Metabolic outcomes after revisional bariatric surgery: a systematic review and meta-analysis

Evaluating the impact and costs of conversional or revisional metabolic bariatric surgery on obstructive sleep apnea: Insights from a French nationwide cohort

BACKGROUND

This study assesses the effectiveness of 5 main conversional or revisional metabolic bariatric surgery sequences after sleeve gastrectomy, adjustable gastric banding and gastric bypass on reimbursement and cost of continuous positive airway pressure therapy, the first line treatment for obstructive sleep apnea, in France.

METHODS

This nationwide observational population-based cohort study analyzed data from the French National Health Insurance database. It included all patients who had undergone primary metabolic bariatric surgery in France between January 1, 2012, and December 31, 2014, and followed until December 31, 2020. The study assessed continuous positive airway pressure therapy reimbursement discontinuation and costs of reimbursed continuous positive airway pressure therapy across 5 different conversional or revisional metabolic bariatric surgery sequences.

RESULTS

During follow-up, 6,396 patients underwent the following sequences: sleeve gastrectomy-gastric bypass (n = 2,400), adjustable gastric banding-sleeve gastrectomy (n = 2,277), adjustable gastric banding-gastric bypass (n = 1,173), sleeve gastrectomy-sleeve gastrectomy (n = 546), and gastric bypass-others (n =332), with a rate of obstructive sleep apnea of 15.2%, 12.4%, 15.5% 12.8%, and 9.9% in the year before conversional or revisional metabolic bariatric surgery. The rates of patients who had a discontinuation of continuous positive airway pressure were at 2 and 4 years: 41.1%, 41.9%, 46.4%, 29.3%, and 33.3%; 62.3%, 57.0%, 78.2%; 57.5%, and 44.4%, respectively. At 4 years, the mean annual costs (euros) of obstructive sleep apnea treatment per patient were significantly lower (P < .01) than the costs in the year before conversional or revisional metabolic bariatric surgery for each sequence: 526.9 ± 414.4 vs 257.4 ± 349.7; 368.0 ± 247.5 vs 230.9 ± 288.4; 433.7 ± 326.0 vs 116.8 ± 238.3; 540.7 ± 275.3 vs 248.0 ± 308.4 and 501.2 ± 254.0 vs 281.1 ± 287.0, respectively.

CONCLUSIONS

Our study underscore the effectiveness of conversional or revisional metabolic bariatric surgery in significantly reducing the need and associated costs of continuous positive airway pressure therapy for patients with obstructive sleep apnea postprimary metabolic bariatric surgery over a 4-year period.

Cost-Effectiveness of Sleeve Gastrectomy and Gastric Bypass as Revisional Surgery on Antidiabetic Reimbursement: A Nationwide Cohort Study

Objective

This study compared the effectiveness of 4 main revisional bariatric surgery (RBS) sequences after sleeve gastrectomy (SG) and adjustable gastric banding (AGB), on the reimbursement of antidiabetic treatments in France.

Background

Few large-scale prospective cohort studies have assessed the changes in antidiabetic treatments after RBS.

Method

This nationwide observational population-based cohort study analyzed data from the French National Health Insurance Database. All patients who underwent primary SG and AGB in France between January 2012 and December 2014 were included and followed up until December 31, 2020. The changes in categories and costs of reimbursed antidiabetic treatments across different RBS sequences were assessed (presented as follows: bariatric surgery (BS)-RBS).

Results

Among the 107,088 patients who underwent BS, 6396 underwent RBS, 2400 SG-GBP (SG converted to gastric bypass [GBP] during follow-up), 2277 AGB-SG, 1173 AGB-GBP, and 546 SG-SG. Pre-RBS insulin was used in 10 (2.9%), 4 (0.9%), 8 (2.4%), and 10 (2.6%) patients, respectively. Two years after RBS, the treatment discontinuation or decrease (the change of treatment to a lighter one category rates [eg, insulin to bi/tritherapy]) was 47%, 47%, 49%, and 34%, respectively. Four years after RBS, the median annual cost per patient compared with baseline was lower (P < 0.01) for all sequences, except SG-SG (P = 0.24). The most notable effect concerned AGB-GBP (median of more than 220 euros to 0).

Conclusions

This study demonstrated the positive impact of RBS over a 4-year follow-up period on antidiabetic treatments reimbursement, through the reduction or discontinuation of treatments and a significant decrease in costs per patient.

The risk and benefit of revisional vs. primary metabolic- bariatric surgery and drug therapy - A narrative review

Metabolic and bariatric surgery (MBS) leads to long-term weight loss, reduced risk of cardiovascular events and cancer, and reduced mortality. Sleeve gastrectomy and Roux-en-Y gastric bypass are currently the most common surgical techniques. Weight loss after MBS was previously believed to work through restriction and malabsorption, however, mechanistic studies show that MBS techniques with long term efficacy instead alter physiological signaling between the gut and the brain. In revisional MBS, the initial surgical technique is corrected, modified, or converted to a new one. The indication for revisional MBS can be to achieve further weight loss or improvement in obesity comorbidity, but it may be necessary due to complications (e.g., gastroesophageal reflux or obstruction). Revisional MBS is associated with an increased risk of surgical complications and often less weight loss compared to the results following primary surgery. This narrative review summarizes data from revisional MBS where information is often presented with inconsistent definitions for indications and outcomes, making comparison between strategies difficult. In summary, we suggest careful weighing of potential benefits and risks with revisional MBS, bearing in mind the option of add-on therapy with new anti-obesity drugs.

The outcomes of Re-Redo bariatric surgery-results from multicenter Polish Revision Obesity Surgery Study (PROSS)

The increasing prevalence of bariatric surgery has resulted in a rise in the number of redo procedures as well. While redo bariatric surgery has demonstrated its effectiveness, there is still a subset of patients who may not derive any benefits from it. This poses a significant challenge for bariatric surgeons, especially when there is a lack of clear guidelines. The primary objective of this study is to evaluate the outcomes of patients who underwent Re-Redo bariatric surgery. We conducted a retrospective cohort study on a group of 799 patients who underwent redo bariatric surgery between 2010 and 2020. Among these patients, 20 individuals underwent a second elective redo bariatric surgery (Re-Redo) because of weight regain (15 patients) or insufficient weight loss, i.e. < 50% EWL (5 patients). Mean BMI before Re-Redo surgery was 38.8 ± 4.9 kg/m2. Mean age was 44.4 ± 11.5 years old. The mean %TWL before and after Re-Redo was 17.4 ± 12.4% and %EBMIL was 51.6 ± 35.9%. 13/20 patients (65%) achieved > 50% EWL. The mean final %TWL was 34.2 ± 11.1% and final %EBMIL was 72.1 ± 20.8%. The mean BMI after treatment was 31.9 ± 5.3 kg/m2. Complications occurred in 3 of 20 patients (15%), with no reported mortality or need for another surgical intervention. The mean follow-up after Re-Redo was 35.3 months. Although Re-Redo bariatric surgery is an effective treatment for obesity, it carries a significant risk of complications.

Impact of Bariatric Surgery on Outcomes of Patients with Inflammatory Bowel Disease: a Nationwide Inpatient Sample Analysis, 2005-2018

PURPOSE

The global prevalence of inflammatory bowel disease (IBD) has steadily risen over the past few decades. Bariatric surgery stands out as an effective strategy for inducing weight loss. This study investigated the impacts of bariatric surgery on the clinical outcomes in patients with IBD.

MATERIALS AND METHODS

Data of hospitalized patients aged ≥ 18 years with IBD were extracted from the Nationwide Inpatient Sample (NIS) 2005-2018. The patients were categorized according to whether they underwent bariatric surgery or not. Univariate and multivariable logistic regression analyses were performed to determine the associations between bariatric surgery, prolonged LOS, unfavorable discharge, hospital mortality, and morbidity.

RESULTS

Data from 807,843 hospitalized patients with IBD were extracted. After exclusions and propensity-score matching, 80,545 patients were analyzed, with 16,109 undergoing bariatric surgery and 64,436 not. A total of 23% of patients had a prolonged LOS, 8% had unfavorable discharge, and the mortality rate was 1.2%. Multivariable analyses revealed that, compared to patients without bariatric surgery, patients with bariatric surgery had significantly decreased odds of prolonged LOS (adjusted odds ratio [aOR], 0.89; 95% CI 0.85-0.93), unfavorable discharge (aOR, 0.83; 95% CI: 0.77-0.89), and mortality (aOR, 0.54; 95% CI: 0.44-0.67), but had increased odds of morbidity (aOR, 1.09; 95% CI 1.04-1.13).

CONCLUSION

In adults with IBD, bariatric surgery is associated with favorable outcomes concerning hospital LOS, discharge status, and mortality. However, the risk of overall morbidity is slightly increased in those who received bariatric surgery compared to those who did not.

Trends and safety of bariatric revisional surgery in Italy: multicenter, prospective, observational study

BACKGROUND

Revisional bariatric surgery (RBS) represents a further solution for patients who experience inadequate weight loss (IWL) following primary bariatric surgery (BS) or significant weight regain (WR) following initial satisfactory response. RBS guidelines are lacking; however, an increased trend in further BS offerings has been reported recently.

OBJECTIVE

Analyze trend, mortality, complication, readmission, and reoperation rates for any reason at 30 days after RBS in Italy.

SETTING

Ten Italian high-volume BS centers (university hospitals and private centers).

METHODS

Prospective, observational, multicenter study enrolling patients undergoing RBS between October 1, 2021, and March 31, 2022, registering reasons for RBS, technique, mortality, intraoperative and perioperative complications, readmissions, and reinterventions for any reason. Patients undergoing RBS during the same calendar interval in 2016-2020 were considered control patients.

RESULTS

A total of 220 patients were enrolled and compared with 560 control-group patients. Mortality was .45% versus .35% (n.s), with an overall mortality of .25%, while open surgery or conversion to open surgery was registered in 1%. No difference was found for mortality, morbidity, complications, readmission (1.3%), and reoperation rates (2.2%). IWL/WR was the most frequent cause, followed by gastroesophageal reflux disease; Roux-en-Y gastric bypass was the most used revisional procedure (56%). Sleeve gastrectomy was the most revised procedure in the study group, while gastric banding was the most revised in the control group. RBS represents up to 9% of the total BS in the Italian participating centers.

CONCLUSIONS

Laparoscopy represents the standard approach for RBS, which appears safe. Current Italian trends show a shift toward sleeve gastrectomy being the most revised procedure and Roux-en-Y gastric bypass being the most frequent revisional procedure.

Is one-anastomosis gastric bypass a good revisional bariatric surgery? A single-center retrospective cohort study

<b><br>Introduction:</b> The rate of revisional surgeries following sleeve gastrectomy (SG) has increased. One-anastomosis gastric bypass (OAGB) appears to have multiple advantages as a primary bariatric procedure. OAGB as revisional surgery is still being investigated.</br> <b><br>Aim:</b> Evaluation of the efficacy and safety of OAGB performed as a post-SG revisional surgery.</br> <b><br>Materials and methods:</b> A single-center, retrospective cohort study was conducted using a routinely collected database of adults undergoing revisional OAGB after SG. A survey of patients was conducted, obtaining information on changes in body weight and improvement in gastroesophageal reflux disease (GERD) and obesity-related diseases.</br> <b><br>Results:</b> The study group included 74 patients: 59 women (80%) and 15 men, mean age of 41.61 9.21 years. The most common indication for OAGB was weight regain. The follow-up was up to 7 years, the mean time was 3.58 1.21 years. The mean preoperative body mass index (BMI) was 40.38 6.15. All patients experienced significant weight loss, reaching a BMI of 33.61 (27.28- 37.13) at the last observation. After surgery, 35% of patients achieved successful weight loss and 48% of patients achieved remission or improvement of GERD.</br> <b><br>Conclusions:</b> Revisional OAGB seems to be a good alternative after a failed SG in terms of obesity-related disease recurrence, not of weight regain. Long-term follow-up revealed that only a third of patients achieved successful weight loss. When proposing revisional OAGB, the risk of complications - mainly anemia and the possibility of de novo GERD should be considered.</br>.

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.

Revisional bariatric surgery after adjustable gastric band: a multicenter Polish Revision Obesity Surgery Study (PROSS)

BACKGROUND

Adjustable gastric band (AGB) hadbeen the preferred treatment for morbid obesity because it is minimally invasive and reversible. But now it seems to be slowly becoming a historic procedure due to the disappointing effects. The aim of the study was to systematize and present the available data on revisional bariatric surgery (RBS) after AGB among Polish patients.

METHODS

It is a multicenter, retrospective analysis of patients undergoing laparoscopic RBS after AGB in 12 Polish bariatric centers. The database included patient demographics, comorbidities and surgical outcomes.

RESULTS

The group consisted of 234 patients who underwent AGB, which accounted for 29% of revisional cases recorded in the Polish Revisional Obesity Surgery Study (PROSS). 195 were women (83%), and 39 were men (17%). One hundred seventy-five patients after AGB experienced a weight regain (74.5%), 36 patients a gastric band slippage (15.0%), 14 patients had gastric band intolerance (6.0%). Types of RBS included 116 sleeve gastrectomies (SG) (49.4%), 86 Roux-en Y gastric by-passes (RYGB) (36.6%), 20 one anastomosis gastric by-passes (OAGB) (8,5%). The highest weight loss expressed as %EBMIL was observed after OAGB (63.5 ± 32.4%).

CONCLUSIONS

The main indication for RBS after AGB was weight regain. SG was the most frequently chosen type of RBS after AGB. RBS after AGB leads to weight loss and improvement in type 2 diabetes and hypertension with an acceptable low risk of complications.

TRIAL REGISTRATION

NCT05108532.

Weight loss specific to indication, remission of diabetes, and short-term complications after sleeve gastrectomy conversion to Roux-en-Y gastric bypass: a systematic review and meta-analysis

Laparoscopic sleeve gastrectomy (SG) is the most frequently performed bariatric procedure worldwide. Long-term complications such as insufficient weight loss (IWL) and gastroesophageal reflux disease (GERD) may necessitate SG conversion to Roux-en-Y gastric bypass (RYGB). The aim of this review was to determine the indication-specific weight loss and diabetes remission after SG conversion to RYGB (STOBY). Our objective was to extract all available published data on indication for conversion, weight loss, remission of diabetes, and short-term complications after STOBY. A systematic literature search was conducted to identify studies reporting outcomes following STOBY. A random effects model was used for meta-analysis. The search identified 44 relevant studies. Overall short-term (12-mo) excess weight loss (EWL) was 54.6% (95% confidence interval [CI], 46%-63%) in 23 studies (n = 712) and total weight loss (TWL) was 19.9% (95% CI, 14%-25%) in 21 studies (n = 740). For IWL, short-term (12-mo) pooled weight loss outcomes were 53.9% EWL (95% CI, 48%-59%) in 14 studies (n = 295) and 22.7% TWL (95% CI, 17%-28%) in 12 studies (n = 219), and medium-term (2-5 yr) outcomes were 45.8% EWL (95% CI, 38%-53%) in 7 studies (n = 154) and 20.6% TWL (95% CI, 15%-26%) in 9 studies (n = 206). Overall diabetes remission was 53% (95% CI, 33%-72%), and the perioperative complication rate was 8.2% (95% CI, 7.6%-8.7%). Revisional SG conversion to RYGB for IWL can achieve good weight loss outcomes and diabetes remission.

Weight recurrence after Sleeve Gastrectomy versus Roux-en-Y gastric bypass: a propensity score matched nationwide analysis

BACKGROUND

Literature remains scarce on patients experiencing weight recurrence after initial adequate weight loss following primary bariatric surgery. Therefore, this study compared the extent of weight recurrence between patients who received a Sleeve Gastrectomy (SG) versus Roux-en-Y gastric bypass (RYGB) after adequate weight loss at 1-year follow-up.

METHODS

All patients undergoing primary RYGB or SG between 2015 and 2018 were selected from the Dutch Audit for Treatment of Obesity. Inclusion criteria were achieving ≥ 20% total weight loss (TWL) at 1-year and having at least one subsequent follow-up visit. The primary outcome was ≥ 10% weight recurrence (WR) at the last recorded follow-up between 2 and 5 years, after ≥ 20% TWL at 1-year follow-up. Secondary outcomes included remission of comorbidities at last recorded follow-up. A propensity score matched logistic regression analysis was used to estimate the difference between RYGB and SG.

RESULTS

A total of 19.762 patients were included, 14.982 RYGB and 4.780 SG patients. After matching 4.693 patients from each group, patients undergoing SG had a higher likelihood on WR up to 5-year follow-up compared with RYGB [OR 2.07, 95% CI (1.89-2.27), p < 0.01] and less often remission of type 2 diabetes [OR 0.69, 95% CI (0.56-0.86), p < 0.01], hypertension (HTN) [OR 0.75, 95% CI (0.65-0.87), p < 0.01], dyslipidemia [OR 0.44, 95% CI (0.36-0.54), p < 0.01], gastroesophageal reflux [OR 0.25 95% CI (0.18-0.34), p < 0.01], and obstructive sleep apnea syndrome (OSAS) [OR 0.66, 95% CI (0.54-0.8), p < 0.01]. In subgroup analyses, patients who experienced WR after SG but maintained ≥ 20%TWL from starting weight, more often achieved HTN (44.7% vs 29.4%), dyslipidemia (38.3% vs 19.3%), and OSAS (54% vs 20.3%) remission compared with patients not maintaining ≥ 20%TWL. No such differences in comorbidity remission were found within RYGB patients.

CONCLUSION

Patients undergoing SG are more likely to experience weight recurrence, and less likely to achieve comorbidity remission than patients undergoing RYGB.

Conversion of gastric sleeve to Roux-en-Y gastric bypass and biliopancreatic diversion/duodenal switch: safe and viable options

BACKGROUND

Sleeve gastrectomy (SG) remains the most performed bariatric surgery. As numbers of SG increase, so do the numbers of patients requiring conversion for insufficient weight loss or weight regain. However, the literature has cited complication rates as high as 30% for reoperative bariatric surgery.

OBJECTIVE

With the recent inclusion of conversion surgery variables in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, we compared the safety and efficacy of SG conversion to Roux-en-Y gastric bypass (RYGB) versus biliopancreatic diversion and duodenal switch (BPD/DS).

SETTING

MBSAQIP database.

METHODS

Analysis of the 2020 MBSAQIP Participant Use Files revealed 6020 patients who underwent SG conversion to RYGB (5348) and BPD/DS (672). We examined 30-day outcomes including death, anastomotic leak, readmission, any complication, dehydration, and weight loss.

RESULTS

There was no statistically significant difference in mortality (.12% versus 0%) or; complication rate (6.5% versus 5.1%) with SG conversion to RYGB or BPD/DS. There was a statistically significant difference in anastomotic leak (.5% versus 1.2%, P = .024). Interestingly, BPD/DS was less likely to require dehydration treatments (4.2% versus 2.2%, P = .009) and had fewer readmissions within 30 days (7.3% versus 5.4%, P = .043).

CONCLUSIONS

Complication rates after conversion of SG to RYGB or BPD/DS may be significantly lower than previously reported and only slightly higher than after primary weight loss surgery. SG conversion to either RYGB or BPD/DS remain safe, viable options for patients who had insufficient weight loss or regain, and BPD/DS may be the better option in the appropriate patient.

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.

Methodological appraisal of the evidence about efficacy of metabolic surgery in adults with non-morbid obesity and hypertension: An overview of systematic reviews

BACKGROUND

Nowadays, the high morbimortality of obesity is mainly related to diabetes, cancer, and hypertension. It is reported that obesity in patients with hypertension can lead to resistance to pressure reduction through pharmacological therapy and lifestyle changes, so bariatric surgery emerges as a proposed treatment for obesity.

METHODS

We performed an umbrella review that included systematic reviews of clinical trials that evaluated patients with hypertension and non-morbid obesity. The quality and certainty of the evidence was evaluated with the AMSTAR-II and GRADE tools.

RESULTS

677 systematic reviews were identified, of which only three were included for analysis. We considered the outcomes addressed by the reviews on hypertension, identifying that 5 RCTs evaluated pressure reduction at 1 year of follow-up and 5 RCTs at more than 1 year, 5 RCTs evaluated hypertension rate, 6 RCTs analyzed changes in systolic pressure and 5 RCTs changes in diastolic pressure. Likewise, when assessing the methodological quality, it was concluded that the three reviews have critically low quality.

CONCLUSIONS

We found only three systematic reviews that evaluated the topic with critically low methodological quality. They reported results in favor of metabolic surgery, but with very low certainty of evidence.

Lived Experience after Bariatric Surgery among Patients with Morbid Obesity in East Coast Peninsular Malaysia: A Qualitative Study

Living with morbid obesity is challenging since it affects various dimensions of life. Sustainable weight loss via bariatric surgery helps people suffering from morbid obesity to lead a healthy and meaningful life. This study highlights the challenges before bariatric surgery and the impact on one’s life. A phenomenological approach was employed using in-depth interviews with 21 participants (15 females and 6 males) who had undergone surgery at least 6 months prior to the study with the mean age of 42.6 years. Due to excess body weight, the physical limitation had a serious negative impact on their social life, making them targets of bias and stigmatisation. Surgery was the best option for them to attain sustainable weight loss and to lead a new life. However, a few participants struggled with the side effects of surgery. Five themes were discovered, namely, (1) social restraint; (2) experiencing bias and stigmatisation; (3) bringing new life; (4) boosting self-esteem; and (5) facing the negative side of surgery. This study serves as a platform to explore the difficulties faced by people with morbid obesity and the changes that the participants experienced after the surgery for future intervention to curb the rising number of people with morbid obesity.

Defining Global Benchmarks in Elective Secondary Bariatric Surgery Comprising Conversional, Revisional, and Reversal Procedures

OBJECTIVE

To define "best possible" outcomes for secondary bariatric surgery (BS).

BACKGROUND

Management of poor response and of long-term complications after BS is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS.

METHODS

Out of 44,884 BS performed in 18 high-volume centers from 4 continents between 06/2013-05/2019, 5,349 (12%) secondary BS cases were identified. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of centers. Benchmark cases had no previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, thromboembolic events, BMI> 50 kg/m2 or age> 65 years.

RESULTS

The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8 ± 10 years, 8.4 ± 5.3 years after primary BS, with a BMI 35.2 ± 7 kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.6% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.37) and after conversional/reversal or revisional procedures with gastrointestinal suture/stapling (OR 1.84). Benchmark cutoffs for conversional BS were ≤4.5% re-intervention, ≤8.3% re-operation 90-days postoperatively. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation.

CONCLUSION

Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.

Association of metabolic-bariatric surgery with long-term survival in adults with and without diabetes: a one-stage meta-analysis of matched cohort and prospective controlled studies with 174 772 participants

BACKGROUND

Metabolic-bariatric surgery delivers substantial weight loss and can induce remission or improvement of obesity-related risks and complications. However, more robust estimates of its effect on long-term mortality and life expectancy-especially stratified by pre-existing diabetes status-are needed to guide policy and facilitate patient counselling. We compared long-term survival outcomes of severely obese patients who received metabolic-bariatric surgery versus usual care.

METHODS

We did a prespecified one-stage meta-analysis using patient-level survival data reconstructed from prospective controlled trials and high-quality matched cohort studies. We searched PubMed, Scopus, and MEDLINE (via Ovid) for randomised trials, prospective controlled studies, and matched cohort studies comparing all-cause mortality after metabolic-bariatric surgery versus non-surgical management of obesity published between inception and Feb 3, 2021. We also searched grey literature by reviewing bibliographies of included studies as well as review articles. Shared-frailty (ie, random-effects) and stratified Cox models were fitted to compare all-cause mortality of adults with obesity who underwent metabolic-bariatric surgery compared with matched controls who received usual care, taking into account clustering of participants at the study level. We also computed numbers needed to treat, and extrapolated life expectancy using Gompertz proportional-hazards modelling. The study protocol is prospectively registered on PROSPERO, number CRD42020218472.

FINDINGS

Among 1470 articles identified, 16 matched cohort studies and one prospective controlled trial were included in the analysis. 7712 deaths occurred during 1·2 million patient-years. In the overall population consisting 174 772 participants, metabolic-bariatric surgery was associated with a reduction in hazard rate of death of 49·2% (95% CI 46·3-51·9, p<0·0001) and median life expectancy was 6·1 years (95% CI 5·2-6·9) longer than usual care. In subgroup analyses, both individuals with (hazard ratio 0·409, 95% CI 0·370-0·453, p<0·0001) or without (0·704, 0·588-0·843, p<0·0001) baseline diabetes who underwent metabolic-bariatric surgery had lower rates of all-cause mortality, but the treatment effect was considerably greater for those with diabetes (between-subgroup I² 95·7%, p<0·0001). Median life expectancy was 9·3 years (95% CI 7·1-11·8) longer for patients with diabetes in the surgery group than the non-surgical group, whereas the life expectancy gain was 5·1 years (2·0-9·3) for patients without diabetes. The numbers needed to treat to prevent one additional death over a 10-year time frame were 8·4 (95% CI 7·8-9·1) for adults with diabetes and 29·8 (21·2-56·8) for those without diabetes. Treatment effects did not appear to differ between gastric bypass, banding, and sleeve gastrectomy (I² 3·4%, p=0·36). By leveraging the results of this meta-analysis and other published data, we estimated that every 1·0% increase in metabolic-bariatric surgery utilisation rates among the global pool of metabolic-bariatric candidates with and without diabetes could yield 5·1 million and 6·6 million potential life-years, respectively.

INTERPRETATION

Among adults with obesity, metabolic-bariatric surgery is associated with substantially lower all-cause mortality rates and longer life expectancy than usual obesity management. Survival benefits are much more pronounced for people with pre-existing diabetes than those without.

FUNDING

None.