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De Luca M, Zese M, Bandini G, Zappa MA, Bardi U, Carbonelli MG, Carrano FM, Casella G, Chianelli M, Chiappetta S, Iossa A, Martinino A, Micanti F, Navarra G, Piatto G, Raffaelli M, Romano E, Rugolotto S, Serra R, Soricelli E, Vitiello A, Schiavo L, Zani ICM, Ragghianti B, Lorenzoni V, Medea G, Antognozzi V, Bellini R, Berardi G, Campanile FC, Facchiano E, Foletto M, Gentileschi P, Olmi S, Petrelli M, Pilone V, Sarro G, Ballardini D, Bettini D, Costanzi A, Frattini F, Lezoche G, Neri B, Porri D, Rizzi A, Rossini R, Sessa L, D'Alessio R, Di Mauro G, Tolone S, Bernante P, Docimo L, Foschi D, Angrisani L, Basso N, Busetto L, Di Lorenzo N, Disoteo O, Forestieri P, Musella M, Paolini B, Silecchia G, Monami M. SICOB Italian clinical practice guidelines for the surgical treatment of obesity and associated diseases using GRADE methodology on bariatric and metabolic surgery. Updates Surg 2024:10.1007/s13304-024-01996-z. [PMID: 39419949 DOI: 10.1007/s13304-024-01996-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2024] [Indexed: 10/19/2024]
Abstract
Obesity is a chronic disease associated with increased morbidity and mortality and reduced quality of life. Pharmacotherapy can be associated with life style changes in increasing and maintaining weight loss and ameliorating obesity-related complications and comorbidities. In patients affected by obesity and uncontrolled obesity-associated complications or high degrees of BMI (> 40 Kg/m2), metabolic bariatric surgery can be a valid therapeutic option. Many different types of surgical procedures have been developed in last decades, mainly performed via laparoscopic approaches. However, clinical indications for metabolic and bariatric surgery (MBS) and the choice of the most appropriate type of procedure have not been clarified so far.The Italian Society of Bariatric and Metabolic Surgery for Obesity (Società Italiana di Chirurgia dell'Obesità e delle Malattie Metaboliche-SICOB) decided to design and develop the updated version of the Italian guidelines aimed at assisting healthcare professionals in the choice of the surgical option for the treatment of obesity and related conditions. Between June and October 2022, a panel of 24 experts and an evidence review team (ERT, 10 members), participated in the definition of clinical questions, outcomes, and recommendations and collected and analyzed all the available evidence on the basis of pre-specified search strategies. GRADE methodology and PICO (Patient, Intervention, Comparison, Outcome) conceptual framework have been adopted for the development of the present guidelines. Aim of the present guideline is to verify indications to surgery with respect to the presence of comorbid conditions, evaluate the different types of surgical approaches and endoscopic bariatric procedure and revise indication to revision surgery and postoperative procedures.
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Affiliation(s)
- Maurizio De Luca
- Rovigo Hospital, ULSS5 Polesana, Viale Tre Martini, Rovigo, Italy
| | - Monica Zese
- Rovigo Hospital, ULSS5 Polesana, Viale Tre Martini, Rovigo, Italy.
| | - Giulia Bandini
- Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | | | - Ugo Bardi
- Casa Di Cura Privata Salus SpA, Salerno, Italy
| | | | | | - Giovanni Casella
- Università Degli Studi Di Roma La Sapienza, AOU Policlinico Umberto I, Rome, Italy
| | | | | | - Angelo Iossa
- Sapienza Università Di Roma, Polo Ospedaliero Integrato Università Ausl Lt Latina, Latina, Italy
| | | | - Fausta Micanti
- Università Degli Studi Di Napoli "Federico II", Naples, Italy
| | | | | | - Marco Raffaelli
- Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Simone Rugolotto
- Rovigo Hospital, ULSS5 Polesana, Viale Tre Martini, Rovigo, Italy
| | | | | | | | - Luigi Schiavo
- Università Degli Studi Di Salerno A.O.U. San Giovanni Di Dio E Ruggi D'Aragona Ospedale G. Fucito, Salerno, Italy
| | | | - Benedetta Ragghianti
- Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
| | | | | | | | | | | | | | | | | | | | | | | | - Vincenzo Pilone
- Università Degli Studi Di Salerno A.O.U. San Giovanni Di Dio E Ruggi D'Aragona, Salerno, Italy
| | - Giuliano Sarro
- Istituto Ad Alta Specializzazione - San Gaudenzio, Novara, Italy
| | | | - Dario Bettini
- Azienda AUSL Della Romagna Ospedale G.B.Morgagni-L.Pierantoni, Forlì Cesena, Italy
| | | | | | | | | | | | | | | | - Luca Sessa
- Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Gianluca Di Mauro
- Azienda Ospedaliero Universitaria "G. Rodolico- San Marco", Catania, Italy
| | | | - Paolo Bernante
- Centro Interaziendale Chirurgia Metabolica e obesità IRCCS Policlinico Sant'Orsola Ausl Bentivoglio, Bologna, Italy
| | | | | | - Luigi Angrisani
- Ospedale Santa Maria La Bruna, Torre del Greco, Naples, Italy
| | | | - Luca Busetto
- Policlinico Universitario Di Padova, Padua, Italy
| | | | - Olga Disoteo
- ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Mario Musella
- Università Degli Studi Di Napoli "Federico II", Naples, Italy
| | | | | | - Matteo Monami
- Azienda Ospedaliero Universitaria Careggi and University of Florence, Florence, Italy
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Stumpf MAM, Mancini MC. Challenges in the care and treatment of patients with extreme obesity. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2024; 68:e230335. [PMID: 39420906 PMCID: PMC11326745 DOI: 10.20945/2359-4292-2023-0335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 02/25/2024] [Indexed: 10/19/2024]
Abstract
Obesity is a prevalent chronic disease. The management of extreme obesity - i.e., body mass index (BMI) ≥ 50 kg/m2 or obesity class IV and V - is still far from ideal. Individuals with extreme obesity have a high risk of surgical complications, mortality, comorbidities, and reduced weight loss following bariatric surgery. Although lifestyle changes and anti-obesity medications are recommended for all patients with extreme obesity as adjuvants to weight loss, these measures are less effective than bariatric surgery. As a first step, sleeve gastrectomy or an inpatient very-low-calorie diet should be incentivized to enhance weight loss before definitive surgery. Although malabsorptive procedures lead to greater weight loss, they are associated with an increased risk of early complications and malnutrition. Nonstandard techniques employed in clinical trial protocols, such as transit bipartition, may be performed as they maintain a weight loss potency comparable to that of the classic duodenal switch but with fewer nutritional problems. Anatomical causes should be investigated in patients with postoperative suboptimal clinical response or recurrent weight gain. In these cases, the initiation of anti-obesity drugs, endoscopic therapies, or a conversion procedure might be recommended. More studies are needed to address the specific population of patients with extreme obesity, as their outcomes are expected to be distinct from those of patients with lower BMI.
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Affiliation(s)
- Matheo A M Stumpf
- Hospital das Clínicas Faculdade de Medicina Universidade de São Paulo São PauloSP Brasil Unidade de Obesidade, Divisão de Endocrinologia e Metabolismo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - Marcio C Mancini
- Hospital das Clínicas Faculdade de Medicina Universidade de São Paulo São PauloSP Brasil Unidade de Obesidade, Divisão de Endocrinologia e Metabolismo, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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Kermansaravi M, Shikora S, Dillemans B, Kurian M, LaMasters T, Vilallonga R, Prager G, Chiappetta S. The Management of Biliary Disease in Patients with Severe Obesity Undergoing Metabolic and Bariatric Surgery-An International Expert Survey. Obes Surg 2024; 34:1086-1096. [PMID: 38400945 DOI: 10.1007/s11695-024-07101-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/09/2024] [Accepted: 02/15/2024] [Indexed: 02/26/2024]
Abstract
OBJECTIVE This study aimed to survey international experts in metabolic and bariatric surgery (MBS) to improve and consolidate the management of biliary disease in patients with severe obesity undergoing MBS. BACKGROUND Obesity and rapid weight loss after MBS are risk factors for the development of gallstones. Complications, such as cholecystitis, acute cholangitis, and biliary pancreatitis, are potentially life-threatening, and no guidelines for the proper management of gallstone disease exist. METHODS An international scientific team designed an online confidential questionnaire with 26 multiple-choice questions. The survey was answered by 86 invited experts (from 38 different countries), who participated from August 1, 2023, to September 9, 2023. RESULTS Two-thirds of experts (67.4%) perform concomitant cholecystectomy in symptomatic gallstones during MBS. Half of experts (50%) would wait 6-12 weeks between both surgeries with an interval approach. Approximately 57% of the experts prescribe ursodeoxycholic acid (UDCA) prophylactically after MBS, and most recommend a 6-month course. More than the half of the experts (59.3%/53.5%) preferred laparoscopic assisted transgastric ERCP as the approach for treating CBD stones in patients who previously had RYGB/OAGB. CONCLUSION Concomitant cholecystectomy is preferred by the experts, although evidence in the literature reports an increased complication rate. Prophylactic UDCA should be recommended to every MBS patient, even though the current survey demonstrated that not all experts are recommending it. The preferred approach for treating common bile duct stones is a laparoscopic assisted transgastric ERCP after gastric bypass. The conflicting responses will need more scientific work and clarity in the future.
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Affiliation(s)
- Mohammad Kermansaravi
- Division of Minimally Invasive and Bariatric Surgery, Department of Surgery, Hazrat-E Fatemeh Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
| | - Scott Shikora
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bruno Dillemans
- Department of General Surgery, AZ Sint Jan Brugge-Oostende, Brugge, Belgium
| | - Marina Kurian
- Department of Surgery, NYU Langone Medical Center, New York, NY, 10016, USA
| | - Teresa LaMasters
- UnityPoint Clinic Weight Loss Specialists, West Des Moines, IA, USA
| | - Ramon Vilallonga
- Endocrine, Bariatric and Metabolic Surgery Department, University Hospital Vall Hebron, Barcelona, Spain
| | - Gerhard Prager
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Sonja Chiappetta
- Bariatric and Metabolic Surgery Unit, Department of General and Laparoscopic Surgery, Ospedale Evangelico Betania, Via Argine 604, 80147, Naples, Italy.
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Coogan AC, Williams MD, Krishnan V, Skertich NJ, Becerra AZ, Sarran M, Schimpke S, Torquati A, Omotosho P. Ursodiol Prescriptions Following Bariatric Surgery: National Prescribing Trends and Outcomes. Obes Surg 2023; 33:2361-2367. [PMID: 37392353 DOI: 10.1007/s11695-023-06710-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/23/2023] [Accepted: 06/26/2023] [Indexed: 07/03/2023]
Abstract
BACKGROUND Rapid weight loss after bariatric surgery is a risk factor for gallstone development. Numerous studies have shown that ursodiol after surgery decreases rates of gallstone formation and cholecystitis. Real-world prescribing practices are unknown. This study aimed to examine prescription patterns for ursodiol and reassess its impact on gallstone disease using a large administrative database. METHODS The Mariner database (PearlDiver, Inc.) was queried using Current Procedural Terminology codes for Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) between 2011 and 2020. Only patients with International Classification of Disease codes for obesity were included. Patients with pre-operative gallstone disease were excluded. The primary outcome was gallstone disease within 1 year, which was compared between patients who did and did not receive an ursodiol prescription. Prescription patterns were also analyzed. RESULTS Three hundred sixty-five thousand five hundred patients fulfilled inclusion criteria. Twenty-eight thousand seventy-five (7.7%) patients were prescribed ursodiol. There was a statistically significant difference in development of gallstones (p < 0.001), development of cholecystitis (p = .049), and undergoing cholecystectomy (p < 0.001). There was a statistically significant decrease in the adjusted odds ratio (aOR) for the development of gallstones (aOR 0.81, 95% CI: 0.74, 0.89), development of cholecystitis (aOR 0.59, 95% CI: 0.36, 0.91), and undergoing cholecystectomy (aOR 0.75, 95% CI: 0.69, 0.81). CONCLUSION Ursodiol significantly decreases the odds of development of gallstones, cholecystitis, or cholecystectomy within 1 year following bariatric surgery. These trends hold true when analyzing RYGB and SG separately. Despite the benefit of ursodiol, only 10% of patients received an ursodiol prescription postoperatively in 2020.
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Affiliation(s)
- Alison C Coogan
- Department of Surgery, Rush University Medical Center, 1750 W Harrison, Suite 775, Chicago, IL, 60612, USA.
| | - Michael D Williams
- Department of Surgery, Rush University Medical Center, 1750 W Harrison, Suite 775, Chicago, IL, 60612, USA
| | - Vaishnavi Krishnan
- Department of Surgery, Rush University Medical Center, 1750 W Harrison, Suite 775, Chicago, IL, 60612, USA
| | - Nicholas J Skertich
- Department of Surgery, Rush University Medical Center, 1750 W Harrison, Suite 775, Chicago, IL, 60612, USA
| | - Adan Z Becerra
- Department of Surgery, Rush University Medical Center, 1750 W Harrison, Suite 775, Chicago, IL, 60612, USA
| | - Marc Sarran
- Department of Surgery, Rush University Medical Center, 1750 W Harrison, Suite 775, Chicago, IL, 60612, USA
| | - Scott Schimpke
- Department of Surgery, Rush University Medical Center, 1750 W Harrison, Suite 775, Chicago, IL, 60612, USA
| | - Alfonso Torquati
- Department of Surgery, Rush University Medical Center, 1750 W Harrison, Suite 775, Chicago, IL, 60612, USA
| | - Philip Omotosho
- Department of Surgery, Rush University Medical Center, 1750 W Harrison, Suite 775, Chicago, IL, 60612, USA
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