Bariatric surgery is as safe as other common operations: an analysis of the ACS-NSQIP

Impact of metabolic and bariatric surgery on weight loss and insulin requirements in type 1 and insulin-treated type 2 diabetes

Metabolic and Bariatric Surgery (MBS) is effective in improving metabolic outcomes and reducing weight in patients with obesity and diabetes, with less explored benefits in type 1 diabetes (T1D). This study aimed to evaluate the impact of MBS on weight loss and insulin requirements in T1D patients compared to insulin-treated type 2 diabetes (T2D) patients over a 5-year period. This retrospective analysis included patients who underwent primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) with a confirmed preoperative diagnosis of either T1D or insulin-treated T2D. Primary endpoints focusing on weight loss and secondary outcomes assessing changes in insulin dosage and glycemic control. After 5 years, weight loss was similar across groups, with total weight loss at 14.2% for T1D and 17.6% for insulin-treated T2D in SG, and 22.6% for T1D vs. 26.8% for insulin-treated T2D in RYGB. Additionally, there was a significant reduction in median daily insulin doses from 140.5 units at baseline to 77.5 units at 1 year postoperatively, sustained at 90 units at 5 years. The differential impact of MBS procedure was also highlighted, where RYGB patients showed a more pronounced and enduring decrease in insulin requirements compared to SG.

Perioperative outcomes of same-day discharge laparoscopic Roux-en-Y gastric bypass using the MBSAQIP database

BACKGROUND

There has been a rising trend of outpatient bariatric surgery, particularly accelerated by the COVID-19 pandemic. The aim of this study was to evaluate the safety and outcomes of same-day discharge laparoscopic Roux-en-Y gastric bypass (LRYGB) using the MBSAQIP database.

METHODS

In this retrospective study, the MBSAQIP was queried for patients undergoing non-revisional LRYGB between 2020 and 2021. Two cohorts were established: same-day discharge (SDD; length of stay = 0 days) and next-day discharge (POD1; length of stay = 1 day), with the latter serving as a control group. Univariate analysis and multivariate logistic regression were employed to compare outcomes between cohorts.

RESULTS

A total of 48,408 patients underwent LRYGB, with 1,918 (4.0%) SDD and 46,490 (96.0%) POD1. The two cohorts were similar in mean age (SDD 44.2 ± 11.3 years vs POD1 44.0 ± 11.3 years; p = 0.61) and female sex (SDD 83.8% vs POD1 83.1%; p = 0.43). However, the POD1 cohort had a higher preoperative body mass index (45.4 ± 7.3 vs 44.9 ± 7.3 kg/m2; p < 0.01). Preoperative anticoagulation and obstructive sleep apnea were more prevalent in the POD1 group. There was no difference in overall 30-day overall complication rates (SDD 2.0% vs POD1 2.3%; p = 0.51), reintervention, reoperations, mortality, and emergency department visits between the two cohorts. Readmissions were lower in the SDD cohort (2.9% vs 4.0%; p = 0.02), whereas the need for outpatient intravenous hydration was higher in the SDD cohort (6.7% vs 3.6%; p < 0.01). This finding remained significant even after adjustment for confounders.

CONCLUSION

Same-day LRYGB is safe and feasible, with comparable complication rates to next-day discharge. Notably, SDD is associated with lower readmission rate and higher need for outpatient intravenous hydration, possibly reflecting rigorous bariatric protocols and thorough patient follow-up. Further investigations are warranted to elucidate the selection criteria and optimize postoperative care for outpatient LRYGB.

Novel Surgical Interventions for the Treatment of Obesity

Metabolic and bariatric surgery is widely recognized as the most effective and durable treatment for the disease of obesity and its associated comorbidities. In recent years, the field has seen significant advancements, introducing numerous innovative surgical options. This review aims to comprehensively examine these emerging surgical techniques, which have recently received endorsement from the American Society for Metabolic and Bariatric Surgery (ASMBS). Additionally, we will explore new technologies and methodologies supported by the latest scientific evidence. Our analysis will include a critical evaluation of the efficacy, safety, and long-term outcomes of these novel approaches, providing a detailed update on the current state of metabolic and bariatric surgery, highlighting key developments and their potential implications for clinical practice.

Evaluating the incidence, risk factors and postoperative complications associated with leaks following duodenal switch procedures: an analysis of the MBSAQIP

BACKGROUND

Metabolic and Bariatric Surgery (MBS) is the most effective management for patients with obesity and weight-related medical conditions. Duodenal switch (DS) is a recent MBS procedure with increasing attention in recent years, however the risk of anastomotic or staple line leaks and the lack of efficient surgical expertise hinders the procedure from becoming fully adopted.

OBJECTIVES

To determine the 30-day predictors of leaks following DS and explore their association with other 30-day postoperative complications.

SETTING

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.

METHODS

Patients who underwent a primary biliopancreatic diversion with DS or single-anastomosis duodenoileostomy with sleeve procedure, categorized as DS, were assessed for 30-day leaks. A multivariable logistic regression was constructed to identify the predictors of leaks. The assessment of postoperative complications arising from leaks was also performed.

RESULTS

A total of 21,839 DS patients were included, of which 177 (.8%) experienced leaks within 30 postoperative days. The most significant predictor of leaks was steroid immunosuppressive use (adjusted odds ratio [aOR] = 3.01, 95% confidence interval [CI] [1.56-5.13], P < .001) and age, with each decade of life associated with a 26% increase in risk (aOR = 1.26, 95% CI [1.09-1.45], P = .001). Operative length was also associated with leaks, with every additional 30 minutes increasing the odds of a leak by 23% (aOR = 1.23, 95% CI [1.18-1.29], P < .001). The occurrence of leaks was correlated with postoperative septic shock (Crude Odds Ratio [COR] = 280.99 [152.60-517.39]) and unplanned intensive care unit (ICU) admissions (COR = 79.04 [56.99-109.59]). Additionally, mortality rates increased 17-fold with the incidence of leaks (COR = 17.64 [7.41-41.99]).

CONCLUSIONS

Leaks following DS are a serious postoperative complication with significant risk factors of steroid use, prolonged operative time and advanced age. Leaks are also associated with other severe complications, highlighting the need for early diagnosis and intervention along with additional studies to further validate our results.

Future Prospects of Metabolic and Bariatric Surgery: A Comprehensive Review

BACKGROUND

The field of metabolic and bariatric surgery (MBS) is currently an expanding surgical field with constant refinements in techniques, outcomes, indications, and objectives. MBS has been effectively applied across diverse patient demographics, including varying ages, genders, body mass indexes, and comorbidity statuses.

METHODS

We performed a comprehensive literature review of published retrospective cohort studies, meta-analyses, systematic reviews, and literature reviews from inception to 2024, reporting outcomes of MBS using databases such as PubMed, ScienceDirect, and Springer Link.

RESULTS

MBS is a safe and efficient therapeutic option for patients with obesity and associated medical conditions (mortality rate 0.03-0.2%; complication rates 0.4-1%). The favorable safety profile of MBS in the short-, mid-, and long-term offers the potential to treat patients with obesity and type 2 diabetes mellitus, immunosuppression, chronic anticoagulation, neoplastic disease, and end-organ failure without increased morbidity and mortality.

CONCLUSIONS

In conclusion, the future of MBS lies in the ongoing innovation and adapted therapeutic strategies along with the integration of a variety of other techniques for managing obesity. Careful preoperative assessments, coupled with a multidisciplinary approach, remain essential to ensure optimal surgical outcomes and patient satisfaction after MBS.

Time to Rethink the Approach to Treating Obesity

This Viewpoint describes potential benefits and hurdles to implementing a more personalized approach to obesity treatment through a comprehensive multidisciplinary evaluation that considers surgical, medical, and combined therapies.

Rare Complications Following Laparoscopic Sleeve Gastrectomy

Metabolic and bariatric surgery (MBS) is the most effective and durable therapeutic intervention for patients with obesity. In recent years, laparoscopic sleeve gastrectomy (SG) has become the most commonly performed primary MBS procedure owing to its technical feasibility and excellent short-term outcomes. Despite these favorable results and perceived advantages, SG is associated with several unique complications. Complications such as a postoperative leak or bleeding have been more commonly observed and reported than others, and their management approaches are well described. However, other complications following SG are far less familiar to surgeons, which may delay recognition and result in poor patient outcomes. Of these complications, we describe splenic injuries; esophageal perforation; staple line malformations; stapling of intraluminal devices; phytobezoar formation; gastro-colic, gastro-pleural and gastro-bronchial fistula; pancreatic leak; and portomesenteric venous thrombosis. It is paramount for surgeons to be aware of these underreported issues and have the resources to learn how to recognize and manage them when they arise. This review aims to describe rare (i.e., reported incidence <1%) and underdescribed complications after SG, focusing on causes, clinical presentation, prevention strategies, and management.

Bariatric surgery and the diseased kidney: a 5-year assessment of safety and postoperative renal outcomes

BACKGROUND

Obesity and its related medical conditions are well-established contributors to the development of chronic kidney disease (CKD). Metabolic and bariatric surgery (MBS), including procedures such as sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), is a potential intervention for these individuals. However, the heightened risk of postoperative complications casts doubts on the suitability of MBS in this population. Our aim is to evaluate the long-term safety, anthropometric and renal outcomes of MBS in patients with CKD.

METHODS

A retrospective review of patients who underwent primary laparoscopic MBS with a BMI ≥ 35 kg/m2 and a preoperative diagnosis of stage 2 to 5 CKD. Criteria for CKD diagnosis and staging were based on estimated glomerular filtration rate measurements in accordance with established guidelines. Anthropometric and renal outcomes were measured at 3-, 6-, 12-, 24- and 60-months postoperatively.

RESULTS

A total of 302 patients (177 SG, 125 RYGB) were included. RYGB was preferred for patients with stage 3 CKD, while SG was more common in stages 4 and 5. At 5-year follow-up, percentage of total weight loss was higher in the RYGB cohort compared to SG (25.1% vs. 18.6%, p = 0.036). Despite SG patients having more advanced CKD, the incidence of late complications was significantly higher following RYGB, with 11 incidents (8.8%), compared to the SG cohort with only 4 cases (2.3%) (p = 0.014). In those with preoperative CKD stage 3, 76 patients (43.2%) improved to stage 2, with another 9 patients (5.1%) improving further to stage 1. Of all patients, 63 (20.8%) eventually received a successful renal transplant.

CONCLUSIONS

MBS is an effective strategy for sustained weight loss in patients with CKD with acceptable complications rates. RYGB leads to a higher percentage of overall weight loss, albeit with an elevated likelihood of late surgical complications. Future studies are needed to determine the safety of MBS in this demographic.

Trends and Outcomes Associated With Bariatric Surgery and Pharmacotherapies With Weight Loss Effects Among Patients With Heart Failure and Obesity

BACKGROUND

Utilization patterns of bariatric surgery among older patients with heart failure (HF), and the associations with cardiovascular outcomes, are not well known.

METHODS

Medicare beneficiaries with HF and at least class II obesity from 2013 to 2020 were identified with Medicare Provider Analysis and Review 100% inpatient files and Medicare 5% outpatient files. Patients who underwent bariatric surgery were matched to controls in a 1:2 ratio (matched on exact age, sex, race, body mass index, HF encounter year, and HF hospitalization rate pre-surgery/matched period). In an exploratory analysis, patients prescribed pharmacotherapies with weight loss effects (semaglutide, liraglutide, naltrexone-bupropion, or orlistat) were identified and matched to controls with a similar strategy in addition to HF medical therapy data. Cox models evaluated associations between weight loss therapies (as a time-varying covariate) and mortality risk and HF hospitalization rate (calculated as the rate of HF hospitalizations following index HF encounter per 100 person-months) during follow-up.

RESULTS

Of 298 101 patients with HF and body mass index ≥35 kg/m2, 2594 (0.9%) underwent bariatric surgery (45% men; mean age, 56.2 years; mean body mass index, 51.5 kg/m2). In propensity-matched analyses over a median follow-up of 4.7 years, bariatric surgery was associated with lower risk of all-cause mortality (HR, 0.55 [95% CI, 0.49-0.63]; P<0.001), greater reduction in HF hospitalization rate (rate ratio, 0.72 [95% CI, 0.67-0.77]; P<0.001), and lower atrial fibrillation risk (HR, 0.78 [95% CI, 0.65-0.93]; P=0.006). Use of pharmacotherapies with weight loss effects was low (4.8%), with 96.3% prescribed GLP-1 (glucagon-like peptide-1) agonists (semaglutide, 23.6%; liraglutide, 72.7%). In propensity-matched analysis over a median follow-up of 2.8 years, patients receiving pharmacotherapies with weight loss effects (versus matched controls) had a lower risk of all-cause mortality (HR, 0.82 [95% CI, 0.71-0.95]; P=0.007) and HF hospitalization rate (rate ratio, 0.87 [95% CI, 0.77-0.99]; P=0.04).

CONCLUSIONS

Bariatric surgery and pharmacotherapies with weight loss effects are associated with a lower risk of adverse outcomes among older patients with HF and obesity; however, overall utilization remains low.