Reduction in early mortality outcomes after bariatric surgery in France between 2007 and 2012: A nationwide study of 133,000 obese patients

Therapeutic Options for Recurrence of Weight and Obesity Related Complications After Metabolic and Bariatric Surgery: An IFSO Position Statement

Obesity is a chronic disease that may require multiple interventions and escalation of therapy throughout the years. Until recently, no universal definition existed for recurrent weight gain and insufficient weight loss. Standardization of reporting is key so outcomes can be compared and data can be pooled. The recent IFSO consensus provided standard terminology and definitions that will likely resolve this in the future, and publishers will need to enforce for authors to use these definitions. This current IFSO position statement provides guidance for the management of recurrent weight gain after bariatric surgery.

Osteoarthritis in patients with obesity: The bariatric surgery impacts on its evolution

Obesity is one of the main modifiable risk factors for osteoarthritis (OA). Moreover, obesity is associated with greater pain intensity and functional limitation, but also with a significantly lower responder rate to intra-articular treatments. Consequently, an arthroplasty is indicated earlier and more frequently in patients with obesity. However, pain and functional symptoms improve slightly less after arthroplasty in patients with obesity, who display higher incidence of early and late complications following prosthetic surgery. Bariatric surgery (BS) has increased worldwide and is efficient to induce major and sustainable weight-loss. Importantly, BS significantly reduces pain and functional limitation in patients with symptomatic knee OA. Biomarkers analysis also revealed a decrease in catabolic factors and an increase in anabolic one after BS suggesting a structural protective effect in knee OA. Nevertheless, the impact of BS prior to arthroplasty remains unclear. BS seems to decrease short- and mid-term complications such as infections or thrombosis. However, BS does not appear to modify long-term complications rate, and may even increase it, especially revisions and infections. Although few studies have compared the symptomatic and functional outcomes of joint replacement with or without BS, these are not significantly improved by prior BS. Despite these heterogeneous results, medico-economic studies found that BS prior to arthroplasty was cost-effective. To conclude, BS could significantly reduce the symptoms of OA and potentially slow its progression, but appears more disappointing in preventing long-term complications of arthroplasties and improving their functional results.

Results from the Scandinavian Obesity Surgery Registry: A narrative review

In 2007, the Scandinavian Obesity Surgery Registry (SOReg) was started by the profession to monitor the results of bariatric surgery and to provide a high-quality database for research. In the end of August 2023, SOReg contains 88,379 patients (body mass index [BMI] 41.7 kg/m2 , 41.2 years, 77.1% females, gastric bypass 76.8%). In this narrative review, we demonstrate that preoperative weight loss is of value and that the laparoscopic double omega-loop technique is highly suitable for gastric bypass. Closing the mesenteric openings is, however, important. Swedish bariatric surgery has low mortality, and our results are comparative to those of other countries. Significant long-term improvements are found in common obesity-related diseases such as diabetes, hypertension, and sleep apnea. Furthermore, the risk for cardiac failure and major adverse cardiovascular events is significantly reduced. Pregnancy-related outcomes are also improved. Gastric bypass results in significant improvements in quality of life and seems to be cost saving. We have revealed that low socioeconomic status is associated with reduced chance of undergoing bariatric surgery and inferior outcomes. Of note, we have performed several randomized clinical trials within the registry database. In conclusion, high-quality national registry databases, such as SOReg, are important for maintaining high-quality care and present a platform for extensive research.

Sleeve gastrectomy as a surgical technique in bariatric surgery: Results of safety and effectiveness

INTRODUCTION

The aim of this study is to evaluate the safety and effectiveness results of sleeve gastrectomy as a bariatric technique.

METHODS

Observational follow-up study of a cohort of patients who underwent sleeve gastrectomy in our center between 2008 and 2017. A total of 223 patients were included: 166 as a primary technique (group 1) and 57 as a hypothetical first stage (group 2).

RESULTS

In group 1, the postoperative morbidity is 12.6%, with a fistula rate of 4.2%; 5.4% required reoperation and mortality was 0.6%. In group 2, postoperative morbidity is 14%, with a fistula rate of 5.3%; 10.5% required reoperation and mortality was 5.3%. In group 1, 79.6% and 62.5% of patients at 2 and 5 years respectively managed to achieve a % EBMIL > 50%. In group 2, the second stage was completed only in 8 patients (14.0%). Of the patients who did not complete the second stage, 32.2% and 5.9% achieved a % EEBMIL > 100% at 2 and 5 years. Analyzing those who completed the second stage, the mean EEBMIL% was 90.5% and 93.4% at 2 and 5 years.

CONCLUSIONS

Sleeve gastrectomy is a safe technique in patients with BMI < 45 and effective in terms of weight loss in the short-medium term. In patients with BMI > 55, a preoperative optimization aimed at reducing morbidity and mortality is necessary, as well as adequately planning the second stage, without which it is clearly insufficient.

A French National Study on Gastropleural and Gastrobronchial Fistulas After Bariatric Surgery: the Impact of Therapeutic Strategy on Healing

PURPOSE

Gastropleural and gastrobronchial fistulas (GPF/GBFs) are serious but rare complications after bariatric surgery whose management is not consensual. The aim was to establish a cohort and evaluate different clinical presentations and therapeutic options.

MATERIALS AND METHODS

A multicenter and retrospective study analyzing GPF/GBFs after bariatric surgery in France between 2007 and 2018, via a questionnaire sent to digestive and thoracic surgery departments.

RESULTS

The study included 24 patients from 9 surgical departments after initial bariatric surgery (21 sleeve gastrectomies; 3 gastric bypass) for morbid obesity (mean BMI = 42 ± 8 kg/m²). The GPF/GBFs occurred, on average, 124 days after bariatric surgery, complicating an initial post-operative gastric fistula (POGF) in 66% of cases. Endoscopic digestive treatment was performed in 79% of cases (n = 19) associated in 25% of cases (n = 6) with thoracic endoscopy. Surgical treatment was performed in 83% of cases (n = 20): thoracic surgery (n = 5), digestive surgery (n = 8), and combined surgery (n = 7). No patient died. Overall morbidity was 42%. The overall success rate of the initial and secondary strategies was 58.5% and 90%, respectively. The average healing time was approximately 7 months. Patients who had undergone thoracic surgery (n = 12) had more initial management failures (n = 9/12) than patients who had not (n = 3/12), p = 0.001.

CONCLUSION

Complex and life-threatening fistulas that are revealed late require a multidisciplinary strategy. Thoracic surgery should be reserved once the abdominal leak heals; otherwise, it is associated with a higher risk of failure.

Postoperative care fragmentation in bariatric surgery and risk of mortality: a nationwide study

BACKGROUND

Readmission after bariatric surgery may to lead to fragmentation of care if readmission occurs at a facility other than the index hospital. The effect of readmission to a nonindex hospital on postoperative mortality remains unclear for bariatric surgery.

OBJECTIVES

To determine postoperative mortality rates according to readmission destinations.

SETTING

Nationwide analysis of all surgical facilities in France.

METHODS

Multicenter, nationwide study of adult patients undergoing bariatric surgery from January 1, 2013, through December 31, 2018. Data from all surgical facilities in France were extracted from a national hospital discharge database.

RESULTS

In a cohort of 278,600 patients who received bariatric surgery, 12,760 (4.6%) were readmitted within 30 days. In cases of readmission, 23% of patients were admitted to a nonindex hospital. Patients readmitted to a nonindex facility had different characteristics regarding sex (men, 23.6% versus 18.2%, respectively; P < .001), co-morbidities (Charlson Co-morbidity Index, .74 versus .53, respectively; P < .001), and travel distance (38.3 km versus 26.9 km, respectively; P < .001) than patients readmitted to the index facility. The main reasons for readmission were leak/peritonitis and abdominal pain. The overall mortality rate after readmission was .56%. The adjusted odds ratio (OR) of mortality for the nonindex group was 4.96 (95% confidence interval [CI], 3.1-8.1; P < .001). In the subgroups of patients with a gastric leak, the mortality rate was 1.5% and the OR was 8.26 (95% CI, 3.7-19.6; P < .001).

CONCLUSION

Readmissions to a nonindex hospital are associated with a 5-fold greater mortality rate. The management of readmission for complications after bariatric surgery should be considered as a major issue to reduce potentially preventable deaths.

Colorectal Cancer Risk Following Bariatric Surgery in a Nationwide Study of French Individuals With Obesity

Importance

Although bariatric surgery is effective against morbid obesity, the association of this surgery with the risk of colorectal cancer remains controversial.

Objective

To assess whether bariatric surgery is associated with altered risk of colorectal cancer among individuals with obesity.

Design, Setting, and Participants

This retrospective, population-based, multicenter, cohort study based on French electronic health data included 1 045 348 individuals with obesity, aged 50 to 75 years, and free of colorectal cancer at baseline. All inpatients with obesity having data recorded during a hospital stay between 2009 and 2018 by the French national health insurance information system database were followed up for a mean (SD) of 5.3 (2.1) years for those who did not undergo bariatric surgery and 5.7 (2.2) years for those who underwent bariatric surgery. Two groups of patients comparable in terms of age, sex, body mass index, follow-up, comorbidities, and conditions who did or did not undergo surgery were also obtained by propensity score matching.

Exposures

Bariatric surgery (n = 74 131), including adjustable gastric banding, sleeve gastrectomy, gastric bypass; or no bariatric surgery (n = 971 217).

Main Outcomes and Measures

Primary outcome was incident colorectal cancer. Standardized incidence ratios were calculated using age-, sex-, and calendar year-matched colorectal cancer incidence among the general French population during the corresponding years. Secondary outcome was incident colorectal benign polyps.

Results

Among a total of 1 045 348 patients, the mean (SD) age was 57.3 (5.5) years for the 74 131 patients in the surgical cohort vs 63.4 (7.0) years for the 971 217 patients in the nonsurgical cohort. The mean (SD) follow-up was 6.2 (2.1) years for patients who underwent adjustable gastric banding, 5.5 (2.1) years for patients who underwent sleeve gastrectomy, and 5.7 (2.2) years for patients who underwent gastric bypass. In total, 13 052 incident colorectal cancers (1.2%) and 63 649 colorectal benign polyps were diagnosed. The rate of colorectal cancer was 0.6% in the bariatric surgery cohort and 1.3% in the cohort without bariatric surgery. In the latter cohort, 9417 cases were expected vs 12 629 observed, a standardized incidence ratio of 1.34 (95% CI, 1.32-1.36). In the bariatric surgery cohort, 428 cases were expected and 423 observed, a standardized incidence ratio of 1.0 (95% CI, 0.90-1.09). Propensity score-matched hazard ratios in comparable operated vs nonoperated groups were 0.68 (95% CI, 0.60-0.77) for colorectal cancer and 0.56 (95% CI, 0.53-0.59) for colorectal benign polyp. There were fewer new diagnoses of colorectal cancer after gastric bypass (123 of 22 343 [0.5%]) and sleeve gastrectomy (185 of 35 328 [0.5%]) than after adjustable gastric banding (115 of 16 460 [0.7%]), and more colorectal benign polyps after adjustable gastric banding (775 of 15 647 [5.0%]) than after gastric bypass (639 of 20 863 [3.1%]) or sleeve gastrectomy (1005 of 32 680 [3.1%]).

Conclusion and Relevance

The results of this nationwide cohort study suggested that following bariatric surgery, patients with obesity share the same risk of colorectal cancer as the general population, whereas for patients with obesity who do not undergo bariatric surgery, the risk is 34% above that of the general population.

Sleeve gastrectomy as a surgical technique in bariatric surgery: Results of safety and effectiveness

INTRODUCTION

The aim of this study is to evaluate the safety and effectiveness results of sleeve gastrectomy as a bariatric technique.

METHODS

Observational follow-up study of a cohort of patients who underwent sleeve gastrectomy in our center between 2008 and 2017. A total of 223 patients were included: 166 as a primary technique (group 1) and 57 as a hypothetical first stage (group 2).

RESULTS

In group 1, the postoperative morbidity is 12.6%, with a fistula rate of 4.2%; 5.4% required reoperation and mortality was 0.6%. In group 2, postoperative morbidity is 14%, with a fistula rate of 5.3%; 10.5% required reoperation and mortality was 5.3%. In group 1, 79.6% and 62.5% of patients at 2 and 5 years respectively managed to achieve a % EBMIL>50%. In group 2, the second stage was completed only in 8 patients (14.0%). Of the patients who did not complete the second stage, 32.2% and 5.9% achieved a % EEBMIL>100% at 2 and 5 years. Analyzing those who completed the second stage, the mean EEBMIL% was 90.5% and 93.4% at 2 and 5 years.

CONCLUSIONS

Sleeve gastrectomy is a safe technique in patients with BMI<45 and effective in terms of weight loss in the short-medium term. In patients with BMI>55, a preoperative optimization aimed at reducing morbidity and mortality is necessary, as well as adequately planning the second stage, without which it is clearly insufficient.

Alveolar recruitment manoeuvre results in improved pulmonary function in obese patients undergoing bariatric surgery: a randomised trial

Perioperative ventilation is an important challenge of anaesthesia, especially in obese patients: body mass index is correlated with reduction of the pulmonary volume and they develop significantly more perioperative atelectasis and pulmonary complications. The alveolar recruitment manoeuvre is the most effective technique to reverse atelectasis. However, the clinical benefit on lung function in the perioperative period is not clear. The aim of the present study is to assess the perioperative clinical results of systematic alveolar recruitment manoeuvre associated with protective ventilation in patients undergoing laparoscopic bariatric surgery. It was a single-centre, randomised, double blind, superiority trial: control group with standard protective ventilation and recruitment group with protective ventilation and systematic recruitment manoeuvre. The primary outcome was a composite clinical criterion of pulmonary dysfunction including oxygen saturation, oxygen needs and dyspnoea in recovery room and at day 1. Secondary outcomes were recruitment manoeuvre tolerance, pulmonary and non-pulmonary complications, length of hospital stay and proportion of Intensive Care Unit admission. Two hundred and thirty patients were included: 115 in the recruitment manoeuvre group and 115 in the control group, 2 patients were excluded from the analysis in the control group. Patients in the recruitment manoeuvre group had significantly lower rate of pulmonary dysfunction in the recovery room (73% versus 84% (p =  0.043) and 77% versus 88% at postoperative day 1 (p =  0.043)). No significant differences were found for secondary outcomes. No patient was excluded from the recruitment manoeuvre group for intolerance to the manoeuvre. Recruitment manoeuvre is safe and effective in reducing early pulmonary dysfunction in obese patients undergoing bariatric surgery.

Connected Surveillance for Detection of Complications After Early Discharge from Bariatric Surgery

As part of a bariatric enhanced recovery after surgery (ERAS) program, at-home follow-up using a novel Internet application was used to detect early complications. The study aimed to evaluate the safety and effectiveness of this "connected surveillance" protocol over a 10-day follow-up. Patients were monitored 24/7 by a trained nursing team with daily surgeon review of patient self-reports. Morbidly obese patients (n = 281) underwent OAGB (126, 47.70%) or sleeve gastrectomy (138, 52.3%). Of 264 who completed the study (mean age 40 years [20-66]), 3 (1.1%) underwent revision for early complications; there were 6 (2.1%) readmissions and 22 (8.3%) consultations. In a bariatric surgery ERAS program, "Internet-connected surveillance" proved safe and effective in detecting 100% of early complications, and most patients were satisfied with their care.

[SOFFCO-MM guidelines for the resumption of bariatric and metabolic surgery during and after the Covid-19 pandemic]

Face à l’émergence de la pandémie à COVID 19, l’activité de chirurgie bariatrique/métabolique a été arrêtée. Le confinement et l’arrêt de cette chirurgie ont eu un impact sous-estimé sur la population obèse avec prise de poids, et aggravation des comorbidités. Un certain nombre de candidats à cette chirurgie sont exposés à un risque important de mortalité liée à la pandémie. En effet, l’obésité et le diabète sont deux facteurs de risque majeurs de forme grave d’infection à COVID-19. Le seul traitement efficace actuel de l’obésité est la chirurgie métabolique avec un bénéfice rapide et durable. Il paraît donc nécessaire de reprendre une activité de chirurgie métabolique. Le but de ce travail est de hiérarchiser la reprise chirurgicale afin qu’elle soit progressive et cohérente. Les organigrammes proposés aideront les centres à déterminer les patients prioritaires selon la balance bénéfice-risque. Le diabète a une place centrale dans l’arbre décisionnel. Les modalités de reprise seront variables d’un centre à l’autre selon les ressources humaines, matérielles et médicamenteuses, et seront à adapter à l’évolution épidémique. Un consentement éclairé spécifique sera nécessaire. Un dépistage chez les patients obèses est à envisager dont les modalités de dépistage sont élaborées sur la base des connaissances disponibles. En cas de suspicion de COVID, la chirurgie doit être différée. Il faut insister sur les mesures et gestes barrières afin de protéger le patient et le personnel soignant. Un confinement est fortement suggéré pour le patient durant le premier mois postopératoire. Le suivi des patients sera effectué de préférence par téléconsultation.

SOFFCO-MM guidelines for the resumption of bariatric and metabolic surgery during and after the Covid-19 pandemic

Bariatric/metabolic surgery was paused during the Covid-19 pandemic. The impact of social confinement and the interruption of this surgery on the population with obesity has been underestimated, with weight gain and worsened comorbidities. Some candidates for this surgery are exposed to a high risk of mortality linked to the pandemic. Obesity and diabetes are two major risk factors for severe forms of Covid-19. The only currently effective treatment for obesity is metabolic surgery, which confers prompt, lasting benefits. It is thus necessary to resume such surgery. To ensure that this resumption is both gradual and well-founded, we have devised a priority ranking plan. The flow charts we propose will help centres to identify priority patients according to a benefit/risk assessment. Diabetes holds a central place in the decision tree. Resumption patterns will vary from one centre to another according to human, physical and medical resources, and will need adjustment as the epidemic unfolds. Specific informed consent will be required. Screening of patients with obesity should be considered, based on available knowledge. If Covid-19 is suspected, surgery must be postponed. Emphasis must be placed on infection control measures to protect patients and healthcare professionals. Confinement is strongly advocated for patients for the first month post-operatively. Patient follow-up should preferably be by teleconsultation.

Male gender is an independent risk factor for patients undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass: an MBSAQIP® database analysis

BACKGROUND

Male patients undergoing bariatric surgery have (historically) been considered higher risk than females. The aim of this study was to examine the disparity between genders undergoing laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB) procedures and assess gender as an independent risk factor.

METHODS

The MBSAQIP® Data Registry Participant User Files for 2015-2017 was reviewed for patients having primary SG and RYGB. Patients were divided into groups based on gender and procedure. Variables for major complications were grouped together, including but not limited to PE, stroke, and MI. Univariate and propensity matching analyses were performed.

RESULTS

Of 429,664 cases, 20.58% were male. Univariate analysis demonstrated males were older (46.48 ± 11.96 vs. 43.71 ± 11.89 years, p < 0.0001), had higher BMI (46.58 ± 8.46 vs. 45.05 ± 7.75 kg/m², p < 0.0001), and had higher incidence of comorbidities. Males had higher rates of major complications (1.72 vs. 1.05%; p < 0.0001) and 30-day mortality (0.18 vs. 0.07%, p < 0.0001). Significance was maintained after subgroup analysis of SG and RYGB. Propensity matched analysis demonstrated male gender was an independent risk factor for RYGB and SG, major complications [2.21 vs. 1.7%, p < 0.0001 (RYGB), 1.12 vs. 0.89%, p < 0.0001 (SG)], and mortality [0.23 vs. 0.12%, p < 0.0001 (RYGB), 0.10 vs. 0.05%; p < 0.0001 (SG)].

CONCLUSION

Males continue to represent a disproportionately small percentage of bariatric surgery patients despite having no difference in obesity rates compared to females. Male gender is an independent risk factor for major post-operative complications and 30-day mortality, even after controlling for comorbidities.

Association Between Bariatric Surgery and Rates of Continuation, Discontinuation, or Initiation of Antidiabetes Treatment 6 Years Later

Importance

Few large-scale long-term prospective cohort studies have assessed changes in antidiabetes treatment after bariatric surgery.

Objective

To describe the association between bariatric surgery and rates of continuation, discontinuation, or initiation of antidiabetes treatment 6 years after bariatric surgery compared with a matched control obese group.

Design, Setting, and Participants

This nationwide observational population-based cohort study extracted health care reimbursement data from the French national health insurance database from January 1, 2008, to December 31, 2015. All patients undergoing primary bariatric surgery in France between January 1 and December 31, 2009, were matched on age, sex, body mass index category, and antidiabetes treatment with control patients hospitalized for obesity in 2009 with no bariatric surgery between 2005 and 2015.

Exposures

Bariatric surgery, including adjustable gastric banding (AGB), gastric bypass (GBP), and sleeve gastrectomy (SG).

Main Outcome and Measure

Reimbursement for antidiabetes drugs. Mixed-effects logistic regression models estimated factors of discontinuation or initiation of antidiabetes treatment over a period of 6 years.

Results

In 2009, a total of 15 650 patients (mean [SD] age, 38.9 [11.2] years; 84.6% female; 1633 receiving antidiabetes treatment) underwent primary bariatric surgery, with 48.5% undergoing AGB, 27.7% undergoing GBP, and 22.0% undergoing SG. Among patients receiving antidiabetes treatment at baseline, the antidiabetes treatment discontinuation rate was higher 6 years after bariatric surgery than in controls (-49.9% vs -9.0%, P < .001). In multivariable analysis, the main predictive factors for discontinuation were the following: GBP (odds ratio [OR], 16.7; 95% CI, 13.0-21.4), SG (OR, 7.30; 95% CI, 5.50-9.50), and AGB (OR, 4.30; 95% CI, 3.30-5.60) compared with no bariatric surgery, as well as insulin use (OR, 0.17; 95% CI, 0.13-0.22), dual therapy without insulin (OR, 0.38; 95% CI, 0.32-0.45) vs monotherapy, lipid-lowering treatment (OR, 0.76; 95% CI, 0.63-0.91), antidepressant treatment (OR, 0.67; 95% CI, 0.55-0.81), and age (OR, 0.96; 95% CI, 0.95-0.97) per year. For patients without antidiabetes treatment at baseline, the 6-year antidiabetes treatment initiation rate was much lower after bariatric surgery than in controls (1.4% vs 12.0%, P < .001). In multivariable analysis, protective factors were GBP (OR, 0.06; 95% CI, 0.04-0.09), SG (OR, 0.08; 95% CI, 0.06-0.11), and AGB (OR, 0.16; 95% CI, 0.14-0.20) vs controls, and risk factors were as follows: body mass index category (OR, 2.04; 95% CI, 1.68-2.47 for ≥50.0 vs 30.0-39.9 and OR, 1.68; 95% CI, 1.49-1.90 for 40.0-49.9 vs 30.0-39.9), antihypertensive treatment (OR, 1.49; 95% CI, 1.33-1.67), low income (OR, 1.43; 95 % CI, 1.26-1.62), and age (OR, 1.04; 95 % CI, 1.03-1.05) per year.

Conclusions and Relevance

Bariatric surgery was associated with a significantly higher 6-year postoperative antidiabetes treatment discontinuation rate compared with baseline and with an obese control group without bariatric surgery.

Anemia and Bariatric Surgery: Results of a National French Survey on Administrative Data of 306,298 Consecutive Patients Between 2008 and 2016

BACKGROUND

Bariatric surgery (BS) has grown exponentially in France, and long-term anemia due to micronutrient deficiencies has become common.

OBJECTIVES

The objective of this study was to assess the long-term risk of anemia after BS and to investigate the factors associated with the occurrence of this complication.

MATERIALS AND METHODS

Data from the French National Health Service database on patients who had undergone gastric bypass (GB), sleeve gastrectomy (SG), or adjustable gastric banding (AGB), between 2008 and 2016 were extracted. Only patients with a primary intervention were considered.

RESULTS

Data from 306,298 patients (143.733 SG, 79.188 GB, and 36.413 AGB) were analyzed. Overall, 12.930 of them (5.0%) had a diagnosis of anemia due to micronutrient deficiencies as main diagnosis or related diagnosis at time of a hospital stay between 2008 and 2016. In multivariate analysis, GB surgery, female gender, age younger than 52 years, and 25-OH vitamin D deficiency were positively associated with the occurrence of anemia whereas hospital procedural volume was negatively associated. The risk to be diagnosed with anemia after BS was 13.0% after a GB, 5.6% after a SG and 4.0% after an AGB (Log-rank p < 0.0001). The hazard ratio for anemia after GB compared to SG was 2.0 (95% CI 1.9-2.1), adjusted for age and gender.

CONCLUSION

In France, between 2008 and 2016, 5% of patients had anemia after BS. The risk to develop anemia was 2-fold higher after a GB than after a SG. Young women should be particularly aware of this long-term risk.

Perioperative complications of sleeve gastrectomy: Review of the literature

Sleeve gastrectomy (SG) has known a spectacular rise worldwide during the last decade. The absence of digestive anastomosis simplifies the surgical technique, reducing anastomosis-related complications such as fistula, stricture and marginal ulcer. Furthermore, the respect for digestive continuity preserves the functions of pylorus, that regulates gastric emptying, and duodenum, where calcium, B vitamins and iron are absorbed. Despite the multiple advantages, SG also has specific complications such as bleeding, stenosis, portal thrombosis and leak. The staple line leak at the oesophagogastric junction is the most feared complication and its prevention remains difficult, as the involved mechanisms have been only partially elucidated. Its management is long and requires a multidisciplinary technical platform including Intensive Care Unit, digestive endoscopy and interventional radiology as well as a specialised surgeon. The aim of this review is to explain in detail the perioperative complications of SG, their prevention and treatment, referring to the most recent available literature.

Health Care Institutions Volume Is Significantly Associated with Postoperative Outcomes in Bariatric Surgery

PURPOSE

The volume of bariatric surgery has significantly increased over the past decade with concomitant postoperative outcomes improvement. The goal of this nationwide study was to estimate the volume-outcome relationship in bariatric surgery at the hospital level.

MATERIALS AND METHODS

A cross-sectional analysis of all patients who underwent bariatric surgery procedure in France from January 2011 to December 2014 was designed. Volume-outcome relationship was analyzed using generalized estimating equations.

RESULTS

We identified 184,332 inpatient stays for bariatric surgical procedures performed in 606 hospitals. Health care institutions performing more than 200 bariatric cases per year were significantly associated with shorter average length of stay (p < 0.001) and less frequent need for intensive or critical care unit (p = 0.003) during the index stay in comparison with lower volume institutions. Reoperations rate increased from 3.1% [95% CI, 2.8-3.3] (n = 5627) at 1 month to 4.9% [4.6-5.2] at 3 months and 8.2% [7.8-8.7] at 6 months. The risk of reoperation after gastric bypass was 1.37 times less frequent in higher volume institutions (≥ 200 inpatient stays per year, p = 0.003), while it was 1.26 times more frequent after gastric banding in higher volume institutions (p = 0.057) and was unaltered regarding sleeve gastrectomy (p = 0.819).

CONCLUSION

This study showed for the first time in bariatric surgery that reoperation rate after gastric bypass or sleeve significantly increased at 3 and 6 months postoperatively. Health care institutions performing more than 200 bariatric cases per year were significantly associated with improved postoperative outcomes and less frequent need for reoperation.

Sleeve Gastrectomy After Liver Transplantation: Feasibility and Outcomes

BACKGROUND

Knowledge regarding the feasibility and safety of sleeve gastrectomy (SG) in obese liver transplant recipients is scarce. We report our experience of sleeve gastrectomy following liver transplantation (LT).

METHODS

All patients who had undergone LT and subsequently underwent SG at our institution were retrospectively reviewed. Surgical outcomes, liver and kidney function tests, outcomes of obesity-related comorbidities, and excess weight loss were analyzed.

RESULTS

Between May 2008 and February 2015, six consecutive patients underwent SG after LT. Three procedures (50%) were performed totally by laparoscopy, and three by upfront laparotomy for concomitant incisional hernia complex repair. Within the first 30 days, one complication occurred: early gastric fistula that required multiple endoscopic procedures and re-intervention, followed by death 19 months after SG due to multi-organ failure. Another patient had one late complication: chronic infection on a parietal mesh successfully controlled by mesh removal. Excess weight loss averaged 76% at 2 years with a median BMI of 28 (21-39) kg/m². Median follow-up was 37.2 months (range 13-101 months). Median length of stay was 9 days (range: 6-81 days).

CONCLUSIONS

SG is technically feasible after LT and resulted in weight loss without adversely affecting graft function and immunosuppression. However, morbidity and mortality are high.

One-Year Mortality after Contemporary Laparoscopic Bariatric Surgery: An Analysis of the Bariatric Outcomes Longitudinal Database

BACKGROUND

Contemporary mortality after bariatric surgery is low and has been decreasing over the past 2 decades. Most studies have reported inpatient or 30-day mortality, which may not represent the true risk of bariatric surgery. The objective of this study was to examine 1-year mortality and factors predictive of 1-year mortality after contemporary laparoscopic bariatric surgery.

STUDY DESIGN

Using the 2008 to 2012 Bariatric Outcomes Longitudinal Database (BOLD), data from 158,606 operations were analyzed, including 128,349 (80.9%) laparoscopic Roux-en-Y gastric bypass (LRYGB) and 30,257 (19.1%) laparoscopic sleeve gastrectomy (LSG) operations. Multivariate logistic regression was used to determine independent risk factors associated with 1-year mortality for each type of procedure.

RESULTS

The 30-day and 1-year mortality rates for LRYGB were 0.13% and 0.23%, respectively, and for LSG were 0.06% and 0.11%, respectively. Risk factors for 1-year mortality included older age (LRYGB: adjusted odds ratio [AOR] 1.05 per year, p < 0.001; LSG: AOR 1.08 per year, p < 0.001); male sex (LRYGB: AOR 1.88, p < 0.001); higher BMI (LRYGB: AOR 1.04 per unit, p < 0.001; LSG: AOR 1.05 per unit, p = 0.009); and the presence of 30-day leak (LRYGB: AOR 25.4, p < 0.001; LSG: AOR 35.8, p < 0.001), 30-day pulmonary embolism (LRYGB: AOR 34.5, p < 0.001; LSG: AOR 252, p < 0.001), and 30-day hemorrhage (LRYGB: AOR 2.34, p = 0.001).

CONCLUSIONS

Contemporary 1-year mortality after laparoscopic bariatric surgery is much lower than previously reported, at <0.25%. It is important to continually refine techniques and perioperative management in order to minimize leaks, hemorrhage, and pulmonary embolus after bariatric surgery because these complications contribute to a higher risk of mortality.

[Relevance of bariatric surgery care]

The relevance of care in bariatric surgery must be judged in terms of the resulting benefit/risk balance. Laparoscopic approach has been proved to reduce postoperative mortality. Postoperative mortality is less than 0.1% in France. Depending on procedures, long-term percentage of weight loss is estimated around 15-30%. Long-term mortality and cardiovascular events are reduced compared to control patients. The over-risk of suicide should be known. Long-term follow-up after bariatric surgery is poor in France.

Long-Term Outcomes of the Laparoscopic Adjustable Gastric Banding: Weight Loss and Removal Rate. A Single Center Experience on 301 Patients with a Minimum Follow-Up of 10 years

BACKGROUND

Obesity is a chronic disease that requires procedures to enable to maintain good long-term results. Laparoscopic adjustable gastric banding (LAGB) studies with a long-term follow-up are limited and have often given conflicting results. We report our results in terms of banding life span and weight loss in a cohort of 301 patients operated on LAGB with a minimum follow-up of 10 years.

METHODS

All patients who underwent LAGB at our university hospital between 1998 and 2004 were included in this study. The main outcome was band survival and complications that led to band removal, and the secondary outcome was weight loss. We present raw data and data after imputation for patients lost at follow-up.

RESULTS

Most patients were women (83 %), and the mean body mass index (BMI) baseline was 45.2 ± 6.7. The pars flaccida technique was performed in 50.9 % of the patients. All patients had at least 10 years of follow-up (range 10-16 years). Data were available at 10 years for 79.7 % and at 15 years for 80.6 %. Band survival was 65.8 % at 10 years and 53.3 % at 15 years. Mean excess weight loss (EWL) at 5, 10, and 15 years was 41.4, 38.7, and 35.1 %, respectively.

CONCLUSION

Despite the encouraging short-term results, LAGB shows long-term disappointing results in terms of weight loss and complication rates. The removal rate increases with time (about 3-4 % per year), and at 15 years, almost half of the bands had been removed.

Aggressive clinical approach to obesity improves metabolic and clinical outcomes and can prevent bariatric surgery: a single center experience

BACKGROUND

The number of bariatric procedures has exponentially increased in the past decade, as a result of the lack of successful clinical weight-loss interventions. The main reasons for the failure of clinical obesity management are: (1) anti-obesity medications are administered as monotherapies (or pre-combined drugs); (2) lack of combination between pharmacotherapy and non-pharmacological modalities; (3) short duration of pharmacotherapy for obesity; (4) lack of weight-loss maintenance strategies; (5) misunderstanding of the complex pathophysiology of obesity; and (6) underprescription of anti-obesity medications. We developed a protocol that can potentially overcome the drawbacks that may lead to the failure of clinical therapy for obesity. The aim of this study is therefore to report the clinical and metabolic effects of our proposed obesity-management protocol over a 2-year period, and to determine whether this more intensive approach to obesity management is feasible and a possible alternative to bariatric surgery in patients with moderate-to-severe obesity.

METHODS

This retrospective study involved 43 patients in whom bariatric surgery was indicated. Patients underwent an intensive anti-obesity protocol that included pharmacotherapy with multiple drugs; intense surveillance with monthly body analysis by air-displacement plethysmography, electrical bioimpedance, and 3D body scans; weekly psychotherapy; diet planning with a dietician every 2 months; and exercises at least 3 times a week with exercises prescribed by a personal trainer at least once a month. Body weight (BW), total weight excess (TWE), obesity class, body mass index, fat weight, muscle weight, waist circumference, and visceral fat were analyzed. Markers of lipid and glucose metabolism, liver function, and inflammation were also evaluated. Therapeutic success was defined as >20% BW loss or >50% decrease in TWE after 1 year.

RESULTS

Significant improvements were observed in all clinical and metabolic parameters. Thirty-eight (88.4%) patients achieved 10% BW loss, and 32 (74.4%) achieved 20% BW loss. TWE decreased by >50% in 35 (81.4%) patients. Forty (93.0%) patients were able to avoid bariatric surgery.

CONCLUSION

An intensive clinical approach to obesity management can be an effective alternative to bariatric surgery, although further randomized controlled studies are necessary to validate our findings.

[The place of bariatric surgery in the management of obesity]

Surgical treatment of obesity, also called "bariatric surgery", is the reference treatment for severe and morbid forms of obesity after proper multidisciplinary medical treatment has failed. However, it is only one step in the pathway of the obese patient and should only be envisaged in the framework of lifelong nutritional care.

Quality criteria in bariatric surgery: Consensus review and recommendations of the Spanish Association of Surgeons and the Spanish Society of Bariatric Surgery

Bariatric surgery has proven to be highly effective in controlling obesity and metabolic syndrome; the results of this surgery are not only expressed in terms of weight loss, but also in terms of resolution of comorbidities, improved quality of life and complications. The different parameters used to measure these outcomes require uniformity and reference patterns. Therefore, it is essential to identify those indicators and quality criteria that are helpful in defining the «best practice» principles in bariatric surgery. In this regard, the Section of Obesity of the Spanish Association of Surgeons, in collaboration with the Spanish Society for Bariatric Surgery (SECO), present as an objective to identify the key points that define «quality» in this type of surgery. We describe the main indicators based on the published literature as well as the criteria for referral of the main comorbidities according to the evidence found and grades of recommendation.

[Management of failures and complications in weight loss surgery]

The specific management of the surgical risks linked to obesity, as well as technological advances combined with the standardisation of techniques, have significantly reduced the morbidity and mortality associated with bariatric surgery over recent decades. However, as with all surgery, patients are exposed to medical and surgical failures and complications.

Bariatric Surgery: Overview of Procedures and Outcomes

Bariatric surgery is the most efficient and long-lasting weight loss therapy available. Its safety has improved over tenfold over the last decade. With the advent of laparoscopy, mortality rates of are now under 1 per 1400 cases in accredited centers. Gastric bypass reduces diabetes-related mortality by 92% over 7 years and long lasting remission has been demonstrated in observational studies covering >10,000 patients and multiple randomized control trials. The benefit of bariatric surgery on diabetes is so substantial that these procedures should be considered in all type 2 diabetic patients with a BMI > 35 kg/m(2).

Surgery for type 2 diabetes: the case for Roux-en-Y gastric bypass

The Roux-en-Y gastric bypass (RYGB) has traditionally been the most common bariatric procedure. Long-term data on the efficacy of RYGB demonstrate a long-lasting benefit in weight loss and control of the metabolic syndrome. Although observations of type 2 diabetes (T2D) resolution after RYGB have been reported for 3 decades, it was not until recently that multiple randomized trials comparing RYGB to medical therapy verified the same thing: RYGB leads to significantly greater diabetes control and remission. Even though T2D can relapse, there remains a significant overall benefit of bariatric surgery regarding the downstream effects of T2D: cardiovascular risk and micro- and macrovascular complications. Limited data are available on the comparative effectiveness of RYGB and sleeve gastrectomy in improving glucose homeostasis, but studies including both surgical procedures suggest that the benefit of RYGB in T2D may be more profound. Although further research is needed to examine closely any differences between these 2 procedures, multiple studies underscore the unprecedented value of bariatric surgery for the control and remission of T2D.