Reflux After Sleeve Gastrectomy: An Update

Managing the Bariatric Surgery Patient: Presurgery and Postsurgery Considerations

Obesity has extensive health repercussions, and bariatric surgery remains a viable solution to address this issue. This article focuses on the preoperative and postoperative management strategies required to achieve successful and durable outcomes in bariatric surgery patients. Preoperative assessment includes appropriate patient selection, psychosocial evaluation, nutritional analysis, and behavioral/medical counseling. Postoperative assessment includes immediate perioperative care, diet transition, nutritional needs management, and handling of complications associated with bariatric surgery.

Preoperative Oesophagogastroduodenoscopy and the Effect on Bariatric Surgery: a Systematic Review and Meta-Analysis

Preoperative oesophagogastroduodenoscopy (OGD) in bariatric surgery remains a controversial topic, with a large variety in practice globally. An electronic database search of Medline, Embase and PubMed was performed in an aim to categorise the findings of preoperative endoscopies in bariatric patients. A total of 47 studies were included in this meta-analysis resulting in 23,368 patients being assessed. Of patients assessed, 40.8% were found to have no novel findings, 39.7% had novel findings which did not affect surgical planning, 19.8% had findings that affected their surgery and 0.3% were ruled to not be suitable for bariatric surgery. Preoperative OGD is altering surgical planning in one-fifth of patients; however, further comparative studies are required to determine if each patient should undergo this procedure especially if asymptomatic.

Evolution of Bariatric Surgery in Italy in the Last 11 Years: Data from the SICOB Yearly National Survey

BACKGROUND

Bariatric surgery (BS) is a relatively novel surgical field and is in continuous expansion and evolution.

PURPOSE

Aim of this study was to report changes in Italian surgical practice in the last decade.

METHODS

The Società Italiana di Chirurgia dell'Obesità (SICOB) conducted annual surveys to cense activity of SICOB centers between 2011 and 2021. Primary outcome was to detect differences in frequency of performance of adjustable gastric banding (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass (OAGB), bilio-pancreatic diversion (BPD), and gastric plication (GP). Secondary outcome was to detect differences in performance of main non-malabsorptive procedures (AGB + SG) and overall bypass procedures (RYGB + OAGB). Geographical differences were also investigated.

RESULTS

Median response rate was 92%. AGB declined from 36% of procedures in 2011 to 5% in 2021 (p < 0.0001). SG increased from 30% in 2011 to 55% in 2021 (p < 0.0001). RYGB declined from 25 to 12% of procedures (p < 0.0001). OAGB rose from 0% of procedures in 2011 to 15% in 2021 (p < 0.0001). BPD underwent decrease from 6.2 to 0.2% in 2011 and 2021, respectively (p < 0.0001). Main non-malabsorptive procedures significantly decreased while overall bypass procedures remained stable. There were significant differences among regions in performance of SG, RYGB, and OAGB.

CONCLUSIONS

BS in Italy evolved significantly during the past 10 years. AGB underwent a decline, as did BPD and GP which are disappearing and RYGB which is giving way to OAGB. The latter is rising and is the second most-performed procedure after SG which has been confirmed as the preferred procedure by Italian bariatric surgeons.

Safety and Efficacy of Laparoscopic Vertical Clip Gastroplasty: Early Results of an Italian Multicenter Study

PURPOSE

Sleeve gastrectomy, the most commonly performed bariatric surgery procedure, carries limitations both short term including postoperative complications such as hemorrhage and gastric fistula and long term such as weight regain and gastroesophageal reflux. A new procedure has been proposed to overcome many of these limitations: laparoscopic vertical clip gastroplasty (LVCG) with BariClip.

MATERIALS AND METHODS

Fifty patients were offered LVCG and enrolled for a feasibility study in two referral bariatric centers. Indication was given as for sleeve gastrectomy, after a multidisciplinary path evaluating age, gender, BMI, comorbidities, eating behaviors, and gastroesophageal reflux. The primary outcome was major postoperative complications. Secondary outcomes included weight loss, incidence of de-novo GERD, and comorbidity resolution.

RESULTS

Patients had a mean age of 44 years and mean BMI of 37 kg/m² ± 6.2. All procedures were performed successfully in laparoscopy, with no conversion or intraoperative adverse events. The overall major postoperative complication rate was 6%. Re-operation was required in three patients for slippage. No mortality occurred. Excess weight loss, excess BMI loss, and total weight loss at 6 months were 36%, 57%, and 22%, respectively. There was no instance of de-novo GERD. Resolution of hypertension occurred in 50% of cases, OSAS in 65% of cases, and DMII in 80% of cases.

CONCLUSION

The safety of LVCG procedure has been reproduced in a multicentric, multi-surgeon study. Weight loss outcomes appear promising. A randomized trial is needed to fully assess the benefits of LVCG.

Impact of concurrent hiatal hernia repair during laparoscopic sleeve gastrectomy on patient-reported gastroesophageal reflux symptoms: a state-wide analysis

BACKGROUND

Concurrent hiatal hernia repair (HHR) during laparoscopic sleeve gastrectomy (LSG) may improve gastroesophageal reflux disease (GERD) symptoms. However, patient-reported outcomes are limited, and the influence of surgeon technique remains unclear.

OBJECTIVES

To assess patient-reported GERD severity before and after LSG with and without concomitant HHR.

SETTING

Teaching and non-teaching hospitals participating in a state-wide quality improvement collaborative.

METHODS

Using a state-wide bariatric-specific data registry, all patients who underwent a primary LSG between 2015 and 2019 who completed a baseline and 1 year validated GERD health related quality of life (GERD-HRQL) survey were identified (n = 11,742). GERD severity at 1 year as well as 30-day risk-adjusted adverse events was compared between patients who underwent LSG with or without HHR. Results were also stratified by anterior versus posterior HHR.

RESULTS

A total of 4015 patients underwent a LSG-HHR (34%). Compared to patients who underwent LSG without HHR, LSG-HHR patients were older (47.8 yr versus 44.6 yr; P < .0001), had a lower preoperative body mass index (BMI) (45.8 kg/m² versus 48 kg/m²; P < .0001) and more likely to be female (85.2% versus 77.6%, P < .0001). Patients who underwent a posterior HHR (n = 3205) experienced higher rates of symptom improvement (69.5% versus 64.0%, P = .0014) and lower rates of new onset symptoms at 1 year (28.2% versus 30.2%, P = .0500). Patients who underwent an anterior HHR (n = 496) experienced higher rates of hemorrhage and readmissions with no significant difference in symptom improvement.

CONCLUSIONS

Concurrent posterior hiatal HHR at the time of sleeve gastrectomy can improve reflux symptoms. Patients undergoing anterior repair derive no benefit and should be avoided.

Comparison of Sleeve Gastrectomy vs Intensive Lifestyle Modification in Patients With a BMI of 30 to Less Than 35

IMPORTANCE

There is a lack of studies evaluating sleeve gastrectomy compared with intensive lifestyle treatment in patients with class 1 obesity (body mass index [BMI] 30 to <35 [calculated as weight in kilograms divided by height in meters squared]).

OBJECTIVE

To compare outcomes and safety of sleeve gastrectomy compared with intensive nonoperative obesity treatment in patients with class 1 obesity.

DESIGN, SETTING, AND PARTICIPANTS

This matched, nationwide cohort study included patients with class 1 obesity who underwent a sleeve gastrectomy or intensive lifestyle treatment between January 1, 2012, and December 31, 2017, and who were registered in the Scandinavian Obesity Surgery Registry or the Itrim health database. Participants with class 1 obesity were matched 1:2 using a propensity score including age, sex, BMI, treatment year, education level, income, cardiovascular disease, and use of antibiotic drugs, antidepressants, and anxiolytics.

INTERVENTIONS

Sleeve gastrectomy or intensive lifestyle treatment.

MAIN OUTCOMES AND MEASURES

Outcomes included weight loss after intervention, changes in metabolic comorbidities, substance use disorders, self-harm, and major cardiovascular events retrieved from the National Patient Register, Prescribed Drug Register, and Cause of Death Register as well as the Scandinavian Obesity Surgery Registry and the Itrim health database. Data were analyzed from December 1, 2021 until May 31, 2022.

RESULTS

The study included 1216 surgery patients and 2432 lifestyle participants with similar mean (SD) BMI (32.8 [1.4] vs 32.9 [1.4]), mean (SD) age (42.4 [9.7] vs 42.6 [12.7] years), and sex (1091 [89.7%] vs 2191 [90.1%] women). Surgery patients had greater 1-year weight loss compared with controls (22.9 kg vs 11.9 kg; mean difference, 10.7 kg; 95% CI, 10.0-11.5 kg; P < .001). Over a median follow-up of 5.1 years (IQR, 3.9-6.2 years), surgery patients had a lower risk of incident use of diabetes drugs (59.7 vs 100.4 events per 10 000 person-years; hazard ratio [HR], 0.60; 95% CI, 0.39-0.92; P = .02) and greater 2-year diabetes drug remission (48.4% vs 22.0%; risk difference 26.4%; 95% CI, 11.7%-41.0%; P < .001), but higher risk for substance use disorder (94 vs 50 events per 10 000 person-years; HR, 1.86; 95% CI, 1.30-2.67; P < .001) and self-harm (45 vs 25 events per 10 000 person-years; HR, 1.81; 95% CI, 1.09-3.01; P = .02). No between-group difference in occurrence of major cardiovascular events was observed (23.4 vs 24.8 events per 10 000 person-years; HR, 0.96; 95% CI, 0.49-1.91; P = .92).

CONCLUSIONS AND RELEVANCE

In this cohort study, compared with intensive nonoperative obesity treatment, sleeve gastrectomy in patients with class 1 obesity was associated with greater weight loss, diabetes prevention, and diabetes remission but a higher incidence of substance use disorder and self-harm.