelines.

OBJECTIVE

To review risk factors influencing perioperative morbidity.

METHODS

A retrospective study was conducted to analyze the results of surgical treatment among 12 Polish bariatric centers. Inclusion criteria were laparoscopic revisional bariatric surgeries and patients ≥18 years of age. The study included 795 patients, of whom 621 were female; the mean age was 47 years (range: 40-55 years).

RESULTS

Perioperative morbidity occurred in 92 patients (11.6%) enrolled in the study, including 76 women (82.6%). The median age was 45 years (range: 39-54 years). Statistically significant risk factors in univariate logistic regression models for perioperative complications were the duration of obesity, revisional surgery after Roux-en-Y gastric bypass (RYGB) or adjustable gastric band (AGB), difference in body mass index before revisional surgery and the lowest achieved after primary surgery, and postoperative morbidity of the primary surgery as the cause for revisional bariatric surgery. These factors were included in the multivariate regression model. Revisional surgery after AGB (odds ratio [OR] = 2.18; 95% confidence interval [CI]: 1.28-3.69; P = .004), revisional surgery performed after RYGB (OR = 6.52; 95% CI: 1.98-21.49; P = .002), and revisions due to complication of the primary surgery (OR = 1.89; 95% CI: 1.06-3.34; P = .030) remained independent risk factors for perioperative morbidity.

CONCLUSION

Revisional operations after RYGB or AGB and those performed because of postoperative morbidity after primary surgery as the main cause for revisional surgery were associated with a significantly increased risk of postoperative morbidity.

Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass to Enhance Weight Loss: Single Enterprise Mid-Term Outcomes and Literature Review

Background

Suboptimal weight loss (SWL) occurs up to 30% after sleeve gastrectomy (SG). Conversion to Roux-en-Y gastric bypass (cRYGB) has shown heterogeneous results in terms of additional weight loss and resolution of weight-related comorbidities. We aim to evaluate mid-term outcomes of cRYGB specifically for SWL after SG.

Methods

All patients who underwent cRYGB for SWL from April 2010 to June 2019 from prospective registries at three affiliated tertiary care centers were retrospectively reviewed. Patients who underwent revision or conversion for complications were excluded. Mixed-effects and polynomial regression models were used to evaluate weight loss results after conversion.

Results

Thirty-two patients underwent cRYGB from SG. About 68.7% were women with mean age of 46.6 years. Mean body mass index (BMI) before SG was 55.3 kg/m². Before conversion, mean BMI was 44.5 kg/m² with 17.3% total weight loss (TWL). All procedures were completed laparoscopically in a median surgical time of 183 min. Three major complications occurred (9.3%), one gastrojejunal (GJ) leak and two reoperations. Four cases (12.5%) of GJ stenosis were diagnosed. No mortality was registered. Mean follow-up time was 24 months and patients had 36 kg/m² mean BMI, 17.4% TWL, 27.2% had BMI >35 kg/m².

Conclusions

cRYGB after SG for SWL showed good mid-term results, better than those reported in literature.

Does endoscopy at the time of revisional bariatric surgery decrease complication rates? an analysis of the NSQIP database

BACKGROUND

Endoscopy is performed routinely during bariatric surgery. It is often used for provocative testing and intraluminal inspection during Roux-en-Y gastric bypass (RNYGB) and sleeve gastrectomy (SG). Recent publications would indicate about one-quarter of bariatric cases are performed with concurrent endoscopy, resulting in a slight increase in time but no increase in complications within 30 days compared with cases where no endoscopy is performed. Do these results persist for endoscopy during revisional bariatric surgery (RBS)?

METHODS

An analysis of the American College of Surgeons National Surgical Quality Initiative Program (NSQIP) was conducted for the years 2005-2017. Seventeen postoperative outcomes were analyzed in this database. A 1:1 propensity score matching analysis was completed for 13 patient comorbidities and demographics. A McNemar's test for paired categorical variables and a paired t-test for continuous variables were completed, with a significant P value of 0.05. The results were reported as the frequency and percentage for categorical variables and the mean (± standard deviation) for continuous variables.

RESULTS

A total of 7249 RBS cases were identified. After propensity score matching for patient comorbidities and demographics 2329 cases remained. Esophagogastroduodenoscopy (EGD) was performed in 375 (16%) of these patients. There were no differences in complication rates between the two groups.

CONCLUSIONS

Similar to non-revisional bariatric surgery, there is no difference in 30-day postoperative complications when endoscopy is performed in RBS. Endoscopy is performed in about one-sixth of RBS cases.

Analysis of the Factors Contributing to Bariatric Success After Laparoscopic Redo Bariatric Procedures: Results from Multicenter Polish Revision Obesity Surgery Study (PROSS)

INTRODUCTION

With continuously growing number of redo bariatric surgeries (RBS), it is necessary to look for factors determining success of redo-surgeries.

PATIENTS AND METHODS

A retrospective cohort study analyzed consecutive patients who underwent RBS in 12 referral bariatric centers in Poland from 2010 to 2020. The study included 529 patients. The efficacy endpoints were percentage of excessive weight loss (%EWL) and remission of hypertension (HT) and/or type 2 diabetes (T2D).

RESULTS

Group 1: weight regain Two hundred thirty-eight of 352 patients (67.6%) exceeded 50% EWL after RBS. The difference in body mass index (BMI) pre-RBS and lowest after primary procedure < 10.6 kg/m2 (OR 2.33, 95% CI: 1.43-3.80, p = 0.001) was independent factor contributing to bariatric success after RBS, i.e., > 50% EWL. Group 2: insufficient weight loss One hundred thirty of 177 patients (73.4%) exceeded 50% EWL after RBS. The difference in BMI pre-RBS and lowest after primary procedure (OR 0.76, 95% CI: 0.64-0.89, p = 0.001) was independent factors lowering odds for bariatric success. Group 3: insufficient control of obesity-related diseases Forty-three of 87 patients (49.4%) achieved remission of hypertension and/or type 2 diabetes. One Anastomosis Gastric Bypass (OAGB) as RBS was independent factor contributing to bariatric success (OR 7.23, 95% CI: 1.67-31.33, p = 0.008), i.e., complete remission of HT and/or T2D.

CONCLUSIONS

RBS is an effective method of treatment for obesity-related morbidity. Greater weight regain before RBS was minimizing odds for bariatric success in patients operated due to weight regain or insufficient weight loss. OAGB was associated with greater chance of complete remission of hypertension and/or diabetes.

The rising tide of revisional surgery: tracking changes in index cases among bariatric-accredited fellowships

Background

The field of bariatric surgery has seen peaks and troughs in the types of metabolic procedures performed. Our primary aim was to evaluate bariatric case volumes among fellows enrolled in bariatric Fellowship Council (FC)-accredited programs. Our secondary aim was to assess trends in revisional case volumes.

Methods

We reviewed de-identified FC case logs for all bariatric surgery-accredited programs from 2010 through 2019. The number of primary sleeve gastrectomy, gastric band, gastric bypass, biliopancreatic diversion, and major revisional bariatric surgical procedures (defined as a revision with creation of a new anastomosis) were graphed for each academic year. Fellows were stratified into quartiles based on the number of revisional operations per year and graphed over ten years. Volumes of primary gastric bypass, major revisions, and total anastomotic cases were compared over time using ANOVA with p < 0.05 considered significant.

Results

Case volumes for 822 fellows were evaluated. Sleeve gastrectomy had a significant surge in 2010 and plateaued in 2016. The fellows’ number of primary gastric bypasses had a non-significant decrease from 84 to 75 cases/fellow from 2010 to 2019. This decrease was offset by a significant increase in major revisional surgery from 8 to 19 cases/fellow. As a result, the number of anastomotic cases did not change significantly over the study time period. Interestingly, as revisional volume has grown, the gap between quartiles of fellowship programs has widened with the 95th percentile growing at a much faster rate than lower quartiles.

Conclusion

The volume of bariatric procedures performed in the last decade among FC fellows follows similar trends to national data. Major revisional cases have doubled with the most robust growth isolated to a small number of programs. As revisional surgery continues to increase, applicants interested in a comprehensive bariatric practice should seek out training programs that offer strong revisional experience.

Secondary Bariatric Surgery-Does the Type of Index Procedure Affect Outcomes After Conversion?

BACKGROUND

Although revisions account for 17% of cases performed at bariatric centers of excellence, scarce data exists on whether index operation type influences outcomes after secondary operations.

OBJECTIVE

We designed a study investigating the effect of primary procedure type on weight loss and perioperative complications after conversion bariatric surgery.

SETTING

Tertiary Referral Hospital, USA.

METHODS

We performed a retrospective review of patients undergoing conversion from sleeve gastrectomy (SG) or adjustable gastric band (AGB) to Roux-en-Y gastric bypass (RYGB) from 2009 to 2019. Post-operatively, we measured short- and medium-term complications and changes in body weight at various time points. Univariate and regression analyses were performed.

RESULTS

Forty-two (SG) patients and 116 (AGB) patients underwent conversion to RYGB, most commonly for GERD (57.1%) in SG patients vs. weight regain (77.6%) in AGB patients. Mean pre-conversion BMI was 36.7 kg/m² (SG) vs 43.8 kg/m² (AGB). Mean time to conversion (months) was 52.9 (SG) vs 94.7 (AGB). Complication rate was 9.5% (SG) vs 6% (AGB) at 30 days (p = 0.48) and 31%(SG) vs 14.5% (AGB) (p = 0.02) at 2 years. Mean post conversion %TWL was 11.6% (SG) vs 24.6% (AGB) in patients with GERD/dysphagia (p = 0.014) and 20.7% (SG) vs 27.6% (AGB) in patients converted for weight-related reasons (p = 0.027) at 1 year. Overall mean %TWL was 13.2% (SG) vs 24.7% (AGB) at 2 years (p < 0.0035).

CONCLUSION

After conversion to RYGB, patients with AGB experience better short- and medium-term weight loss than those with SG, even after accounting for conversion indications. SG to RYGB conversions have a higher resolution of reflux disease.

Bariatric Surgery Conversions in MBSAQIP Centers: Current Indications and Outcomes

BACKGROUND

The demand for revisional bariatric surgery has increased, and bariatric conversions (BC) to a different procedure represent most of the revisional cases. The 2020 Metabolic and Bariatric Surgery Accreditfnation and Quality Improvement Program (MBSAQIP) database was expanded to include additional variables on BC. This study aims to analyze the indications and outcomes of BC.

METHODS

A retrospective analysis of the 2020 MBSAQIP database was performed. Patients who underwent BC were included in the analysis. Index procedures, rates, and indications for BC of the different bariatric operations were described. Outcomes of the most frequent BC were analyzed.

RESULTS

A total of 168,548 bariatric surgeries were done; 20,387 (12.1%) were revisional, and from those 15,031 (73.7%) were BC. The most converted index operations were sleeve gastrectomy (SG) (49.3%) and adjustable gastric banding (AGB) (45.9%). The most frequent conversions were SG to Roux-en-Y gastric bypass (RYGB) (40.3%) for gastroesophageal reflux disease (GERD) (54.2%) and weight loss failure (WLF) (35.8%), AGB to SG (27%) or RYGB (16.2%) for WLF (67% and 61.3%, respectively), and SG to biliopancreatic diversion with duodenal switch (3.2%) or single anastomosis duodeno-ileal bypass (2%) for WLF (91.2% and 92.4%, respectively). Postoperative overall morbidity, serious morbidity, reoperation, and mortality rates ranged from 5.3 to 20.8%, 2.3 to 19.2%, 1.5 to 10%, and 0 to 0.8%, respectively.

CONCLUSIONS

BC represents the most frequent revisional bariatric procedure. GERD and WLF are the main causes for BC. Further research is needed to define the ideal BC according to the index procedure and indication.

Mid-term quality of life after gastric band removal and single-stage conversion to gastric bypass: a single-center cohort study

BACKGROUND

Revision surgeries in patients with failed gastric banding including band removal are increasingly necessary. However, long-term outcomes after band removal alone are unsatisfactory due to weight regain and limited improvement in quality of life. This study aimed to report mid-term quality of life outcomes after gastric band removal and single-stage conversion to Roux-en-Y gastric bypass.

METHODS

Data of 108 patients who underwent conversion surgery from 2011 to 2017 were extracted from a prospective database and retrospectively analyzed. During follow-up visits, physical and laboratory data as well as quality of life questionnaires were obtained.

RESULTS

Postoperative mean Moorehead score increased significantly after 1 year (1.62 ± 0.86, p < 0.001) and after 5 years (1.55 ± 0.84, p < 0.001) compared to baseline values (0.72 ± 1.1). The mean follow-up time was 53 months. Moorehead scores at 1, 2, and 5 years postoperative were available in 75% (n = 81), 71% (n = 77), and 42% (n = 45) of cases, respectively. Mixed ANOVA analysis showed a significantly superior increase in Moorehead score in males (p = 0.024). No other significant predictors were identified. Lasting BMI reduction (- 4.6 to 33.0 ± 6.7 kg/m², p < 0.001) and weight loss (- 12.9% (- 13.6 kg), p < 0.001) 5 years after conversion surgery were seen. Postoperative complications occurred in 35% (n = 38) of patients with a re-operation rate of 30.5% (n = 33).

CONCLUSION

The current study shows that band removal with single-stage gastric bypass in patients with failed gastric banding leads to a lasting improvement in quality of life and may be the rescue procedure of choice in this setting.

Minimally Invasive Revisional Bariatric Surgery in a MBSAQIP Accredited High-Volume Center

Background

With the rising number of bariatric surgeries performed annually, there has also been an increase in revisional bariatric surgeries (RBS). The aim of this study is to evaluate the safety and postoperative outcomes of RBS performed with a minimally invasive approach.

Methods

Retrospective analysis on a prospectively collected database of patients who underwent minimally invasive RBS between 2012 and 2019. Primary endpoints were conversion rate, major morbidity, mortality, and 30-day reoperation rate. Comparative analysis of laparoscopic adjustable gastric banding (LAGB) conversion to sleeve gastrectomy (SG) vs. conversion to Roux-en-Y gastric bypass (RYGB) was performed.

Results

A total of 221 patients underwent minimally invasive RBS, 137 (62%) laparoscopically and 84 (38%) robotically. The most common RBS were LAGB to SG (59.3%) and LAGB to RYGB conversions (16.7%). The main indication was weight loss failure (88.7%). Conversion rate, major morbidity, and mortality were 0.9, 3.2, and 0.4%, respectively. Urgent reoperation was required in 3.2% of cases. Total weight loss at 1 and 2-years follow- were 14.3 and 17.3%, respectively. Comparative analysis of LAGB conversion to SG vs. RYGB showed similar major morbidity (SG: 2.3% vs. RYGB 0%, p = 1). Greater total weight loss was achieved in LAGB to RYGB conversions at 1-year (SG: 14.8% vs. RYGB 25.3%, p < 0.001).

Conclusions

Minimally invasive RBS can be performed safely in a broad patient population with low conversion and complication rates, and improved weight loss outcomes. LAGB to RYGB conversions are associated with greater weight loss. Further randomized trials are needed to draw more conclusive recommendations.

Pharmacologic management of weight regain following bariatric surgery

While bariatric surgery restults in significant long-term weight loss for most patients with obesity, post-surgical weight gain affects a considerable percentage of patients to varying degrees of severity. Furthermore, a small but significant percentage of patients experience inadequate post-surgical weight loss. Although many studies have examined the role of anti-obesity medications to address post-operative weight regain, an evidence-based consensus has not yet been achieved because of the heterogeneity of populations studied and the studies themselves. Observational studies in the post-bariatric surgery population consistently demonstrate the benefit of medical weight management after bariatric surgery, with most evidence highlighting liraglutide, topiramate, and phentermine/topiramate. New anti-obesity medications are anticipated to be helpful for post-surgical weight optimization given their efficacy in the non-surgical population.

Stapler Malfunctions in Bariatric Surgery: An Analysis of the MAUDE Database

Background

Staple line leaks are a serious problem in bariatric surgery and a major cause of serious morbidity and mortality. Adverse events caused by medical devices are reported to the Food and Drug Administration which maintains the Manufacturer and User Facility Device Experience (MAUDE) database. We examined adverse stapler events reported to the MAUDE database, specifically with regards to bariatric surgery.

Methods

The MAUDE database was queried for adverse events caused by staplers between January 1, 2018 - December 31, 2020; events reported by Intuitive, Ethicon, and Medtronic/Covidien; and limited our search to "gastric bypass", "sleeve gastrectomy", "stapler malfunction" combined with each company.

Results

There were 883 adverse events reported for Medtronic, 353 for Ethicon, and 35 for Intuitive. Approximately 3.5 million staple reloads sold in the study period. The reported misfire rate for Medtronic was 0.04% and for Ethicon was 0.02%. Data for Intuitive was unavailable. The most common reported event for Medtronic was failure to fire (n = 349), followed by misfire (n = 186). For Ethicon, the most common event was failure to fire (n = 146), followed by mechanical problems (n = 27). The most common event with the Intuitive stapler was leak (n = 10) and bleeding from staple line (n = 8).

Conclusions

Stapler malfunction is a very rare event in metabolic and bariatric surgery. All of the major stapler producers have transitioned to powered staplers with excellent safety profiles. Open and honest reporting about stapler malfunction is essential to determine the true safety of these ubiquitous devices.

Impact of the calibration bougie diametre during laparoscopic sleeve gastrectomy on the rate of postoperative staple-line leak (BOUST): study protocol for a multicentre randomized prospective trial

Background

Laparoscopic sleeve gastrectomy (LSG) has become an increasing bariatric procedure. The basic principle is to create a narrow stomach along the lesser curvature, using a calibration bougie as a template to perform a vertical partial gastrectomy, resecting the greater curvature and fundus of the stomach. The most common postoperative complication is gastric leak from the staple line, observed in approximately 3% of cases, which can result in long and incapacitating treatment. The diametre of the bougie used to calibrate the remnant stomach could impact the rate of postoperative gastric leak, a higher diametre being correlated with a lower risk of leak, without lowering long-term weight loss. This is the first randomized trial to compare the outcomes of LSG regarding the use of two different bougie diametres on postoperative gastric leak and mid-term weight loss.

Methods

Bougie Sleeve Trial (BOUST) is a superiority single-blinded randomized national trial, involving 17 centres. Participants will be randomized into two groups. LSG will be performed using a 48-Fr diametre calibration bougie in the experimental group and a standard care (34 to 38-Fr diametre) calibration bougie in the control group. Both groups will take part in a 2-year postoperative follow-up to assess postoperative gastric leak rate and weight loss and quality of life evolution.

Discussion

This study protocol will allow the investigators to determine if the use of a larger calibration bougie during LSG is associated with lower postoperative gastric leak occurrence without impairing mid-term weight loss and quality of life. The results of this trial will provide important data on patient safety and promote best practice for LSG procedures.

Trial registration

ClinicalTrials.govNCT02937649. Registered on 18 October 2016

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05734-3.

It is really time to retire laparoscopic gastric banding? Positive outcomes after long-term follow-up: the management is the key

After the initial widespread diffusion, laparoscopic adjustable gastric banding (LAGB) has been progressively abandoned and laparoscopic sleeve gastrectomy (LSG) has become the worldwide most adopted procedure. Nevertheless, recent reports raised concerns about the long-term weight regain after different bariatric techniques. Considering the large LAGB series recorded in our multicentric bariatric database, we analysed the anthropometric and surgical outcomes of obese patients underwent LAGB at a long-term follow-up, focusing on LAGB management. Between January 2008 to January 2018, demographics, anthropometric and post-operative data of obese patients undergone LAGB were retrospectively evaluated. To compare the postoperative outcomes, the cohort was divided in two groups according to the quantity of band filling (QBF): low band filling group (Group 1) with at most 3 ml of QBF, and patients in the high band filling group (Group 2) with at least 4 ml. 699 obese patients were considered in the analysis (351 in Group 1 and 348 in Group 2). Patients in Group 1 resulted significantly associated (p < 0.05) to higher % EWL and quality of life score (BAROS Score), 49.1 ± 11.3 vs 38.2 ± 14.2 and 5.9 ± 1.8 vs 3.8 ± 2.5, respectively. Moreover, patients with lower band filling (Group 1) complained less episodes of vomiting, epigastric pain and post-prandial reflux and significantly decreased slippage and migration rate (p < 0.001 for all parameters). LAGB is a safe and reversible procedure, whose efficacy is primarily related to correct postoperative handling. Low band filling and strict follow-up seem the success' key of this technique, which deserves full consideration among bariatric procedures.

9-step magnetic assisted conversion from sleeve gastrectomy to roux-en-Y gastric bypass and hiatoplasty by single-port: Case report

RYGB represents one of the best alternatives for weight loss in obese patients achieving a weight loss of up to 60% and a resolution of comorbidities of 70%. Revision surgery contemplates multiple techniques including the conversion from one surgical technique to another, structural changes to the primary technique, among others. GERD is now a long-term problem for patients who have undergone LGS. With this case report, we show the feasibility and viability of making this revisional procedure with magnetic assistance and single-port device. (ClinicalTrials.govNCT04945304). A 32-year-old female patient underwent a SG in September 2018 with a BMI of 30 Kg/m² and no medical history of comorbidities. One year after the surgery the patient reached a BMI of 23,9 Kg/m². In 2020 the multidisciplinary team made a diagnosis of intractable GERD and for that reason, it was decided to perform a conversion surgery to RYGB by single port technique and magnetic assistance. The purpose of this case report is to expose the viability to perform a revisional bariatric surgery with magnetic assistance acting like a second surgical assistant in the steps of the procedure and utilizing a single port device to make fewer before incisions, reduce postoperative pain, length of hospital stay and better cosmesis with a safety approach. We can demonstrate the technical feasibility and safety of performing a conversion surgery of LGS to RYGB and hiatoplasty with magnetic assistance by single port and also demonstrate that the magnetic system serves beyond the liver retraction.

•

Magnetic assistance in bariatric surgery is an innovative tool to achieve excellent results. Some studies demonstrate the good results of utilizing these devices in other fields of surgery.

•

Utilizing a single-port device represents fewer incisions and better cosmesis for the patient without incrementing postoperative complications. With this device, we can reduce postoperative pain, length of hospital stay, and site of infections.

•

Magnetic assistance in other studies demonstrates the safety of utilizing liver magnetic retraction. We show another way to use the magnetic assistance and is acting like a second surgical assistant in other steps of the procedure.

Perioperative Cost Differences Between Laparoscopic Sleeve Gastrectomy and Laparoscopic Roux-en-Y Gastric Bypass: A Single Institutional Review

Background: Minimizing bariatric surgery care costs is important since more than 250,000 patients undergo bariatric surgery annually in the United States. The study objective was to compare perioperative costs for the two most common bariatric procedures: laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). In addition, we sought to identify predictors of high-cost perioperative care. Methods: Adult patients who underwent LSG or LRYGB from 2012 to 2017 were identified using our institutional bariatric surgery database. Perioperative costs, defined as costs incurred from the time of entering the preoperative unit until exiting the postanesthesia care unit, were obtained through billing data. Median perioperative cost components of LSG and LRYGB were compared using Mann-Whitney tests. Multivariable logistic regression was performed to investigate patient-level predictors of high-cost care, defined as the top tercile of perioperative costs. Results: We included 546 bariatric surgery patients with a mean age and body mass index (BMI) of 49.7 years and 45.9 kg/m², respectively. There were no significant differences in median perioperative costs between LSG and LRYGB ($14,942 versus $15,016; P = .80). Stapler use was the largest cost contributor for both procedures, accounting for 27.7% and 29.2% of costs for LSG and LRYGB, respectively. In multivariable analyses, preoperative patient characteristics, including BMI, were not associated with high-cost perioperative care. Conclusions: Perioperative costs for LSG and LRYGB were similar in our single institution study. Reducing costs outside of the operating room, including those related to ED visits and complications, may be more impactful than focusing on cost reduction directly related to perioperative care.

Safety and feasibility of revisional bariatric surgery following Laparoscopic Adjustable Gastric Band - Outcomes from a large UK private practice

BACKGROUND

Revisional bariatric surgery is unavoidable in a proportion of patients. Despite its need, the development of this speciality has been hampered by its complexity and preferred delivery in institutional set ups. Although primary bariatric surgery can be delivered in the private sector; safety and feasibility of revisional bariatric surgery remains unexplored in this setting.

MATERIALS AND METHODS

Patients undergoing revisional bariatric surgery following previous Laparoscopic Adjustable Gastric Band (LAGB) between 2008 and 2019 at a single private bariatric unit with a minimum follow up of at least 6 months were included. The primary aim was safety outcomes and 30-day morbidity.

RESULTS

178 patients with BMI of 45.6 ± 8.2 kg/m² underwent revisional bariatric surgery. One stage conversion was performed for 86.5% of the cases. At 9.5 ± 5.3 months follow up, BMI and percentage excess BMI loss were 31.8 ± 6.2 kg/m² and 62.6 ± 40% respectively. There was no mortality, and the major complication rate was 2.8%. There was no statistically significant difference in the incidence of complications based on one-stage vs. two-stage conversion (p = 0.52). There were no differences in weight loss outcomes post-revisional surgery according to the indication for revision (p = 0.446) or weight loss following primary surgery (p = 0.12).

CONCLUSION

Revisional bariatric surgery can be delivered safely in the private sector with good outcomes. One-stage conversions are feasible and do not detrimentally affect the morbidity of the procedure or the weight loss outcomes. More importantly, success following revisional surgery is independent of the indication for revision and weight loss outcomes following primary surgery.

Laparoscopic Revision for Gastric Clipping: a Single Center Experience and Taiwan Database Review

PURPOSE

Laparoscopic gastric clipping (LGC) is a relatively novel restrictive bariatric surgery wherein a horizontal metallic clip is applied to the gastric fundus. Its intraoperative complications or the difficulties associated with the applied gastric clip (GC) during revisional procedures have seldom been mentioned. Herein, the experience of revisional procedures after initial gastric clipping is reported.

MATERIALS AND METHODS

A retrospective cohort review of LGC based on the Taiwan Bariatric Registry of Taiwan Society Metabolic and Bariatric Surgery was performed. Six patients with severe obesity presented for revisional surgery after initial LGC by other surgeons. Patients' characteristics, indications, and details of revisional surgery were recorded.

RESULTS

Between 2012 and 2019, 39 patients who underwent pure LGC and six patients with previous LGC history were referred for revisional surgery. Their mean age and the mean body mass index were 34.7 ± 9.5 years and 38.4 ± 10.5 kg/m², respectively. Three, two, and one patient underwent revisional surgery for insufficient weight loss, weight recidivism, and intractable belching, respectively. The mean interval between initial LGC and revisional surgery was 40.5 ± 22.4 months. Laparoscopic removal of the GC with concomitant revisional surgeries were collected, including a revision to sleeve gastrectomy (n = 5) and revision to Roux-en-Y gastric bypass (n = 1). Moreover, the mean operative time was 286.8 ± 78.2 min. All patients had uneventful recovery postoperatively but experienced significant adhesion around the GC and the left liver.

CONCLUSION

Laparoscopic revisional surgery with concomitant GC removal for patients with severe obesity after gastric clipping could be feasibly conducted by experienced bariatric surgeons.

The safety of additional procedures at the time of revisional bariatric surgery

BACKGROUND

The third most common bariatric operation is revisions of previous bariatric surgeries. Patients may require revisional bariatric surgery for inadequate weight loss or complications. Patients undergoing revisional bariatric surgery may also have other conditions that require surgery. This study evaluates the 30-day postoperative outcomes of patients undergoing revisional bariatric surgery and additional procedures.

METHODS

A retrospective review of the 2005-2017 ACS NSQIP database identified 7249 patients who underwent revisional bariatric surgery with 3115 (48%) occurring with additional procedures. A 1:1 propensity score matching analysis was completed for 13 patient demographics and comorbidities. Postoperative variables were then analyzed as available in the NSQIP database. Subgroup analyses were completed for those undergoing paraesophageal hernia repair and abdominal wall hernia repair at the time of revisional bariatric surgery.

RESULTS

The most common bariatric surgery that was converted or revised was the AGB (57%) and the most common additional procedure was paraesophageal hernia repair (n = 181, 15%). When additional procedures were completed at the time of revisional bariatric surgery, overall complications (p < 0.001), major systemic complications (p = 0.009) and mortality/major complications (p = 0.018) were all significantly increased. After matching for operative time, only postoperative sepsis remained significant with additional procedures (p = 0.042). In the subgroup analyses on paraesophageal and abdominal wall hernias there were no differences in postoperative complications after matching for operative time.

CONCLUSIONS

Additional procedures, including paraesophageal and abdominal wall hernia repairs at the time of revisional bariatric surgery increase postoperative complications. Operative time was longer when additional procedures were performed. Postoperative sepsis was the only complication which remained significant after propensity matching when additional procedures are completed at the time of revisional bariatric surgery.