How safe bariatric surgery is-An update on perioperative mortality for clinicians and patients

Endoluminal Vacuum Therapy as Effective Treatment for Patients with Postoperative Leakage After Metabolic Bariatric Surgery-A Single-Center Experience

BACKGROUND

Metabolic bariatric surgery (MBS) is standardized and safe. Nevertheless, complications such as anastomotic leakage (AL) or staple-line leakage (SLL) can occur. In upper GI or colorectal surgery, endoluminal vacuum therapy (EVT) offers a therapeutic alternative to revisional surgery. Data on EVT in patients with leakage after MBS remain scarce. The aim of this study is to evaluate the efficacy of EVT and its potential as endoscopic alternative to revisional surgery.

MATERIAL AND METHODS

All patients treated for AL or SLL with EVT after MBS between 01/2016 and 08/2023 at the Department for General Surgery, Medical University Vienna, were included in this retrospective, single-center study. Therapeutic value of EVT as management option for acute postoperative leakage after MBS in daily practice was evaluated. Statistical analyses were performed descriptively.

RESULTS

Twenty-one patients were treated with EVT within the observational period of 7 years. In 11 cases (52.4%), the index surgery was a primary bariatric intervention; in 10 cases (47.6%), a secondary surgery after initial MBS was performed. Favored approach was a combination of revisional surgery and EVT (n = 18; 85.7%), intermediate self-expanding metal stent (SEMS) in 16 (76.2%) cases. EVT was changed six times (0-33) every 3-4 days. Mean EVT time was 25.1 days (3-97). No severe associated complications were detected and EVT showed an efficacy of 95.2%.

CONCLUSION

This small case series supports the trend to establish EVT in daily clinical practice when revisional surgery after MBS is needed, thus preventing further reoperation and reducing associated morbidity and mortality in critically ill patients.

Early postoperative COVID infection is associated with significantly increased risk of venous thromboembolism after metabolic and bariatric surgery

BACKGROUND

Patients who undergo metabolic and bariatric surgery (MBS) are at risk for thromboembolism. Patients are susceptible to coronavirus throughout the perioperative period, which also has a well-known association with thrombotic complications.

OBJECTIVES

To identify and define the association between venous thromboembolism (VTE) and postoperative coronavirus diagnosis in bariatric surgery patients.

SETTING

United States.

METHODS

We conducted a retrospective cohort study using the MBS Accreditation and Quality Improvement Program (MBSAQIP) 2021 database to analyze the incidence of VTE within 30 days of surgery. VTE was a composite variable defined as either postoperative pulmonary embolism or postoperative venous thrombus requiring treatment. Cohorts were stratified by whether the patient was diagnosed with postoperative coronavirus. We created a multivariable logistic regression model to determine the adjusted odds of postoperative VTE based on various factors. Additionally, we conducted subset analyses of sleeve gastrectomy and Roux-en-Y bypass cases, the 2 most frequent bariatric operations in the United States.

RESULTS

Patients diagnosed with postoperative coronavirus were significantly more likely to develop postoperative VTE (1.1% versus .3%, P < .001). In our logistic regression model, the adjusted odds of postoperative VTE for patients with postoperative coronavirus was 3.55 (95% CI: 2.15-5.87, P < .001). For patients who underwent Roux-en-Y bypass, the adjusted odds was even greater at 5.69 (95% CI: 2.76-11.70, P < .001).

CONCLUSIONS

Early postoperative coronavirus infection after MBS is associated with higher odds of postoperative VTE. This persisted on subset analyses of the 2 most common procedures and appeared particularly important for Roux-en-Y bypass. COVID infection after MBS may warrant prolonged VTE prophylaxis.

Outcomes of bariatric surgery in the setting of compensated advanced chronic liver disease associated with clinically significant portal hypertension: a multicenter, retrospective, cohort study on feasibility and safety

BACKGROUND

The obesity epidemic has led to an increase in the proportion of patients with chronic liver disease due to metabolic associated steatosic liver disease and in the prevalence of obesity in patients with cirrhosis. Metabolic and bariatric surgery (MBS) has been proven to determine weight loss, obesity-related medical problems remission, and liver steatosis, inflammation, and fibrosis improvement. However, cirrhosis and portal hypertension are well-known risk factors for increased morbidity and mortality after surgery. The aim of this study is to evaluate the safety of MBS in patients with compensated advanced chronic liver disease (cALCD) and clinically significant portal hypertension (CSPH).

MATERIAL AND METHODS

This is an international, multicentric, retrospective study on 63 individuals affected by obesity with cALCD and CSPH who underwent MBS in tertiary referral centers with experts hepatobiliary surgeons between January 2010 and October 2022. The primary endpoint was postoperative mortality at 90 days. The secondary endpoints included postoperative weight loss at last follow-up and postoperative complication rate. In addition, the authors performed subgroup analyses of Child-Pugh (A vs. B) score, MELD (≤9 vs. >9) score, and type of surgery.

RESULTS

One patient (1.6%) experienced gastric leakage and mortality. There were three (5%) reported cases of portal vein thrombosis, two (3%) postoperative acute renal failure, and one (1.6%) postoperative encephalopathy. Child-Pugh score A resulted to be a protective factor for intraoperative bleeding requiring transfusion at univariate analysis (OR: 0.73, 95% CI: 0.55-0.97, P =0.046) but not at multivariate analysis. MELD>9 score and the type of surgery did not result to be a risk factor for any postoperative complication.

CONCLUSION

MBS is safe in patients with cALCD and CSPH performed in tertiary bariatric referral centers with hepatobiliary expert surgeons. Larger, prospective studies with longer follow-up periods are needed to confirm these results.

Indications and Coverage of Metabolic and Bariatric Surgery: A Worldwide IFSO Survey Comparing Different National Guidelines

INTRODUCTION

Knowing how metabolic and bariatric surgery (MBS) is indicated in different countries is essential information for the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO).

AIM

To analyze the indications for MBS recommended by each of the national societies that comprise the IFSO and how MBS is financed in their countries.

METHODS

All IFSO societies were asked to fill out a survey asking whether they have, and which are their national guidelines, and if MBS is covered by their public health service.

RESULTS

Sixty-three out of the 72 IFSO national societies answered the form (87.5%). Among them, 74.6% have some kind of guidelines regarding indications for MBS. Twenty-two percent are still based on the US National Institute of Health (NIH) 1991 recommendations, 43.5% possess guidelines midway the 1991s and ASMBS/IFSO 2022 ones, and 34% have already adopted the latest ASMBS/IFSO 2022 guidelines. MBS was financially covered in 65% of the countries.

CONCLUSIONS

Most of the IFSO member societies have MBS guidelines. While more than a third of them have already shifted to the most updated ASMBS/IFSO 2022 ones, another significant number of countries are still following the NIH 1991 guidelines or even do not have any at all. Besides, there is a significant number of countries in which surgical treatment is not yet financially covered. More effort is needed to standardize indications worldwide and to influence insurers and health policymakers to increase the coverage of MBS.

Bariatric Surgery and Malpractice: an Extensive Review of Demographics, Complications, Litigation, and Proactive Mitigation Strategies

The rising prevalence of severe obesity has led to a parallel increase in bariatric surgeries, raising a complex array of medicolegal issues. This review aims to analyze and synthesize literature on bariatric surgery malpractice, focusing on patient demographics, surgical complications, litigation costs, and the nature of malpractice cases. A systematic search was conducted across multiple databases for relevant studies published up to May 2023. Our review endeavors to provide insights into these medicolegal challenges and their implications and foster an informed dialogue on strategies for their effective management. By doing so, we hope to enhance ethical and legally sound bariatric practices, safeguarding both patient welfare and surgical practitioners from legal repercussions.

Apprehensions of Morbidly Obese People Regarding Bariatric Surgery

Introduction Obesity has emerged as a major public health issue in both developed and developing countries. The prevalence of obesity is on the rise. Bariatric surgery is acknowledged as the most effective and safe solution for this problem. It has been shown to be effective in sustained weight loss and improving quality of life. The aim of this study was to identify the causes of reluctance to have surgery among patients who were potential candidates for weight loss procedures. Method Morbidly obese people who were enrolled at Khyber Teaching Hospital, Peshawar, from December 2021 to August 2022 were included in the study. It included hospitalized as well as outpatient appointments. A questionnaire was adopted as the data collection tool. Result A total of 107 patients (58 men and 49 women) were enrolled in the study. The median age was 42. Of the 107 patients, 5% (n=5) of the patients were super morbidly obese (BMI >50kg/m2). Seventy-two percent (n=77) of the population considered themselves morbidly obese. Only 22% (n=24) were physically active. Twenty percent (n=21) of the patients reported that they have or are currently trying dietary modifications for weight loss. Young females were most likely to be on dieting programs. Importantly, 56% (n=60) had never heard of bariatric surgery. Exploring the reasons for reluctance among patients revealed that the concern for surgical mortality was the major hindrance. This was followed by being not interested in committing to surgery and recovery. Concerns regarding cost and financing were also the reasons candidates didn't opt for surgical procedures to treat obesity. Conclusion The study concluded that there is a serious lack of knowledge and awareness among physicians and the general public regarding bariatric surgery. Most of the patients who were potential candidates for the procedure weren't aware that obesity had a surgical and definitive treatment. Patients who were aware of the surgical procedure were hesitant to undergo surgery for the management of their weight as they harbored misconceptions, particularly regarding the safety and efficacy of the procedure.

Endoscopy management of sleeve gastrectomy stenosis: what we learned from 202 consecutive patients

BACKGROUND

Gastric sleeve stenosis (GSS) is described in 1%-4% of patients.

OBJECTIVE

To evaluate the role of endoscopy in the management of stenosis after laparoscopic sleeve gastrectomy using a standardized approach according to the characteristic of stenosis.

SETTING

Retrospective, observational, single-center study on patients referred from several bariatric surgery departments to an endoscopic referral center.

METHODS

We enrolled 202 patients. All patients underwent endoscopy in a fluoroscopy setting, and a systematic classification of the type, site, and length of the GSS was performed. According to the characteristics of the stenosis, patients underwent pneumatic dilatation or placement of a self-expandable metal stent or a lumen-apposed metal stent. Failure of endoscopic treatment was considered an indication for redo surgery, whereas patients with partial or complete response were followed up for 2 years. In the event of a recurrence, a different endoscopic approach was used.

RESULTS

We found inflammatory strictures in 4.5% of patients, pure narrowing in 11%, and functional stenosis in 84.5%. Stenosis was in the upper tract of the stomach in 53 patients, whereas medium and distal stenosis was detected in 138 and 11 patients, respectively, and short stenosis in 194 patients. A total of 126 patients underwent pneumatic dilatation, 8 self-expandable metal stent placement, 64 lumen-apposed metal stent positioning, and 36 combined therapy. The overall rate of endoscopy success was 69%.

CONCLUSION

GSS should be considered to be a chronic disease, and the endoscopic approach seems to be the most successful treatment, with a prolonged positive outcome of 69%. Characteristics of the stenosis should guide the most suitable endoscopic approach.