The learning curve of one anastomosis gastric bypass and its impact as a preceding procedure to Roux-en Y gastric bypass: initial experience of one hundred and five consecutive cases

Comparative Study for Safety and Efficacy of OAGB and SADJB-SG: A Retrospective Study

Purpose

Obesity and related complications are managed by One Anastomosis Gastric Bypass (OAGB) and Single Anastomosis Duodeno-Jejunal Bypass with Sleeve Gastrectomy (SADJB-SG), both of which are adapted from traditional gastric bypass procedures. However, there are no current comparative studies on the safety and efficacy of these two surgical procedures.

Patients and Methods

Preoperative baseline data of patients who had undergone OAGB and SADJB-SG surgeries from June 2019 to June 2021 were retrospectively analyzed at our bariatric facility. Postoperative data, including weight changes, improvement in type 2 diabetes (T2DM), and complication rates were collected over 2 years. This was followed by a comprehensive evaluation of the safety and efficacy of the two surgical procedures.

Results

A total of 63 patients completed the follow-up in this study. At the 24-month follow-up, excess weight loss percentage (EWL%) for the OAGB and SADJB-SG was 73.970±5.005 and 75.652±7.953, respectively (P-value = 0.310); total weight loss percentage (TWL%) was 24.006±8.231 and 23.171±6.600, respectively (P-value = 0.665). The diabetes remission rates for the two groups were 71.429% and 69.048%, respectively (P-value = 0.846). The cost for OAGB was 55088.208±1508.220 yuan, which was significantly lower than the 57538.195±1374.994 yuan for SADJB-SG (P-value< 0.001).

Conclusion

The two surgical procedures are reliable in terms of safety and efficacy, and each has distinct advantages. While OAGB has reduced operational expenses, SADJB-SG offers a broader range of applicability.

Metabolic and Bariatric Surgeon Criteria-An International Experts' Consensus

PURPOSE

With the global epidemic of obesity, the importance of metabolic and bariatric surgery (MBS) is greater than ever before. Performing these surgeries requires academic training and the completion of a dedicated fellowship training program. This study aimed to develop guidelines based on expert consensus using a modified Delphi method to create the criteria for metabolic and bariatric surgeons that must be mastered before obtaining privileges to perform MBS.

METHODS

Eighty-nine recognized MBS surgeons from 42 countries participated in the Modified Delphi consensus to vote on 30 statements in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was regarded to indicate a consensus.

RESULTS

Consensus was reached on 29 out of 30 statements. Most experts agreed that before getting privileges to perform MBS, surgeons must hold a general surgery degree and complete or have completed a dedicated fellowship training program. The experts agreed that the learning curves for the various operative procedures are approximately 25-50 operations for the LSG, 50-75 for the OAGB, and 75-100 for the RYGB. 93.1% of experts agreed that MBS surgeons should diligently record patients' data in their National or Global database.

CONCLUSION

MBS surgeons should have a degree in general surgery and have been enrolled in a dedicated fellowship training program with a structured curriculum. The learning curve of MBS procedures is procedure dependent. MBS surgeons must demonstrate proficiency in managing postoperative complications, collaborate within a multidisciplinary team, commit to a minimum 2-year patient follow-up, and actively engage in national and international MBS societies.

Technical Variations and Considerations around OAGB in IFSO-APC and IFSO-MENAC Chapters, an Expert Survey

OBJECTIVE

This study aimed to evaluate the technical variations of one-anastomosis gastric bypass (OAGB) among IFSO-APC and MENAC experts.

BACKGROUND

The multitude of technical variations and patient selection challenges among metabolic and bariatric surgeons worldwide necessitates a heightened awareness of these issues. Understanding different perspectives and viewpoints can empower surgeons performing OAGB to adapt their techniques, leading to improved outcomes and reduced complications.

METHODS

The scientific team of IFSO-APC, consisting of skilled bariatric and metabolic surgeons specializing in OAGB, conducted a confidential online survey. The survey aimed to assess technical variations and considerations related to OAGB within the IFSO-APC and IFSO-MENAC chapters. A total of 85 OAGB experts participated in the survey, providing their responses through a 35-question online format. The survey took place from January 1, 2024, to February 15, 2024.

RESULTS

Most experts do not perform OAGB for children and adolescents younger than 18 years. Most experts create the gastric pouch over a 36-40-F bougie and prefer to create a gastrojejunostomy, at the posterior wall of the gastric pouch. An anti-reflux suture during OAGB is performed in all patients by 51.8% of experts. Most experts set a common limb length of > 4 m in revisional and conversional OAGBs to prevent nutritional complications.

CONCLUSION

The ongoing debate among metabolic and bariatric surgeons regarding the technical variations and patient selection in OAGB remains a significant point of discussion. This survey demonstrated the variations in technical aspects and patient selection for OAGB among MBS surgeons in the IFSO-APC and IFSO-MENAC chapters. Standardizing the OAGB technique is crucial to ensure optimal safety and efficacy in this procedure.

Metabolic and Bariatric Surgery in Children: Current Practices and Outcomes

PURPOSE OF REVIEW

This review will examine the most current evidence for Metabolic and Bariatric Surgery (MBS) in the pediatric population, specifically in terms of weight loss outcomes and improvement in comorbid conditions and complications. Additionally, we compare surgical and non-surgical interventions, review current guidelines, and propose a stepwise evidence-based approach to the management of obesity in children.

RECENT FINDINGS

MBS is a safe option for appropriately selected pediatric patients which leads to significant and sustained weight loss. This weight loss is associated with improvement of related comorbid conditions. Laparoscopic sleeve gastrectomy (LSG) has emerged as the procedure of choice with a better safety profile. Despite the evidence, very few adolescents undergo MBS. New pharmacologic agents specifically the GLP-1/GIP agents have shown early promise especially in patients under body mass index 40, but the long-term effects are unknown. MBS is an effective tool in the management of pediatric obesity, and its use has been recommended by professional societies. Early referral to a multidisciplinary obesity team can help identify appropriate patients.

Initial experience with laparoscopic gastric bypass in an Australian general foregut surgery unit

BACKGROUND

Laparoscopic gastric bypass (LGB) is an increasingly utilized approach to bariatric surgery in Australia. A high proportion of those procedures are revisional due to Australia's legacy of laparoscopic adjustable gastric banding (LAGB), which is not the case internationally. The aim of this study was to compare post-operative outcomes in an Australian general foregut surgery unit against benchmarks published in the literature.

METHODS

This is retrospective cohort study of morbidly obese patients undergoing primary or revisional laparoscopic Roux-en-Y gastric bypass (RYGB) or laparoscopic one anastomosis gastric bypass (OAGB) with the two senior authors between 5 May 2015 and 27 June 2019. Perioperative data for the unit's first 100 cases were collected prospectively, stored on a unit database and analysed. Post-operative complications at 30 days, 90 days, mortality, length of hospital stay, and Defined Adverse Events were chosen as indicators of the perioperative outcome (as defined in the Monash Bariatric Surgery Registry).

RESULTS

In this cohort, 35% of procedures were RYGB and 65% were OAGB. The majority (58%) were revisional procedures. Most patients (74%) were female. The median age was 50. The comorbidity profile of the population was similar to those published internationally. The median hospital stay was 4 days. There was no mortality. Early complications occurred in 9% of patients, with 3% occurring late.

CONCLUSION

Outcomes of our first 100 cases are comparable with those recorded in the literature, notwithstanding a much higher proportion of revisional cases. LGB can be safely introduced in Australian general foregut surgery units by experienced laparoscopic surgeons.

Management of leaks following one-anastomosis gastric bypass: an updated systematic review and meta-analysis of 44 318 patients

INTRODUCTION

One-anastomosis gastric bypass (OAGB) complication, such as leakage, can be dangerous and should be managed properly, yet little data exist in the literature regarding the management of leaks after OAGB, and there are no guidelines to date.

METHODS

The authors performed a systematic review and meta-analysis of the literature and 46 studies, examining 44 318 patients were included.

RESULTS

There were 410 leaks reported in 44 318 patients of OAGB published in the literature, which represents a prevalence of 1% of leaks after OAGB. The surgical strategy was very variable among all the different studies; 62.1% of patients with leaks had to undergo another surgery due to the leak. The most commonly performed procedure was peritoneal washout and drainage (with or without T-tube placement) in 30.8% of patients, followed by conversion to Roux-en-Y gastric bypass in 9.6% of patients. Medical treatment with antibiotics, with or without total parenteral nutrition alone, was conducted in 13.6% of patients. Among the patients with the leak, the mortality rate related to the leak was 1.95%, and the mortality due to the leak in the population of OAGB was 0.02%.

CONCLUSION

The management of leaks following OAGB requires a multidisciplinary approach. OAGB is a safe operation with a low leak risk rate, and the leaks can be managed successfully if detected in a timely fashion.

Standardization of the One-anastomosis Gastric Bypass Procedure for Morbid Obesity: Technical Aspects and Early Outcomes

BACKGROUND

One-anastomosis gastric bypass (OAGB) has become an accepted metabolic/bariatric surgery procedure. This study aimed to describe our center's standardized OAGB operative technique and report early (≤30 d) safety outcomes in patients with severe obesity.

METHODS

The medical records of patients who had undergone either primary (n=681, 88.0%) or revisional OAGB (n=93, 12.0%) were retrospectively evaluated. Patient demographics, operative time, length of hospital stay, readmissions, reoperations, and ≤30-day morbidity and mortality rates were analyzed.

RESULTS

A total of 774 consecutive patients with severe obesity (647 female, 83.6%) underwent OAGB between January 2016 and December 2021. Their mean age was 36.2±10.8 years (range: 18 to 70 y) and mean body mass index was 42.7±4.2 kg/m 2 (range: 17.2 to 61 kg/m 2 ). Mean operating time was 52.6±19.9 minutes (range: 25 to 295 min) and length of hospital stay was 1.6±0.9 days (range: 1 to 9 d). Early postoperative complications occurred in 16 cases (2.1%), including 2 leaks with an intra-abdominal abscess (0.3%), bleeding (n=3, 0.4%), acute kidney failure (n=1, 0.15%), urinary tract infection (n=2, 0.3%), and intensive care unit stay (n=4, 0.5%). Seventy patients (9.1%) were readmitted, and re-laparoscopy was performed in 1 patient (0.1%). There was no mortality.

CONCLUSIONS

In the very early term, OAGB was a safe primary and revisional metabolic/bariatric surgery operation. Consistent performance of a standardized OAGB procedure contributed to low rates of morbidity and mortality in the hands of metabolic/bariatric surgeons with good laparoscopic skills at a high-volume center.

Safety and efficacy of OAGB/MGB during the learning curve: setting a benchmark in a bariatric center of excellence

Very little has been published on the learning curve (LC) of the One Anastomosis /Mini Gastric Bypass (OAGB/MGB). Aim of this study was to compare perioperative outcomes of OABG/MGBs performed during the LC of an experienced laparoscopic surgeon to global benchmark cut-offs. First 200 patients undergoing OAGB/MGB at our university hospital from 2010 to 2016 were retrospectively included in this study. LC of the surgeon was divided in two groups of 100 consecutive patients each and perioperative outcomes were compared to abovementioned global benchmarks for LSG and RYGB. A cumulative sum (CUSUM) analysis was performed for operative time and hospital stay. Uneventful postoperative recovery was recorded in 95% of patients. All benchmark values for RYGB were met in group 2. Comparison with cut-offs for LSG showed longer hospital stay and operative time in both groups but postoperative rate of complications resulted lower even for Group 1. CUSUM graph of the operative time runs randomly above the predetermined limit till the 40th cases but reaches the plateau after the 115th operation. CUSUM curve of the hospital stay reaches the plateau after the 57th case. OAGB/MGB confirms to be a feasible procedure, which can be safely and effectively performed during the learning curve. However, at least 100 hundred cases are required to reduce operative time and hospital stay.

Revisional Surgery of One Anastomosis Gastric Bypass for Severe Protein–Energy Malnutrition

Background: One anastomosis gastric bypass (OAGB) is safe and effective. Its strong malabsorptive component might cause severe protein–energy malnutrition (PEM), necessitating revisional surgery. We aimed to evaluate the safety and outcomes of OAGB revision for severe PEM. Methods: This was a single-center retrospective analysis of OAGB patients undergoing revision for severe PEM (2015–2021). Perioperative data and outcomes were retrieved. Results: Ten patients underwent revision for severe PEM. Our center’s incidence is 0.63% (9/1425 OAGB). All patients were symptomatic. Median (interquartile range) EWL and lowest albumin were 103.7% (range 57.6, 114) and 24 g/dL (range 19, 27), respectively, and 8/10 patients had significant micronutrient deficiencies. Before revision, nutritional optimization was undertaken. Median OAGB to revision interval was 18.4 months (range 15.7, 27.8). Median BPL length was 200 cm (range 177, 227). Reversal (n = 5), BPL shortening (n = 3), and conversion to Roux-en-Y gastric bypass (RYGB) (n = 2) were performed. One patient had anastomotic leak after BPL shortening. No death occurred. Median BMI and albumin increased from 22.4 kg/m² (range 20.6, 30.3) and 35.5 g/dL (range 29.2, 41), respectively, at revision to 27.5 (range 22.2, 32.4) kg/m² and 39.5 g/dL (range 37.2, 41.7), respectively, at follow-up (median 25.4 months, range 3.1, 45). Complete resolution occurs after conversion to RYGB or reversal to normal anatomy, but not after BPL shortening. Conclusions: Revisional surgery of OAGB for severe PEM is feasible and safe after nutritional optimization. Our results suggest that the type of revision may be an important factor for PEM resolution. Comparative studies are needed to define the role of each revisional option.

Areas of Non-Consensus Around One Anastomosis/Mini Gastric Bypass (OAGB/MGB): A Narrative Review

PURPOSE

One anastomosis/mini gastric bypass (OAGB/MGB) is now an established bariatric and metabolic surgical procedure with good outcomes. Despite two recent consensus statements around OAGB/MGB, there are some issues which are not accepted as consensus and need more long-term data and research.

MATERIAL AND METHODS

After identifying the topic of non-consensus from the two recent OAGB/MGB consensuses, PubMed, Scopus, and Cochrane were searched for articles published by November 2020.

RESULTS

In this study, we evaluated these non-consensus topics around OAGB/MGB and all related articles on these topics were assessed by authors to have an argument on these items.

CONCLUSION

There is enough evidence to include OAGB/MGB as an accepted standard bariatric and metabolic surgical procedure. However, long-term data and more research are needed to have a consensus in all aspects including these non-consensus topics.

Reappraisal learning curve of laparoscopic Roux-en Y gastric bypass: retrospective results of one hundred and eight cases from a low-volume unit

Background

This study aimed to reevaluate the learning curve of laparoscopic Roux-en Y gastric bypass (LRYGB) in the modern era while considering a single surgeon’s experience.

Methods

From the beginning of our LRYGB practice, all patients who met the regional criteria and underwent primary LRYGB were retrospectively enrolled. Patients with a body mass index (BMI) > 50 kg/m² were excluded. Those who underwent surgery in 2016–17, 2018 and 2019 by a single surgeon with 10 + years of laparoscopic experience were assigned to groups A, B and C, respectively. The patient demographics and 30-day outcome data, including the operation time, length of stay (LOS), emergency room visits, readmission, and reoperation, were compared among the groups.

Results

One hundred and eight patients met the inclusion criteria; 36, 38, and 34 patients were assigned to groups A, B and C, respectively. There were no differences in age, sex distribution or common comorbidities among the groups; however, B had a lower BMI (35.1 kg/m² vs. 37.0 kg/m²) and a higher rate of hypertension (44.7% vs. 22.2%) than group A. The operation time was markedly reduced (96.1 min and 114.9 min, p < 0.001), and the LOS was shortened (2.2 days and 2.9 days, p < 0.001) in group B compared to group A and remained stationary in group C, with no further reduction in 30-day complications.

Conclusion

The learning process of LRYGB can be shortened to approximately 30 cases if conducted selectively by experienced laparoscopic surgeons. Further follow-up is required to verify the long-term safety and applicability in other patient subgroups.

Bariatric Surgical Simulation: Evaluation in a Pilot Study of SimLife, a New Dynamic Simulated Body Model

Background

The demand for bariatric surgery is high and so is the need for training future bariatric surgeons. Bariatric surgery, as a technically demanding surgery, imposes a learning curve that may initially induce higher morbidity. In order to limit the clinical impact of this learning curve, a simulation preclinical training can be offered. The aim of the work was to assess the realism of a new cadaveric model for simulated bariatric surgery (sleeve and Roux in Y gastric bypass).

Aim

A face validation study of SimLife, a new dynamic cadaveric model of simulated body for acquiring operative skills by simulation. The objectives of this study are first of all to measure the realism of this model, the satisfaction of learners, and finally the ability of this model to facilitate a learning process.

Methods

SimLife technology is based on a fresh body (frozen/thawed) given to science associated to a patented technical module, which can provide pulsatile vascularization with simulated blood heated to 37 °C and ventilation.

Results

Twenty-four residents and chief residents from 3 French University Digestive Surgery Departments were enrolled in this study. Based on their evaluation, the overall satisfaction of the cadaveric model was rated as 8.52, realism as 8.91, anatomic correspondence as 8.64, and the model’s ability to be learning tool as 8.78.

Conclusion

The use of the SimLife model allows proposing a very realistic surgical simulation model to realistically train and objectively evaluate the performance of young surgeons.