Biliopancreatic Limb Length as a Potential Key Factor in Superior Glycemic Outcomes After Roux-en-Y Gastric Bypass in Patients With Type 2 Diabetes: A Meta-Analysis

The Impact of Longer Biliopancreatic Limb Length on Weight Loss and Comorbidity Improvement at 5 Years After Primary Roux-en-Y Gastric Bypass Surgery: A Population-Based Matched Cohort Study

INTRODUCTION

Different limb lengths are used in Roux-en-Y gastric bypass (RYGB) surgery, as there is no consensus which limb length strategy has the best outcomes. The biliopancreatic limb (BPL) is thought to play an important role in achieving weight loss and associated comorbidity resolution. The objective of this study was to assess the impact of a longer BPL on weight loss and comorbidity improvement at 5 years after primary RYGB.

METHODS

All patients aged ≥ 18 years undergoing primary RYGB between 2014-2017 with registered follow-up 5 years after surgery were included. Long BPL was defined as BPL ≥ 100 cm and short BPL as BPL < 100 cm. The primary outcome was achieving at least 25% total weight loss (TWL) at 5 years. Secondary outcomes included absolute %TWL and improvement of comorbidities. A propensity score matched logistic and linear regression was used to estimate the difference in outcomes between patients with long and short BPL.

RESULTS

At 5 years, long BPL had higher odds to achieve ≥ 25% TWL (odds ratio (OR) 1.19, 95% confidence interval (CI) [1.01 - 1.41]) and was associated with 1.26% higher absolute TWL (β = 1.26, 95% CI [0.53 - 1.99]). Furthermore, long BPL was more likely to result in improved diabetes mellitus (OR = 2.17, 95% CI [1.31 - 3.60]) and hypertension (OR = 1.45, 95% CI [1.06 - 1.99]).

CONCLUSION

Patients undergoing RYGB with longer BPL achieved higher weight loss and were more likely to achieve improvement of comorbidities at 5 years.

Barriers to metabolic surgery and how to address them

After bariatric surgery, patients with obesity achieve sustainable weight loss, gain in mobility, quality of life and life expectancy. Bariatric surgery can lead to remission of type 2 diabetes or to long term glycaemic control for patients with type 2 diabetes, while medical treatment has a preventive efficacy on micro and macrovascular complications. This has led to the concept of metabolic surgery to treat type 2 diabetes. Despite the benefits, only a small proportion of eligible patients undergo bariatric/metabolic surgery. Powerful antidiabetic medications, self-estimated lack of knowledge by medical professionals and fear of surgical complications are some of the arguments to prefer medical treatment of type 2 diabetes obesity versus metabolic surgery. We have reviewed in this paper the barriers which explain the low referral rate to metabolic surgery. With the point of view of the diabetologist, the general practitioner and the patient, we have addressed them to help clinicians and patients model an evidenced-based patient-oriented medical plan.

Do all roads lead to Rome?: A retrospective analysis on surgical technique in Roux-en-Y gastric bypass

BACKGROUND

New York University Langone Health has three accredited bariatric centers, with altogether ten different bariatric surgeons. This retrospective analysis compares individual surgeon techniques in laparoscopic or robotic Roux-en-Y gastric bypass (RYGB) to identify potential associations with perioperative morbidity and mortality.

METHODS

All adult patients who underwent RYGB between 2017 and 2021 at NYU Langone Health campuses were evaluated via electronic medical records and MBSAQIP 30-day follow-up data. We surveyed all ten practicing bariatric surgeons to analyze the relationship between their techniques and total adverse outcomes. Bleeding, SSI, mortality, readmission, and reoperation were specifically sub-analyzed via logistic regression.

RESULTS

54 (7.59%) out of 711 patients who underwent laparoscopic or robotic RYGB encountered an adverse outcome. Lower adverse outcomes were observed with laparoscopic approach, creating the JJ anastomosis first, flat positioning, division of the mesentery, Covidien™ laparoscopic staplers, gold staples, unidirectional JJ anastomosis, hand-sewn common enterotomy, 100-cm Roux limb, 50-cm biliopancreatic limb, and routine EGD. Lower bleeding rates were observed with flat positioning, gold staples, hand-sewn common enterotomy, 50-cm biliopancreatic limb, and routine EGD. Lower readmission rates were observed in laparoscopic, flat positioning, Covidien™ staplers, unidirectional JJ anastomosis, and hand-sewn common enterotomy. Gold staples had lower reoperation rates. Otherwise, there was no statistically significant difference in SSI.

CONCLUSION

Certain surgical techniques in RYGB within our bariatric surgery group had significant effects on the rates of total adverse outcomes, bleeding, readmission, and reoperation. Our findings warrant further investigation into the aforementioned techniques via multivariate regression models or prospective study design.

LIMITATIONS

This study was limited by the inherent nature of its retrospective and univariate statistical design. We did not account for the interaction between techniques. The sample size of surgeons was small, and follow-up of 30 days was relatively short. We did not include patient characteristics in the model or control for surgeon skill.

Optimal Small Bowel Limb Lengths of Roux-en-Y Gastric Bypass

PURPOSE OF REVIEW

Gastric bypass and biliopancreatic diversion (BPD) have come full circle, from a loop configuration to a Roux-en-Y and finally back to a loop configuration as one anastomosis gastric bypass and single-anastomosis duodenal switch. Most surgeons performing Roux-en-Y gastric bypass (RYGB) do not measure the common channel (CC) length and most surgeons performing BPD do not measure the biliopancreatic limb length (BPL).

RECENT FINDINGS

The small bowel length in humans is variable from as short as < 400 cm to as long as > 1000 cm. The combination of these two facts means that even if surgeons keep the limb lengths constant, surgeons will get variable limb length due to the variability of small bowel length in patients. Hence, outcomes of weight loss, resolution of medical problems, or developing nutritional deficiencies which are related to limb length are variable. In this article, we evaluate the published literature related to the effect of varying the Roux limb, BPL, CC, and total alimentary limb lengths on the outcomes of RYGB. We have focused on historical and current randomized controlled trials as well as systematic reviews and meta-analysis to outline the current literature and our interpretation of this literature.

Metabolic surgery versus usual care effects on diabetes remission: a systematic review and meta-analysis

BACKGROUND

Bariatric surgery is superior to usual care for diabetes remission. Previous meta-analyses were limited by pooling observational and randomized trials, using various definitions of diabetes remission, and not controlling for various diabetes medications. The current meta-analysis aimed to compare bariatric surgery and usual care regarding the same.

METHODS

We searched PubMed MEDLINE, Web of Science, SCOPUS, and Cochrane Library for relevant articles from the date of the first inception up to February 2023. The keywords diabetes remission, Bariatric surgery, metabolic surgery, lifestyles, usual care, GLIP-1 agonists, insulin use, gastric banding, biliopancreatic diversion, sleeve gastrectomy, and Roux-en-Y gastric bypass, were used. A datasheet was used to extract the relevant data.

RESULTS

Diabetes remission (complete and prolonged) was higher among bariatric surgeries compared to usual care, odd ratio, 0.06, 95 CI, 0.02-0.25 and 0.12, 95 CI, 0.02-0.72, respectively. bariatric surgery patients were younger, had higher HbA1c, odd ratio, - 3.13, 95 CI, - 3.71 to 2.54, and 0.25, 95 CI, 0.02-0.48, respectively, insulin use was higher, and glucagon-like peptide agonists use was lower among bariatric surgery patients, odd ratio, 0.49, 95% CI, 0.24-0.97, and 3.06, 95% CI, 1.44-6.53, respectively.

CONCLUSION

Bariatric surgery was better than usual care in diabetes remission. Bariatric surgery patients were younger, had higher HbA1c, and received more insulin and lower GLP-1 agonists. No differences were evident regarding body mass index and the duration of diabetes. Further trials comparing the new anti-diabetic medications and different forms of bariatric surgery and controlling for the level of exercise and diet are recommended.