Safety outcomes of bariatric surgery in patients with advanced organ disease: the ONWARD study: a prospective cohort study

INTRODUCTION

Increasing numbers of patients with advanced organ disease are being considered for bariatric and metabolic surgery (BMS). There is no prospective study on the safety of BMS in these patients. This study aimed to capture outcomes for patients with advanced cardiac, renal, or liver disease undergoing BMS.

MATERIALS AND METHODS

This was a multinational, prospective cohort study on the safety of elective BMS in adults (≥18 years) with advanced disease of the heart, liver, or kidney.

RESULTS

Data on 177 patients with advanced diseases of heart, liver, or kidney were submitted by 75 centres in 33 countries. Mean age and BMI was 48.56±11.23 years and 45.55±7.35 kg/m 2 , respectively. Laparoscopic sleeve gastrectomy was performed in 124 patients (70%). The 30-day morbidity and mortality were 15.9% ( n =28) and 1.1% ( n =2), respectively. Thirty-day morbidity was 16.4%, 11.7%, 20.5%, and 50.0% in patients with advanced heart ( n =11/61), liver ( n =8/68), kidney ( n =9/44), and multi-organ disease ( n =2/4), respectively. Cardiac patients with left ventricular ejection fraction less than or equal to 35% and New York Heart Association classification 3 or 4, liver patients with model for end-stage liver disease score greater than or equal to 12, and patients with advanced renal disease not on dialysis were at increased risk of complications. Comparison with a propensity score-matched cohort found advanced disease of the heart, liver, or kidney to be significantly associated with higher 30-day morbidity.

CONCLUSION

Patients with advanced organ disease are at increased risk of 30-day morbidity following BMS. This prospective study quantifies that risk and identifies patients at the highest risk.

Marginal Ulcers Following One-Anastomosis Gastric Bypass: a Systematic Review and Meta-analysis

BACKGROUND

Marginal ulcer (MU) is an uncommon but significant complication following one-anastomosis gastric bypass (OAGB). Our study aims to understand the incidence rates, risk factors, and management of MU following OAGB.

METHODS

MEDLINE, Scopus, and Cochrane Library databases were examined to identify all studies on OAGB where authors had reported on MU. Data were collected on basic demographics, incidence rates, risk factors, and management of this condition.

RESULTS

Thirty-two studies involving 8868 patients were analysed. The mean age and body mass index (BMI) of patients in these studies were 40.9 ± 4.5 years and 47.6 ± 5.6 kg/m2, respectively. Among the patient cohort, approximately 72% were female, and 20.6% had preoperative gastroesophageal reflux disease (GERD). The authors described prescribing proton-pump inhibitors (PPI) prophylaxis to 14.1% of patients after surgery. Two hundred twenty-eight patients were reported to have MU. The incidence of MU was 2.59% (95% CI 1.89-3.52), of which 53 patients presented within 12 months, 24 patients presented after 31 months, and five patients after 6 years. One hundred forty-six patients did not have presentation time documented. Sixty-five patients were described to have MU diagnosed on endoscopy, of which 54 were symptomatic and 11 were asymptomatic. The authors were, however, not specific on the choice of investigation for the remaining 163 patients. Of patients, 89.7% were treated conservatively with PPIs, whilst 10.3% had surgery to treat MU.

CONCLUSIONS

Marginal ulcer is an uncommon complication following OAGB. The majority of patients are treated conservatively with PPIs. Larger, well-designed studies reporting on risk factors, investigation, and management of MU following OAGB are warranted.

Outcomes at 10-Year Follow-Up after Roux-en-Y Gastric Bypass, Biliopancreatic Diversion, and Sleeve Gastrectomy

INTRODUCTION

Morbid obesity is a well-defined chronic disease, the incidence of which is constantly rising. Surgical treatment of morbid obesity has produced superior outcomes compared to conventional weight loss measures. Currently, there is a gap in the literature regarding long-term outcomes. Our single-institution, retrospective cohort study aims to evaluate weight loss outcomes, comorbidity reduction, and adverse effects at 10 years following Roux-en-Y Gastric Bypass (RYGB), Biliopancreatic Diversion (BPD), and Sleeve Gastrectomy (SG).

MATERIALS AND METHODS

We included all consecutive patients with 10-year follow-up records operated on within our institution. The comparison was carried out on the average percentage of weight and BMI loss. Nausea and vomiting were evaluated through self-reporting Likert scales. Diabetes resolution and nutritional deficiencies were also evaluated.

RESULTS

A total of 490 patients from 1995 up to 2011 were included in our study. Of these, 322 underwent RYGB, 58 underwent long-limb BPD, 34 underwent laparoscopic RYGB with fundus excision, 47 underwent laparoscopic SG, and 29 underwent laparoscopic RYGB as a revision of prior SG. RYGB and BPD were significantly associated with higher percentages of weight loss (37.6% and 37.5%), but were not found to be independent predictors of weight loss. Nausea and vomiting were associated with SG and laparoscopic RYGB with fundus excision, more so than the other operations. No differences were observed regarding diabetes resolution and nutritional deficiencies.

CONCLUSIONS

Longer follow-up reports are important for the comparison of outcomes between different types of bariatric operations. BPD and RYGB resulted in superior weight loss, with no observed differences in diabetes resolution and adverse outcomes.

Weight Loss After Bariatric Surgery in Morbidly Obese End-Stage Kidney Disease Patients as Preparation for Kidney Transplantation. Matched Pair Analysis in a High-Volume Bariatric and Transplant Center

Background

The number of morbidly obese kidney transplant candidates is growing. They have limited access to kidney transplantation and are at a higher risk of postoperative complications. Bariatric surgery is considered as a safe weight loss method in those patients.

Objectives

Matched pair analysis was designed to analyze the preparatory and postoperative weight loss after bariatric procedures in end-stage kidney disease (ESKD) and non-ESKD morbidly obese patients.

Methods

Twenty patients with ESKD underwent bariatric surgery in our Centre of Excellence for Bariatric and Metabolic Surgery between 2015 and 2019 (nine one-anastomosis gastric bypasses, nine Roux-en-Y gastric bypasses, and two sleeve gastrectomies). They were compared with matched pairs from a dataset of 1199 morbidly obese patients without ESKD. Data on demographic factors and comorbidities was recorded. BMI was obtained at the start of the preparatory period preceding the bariatric procedure, at the time of procedure, and during the 1-year follow-up.

Results

The ESKD and non-ESKD patients did not differ significantly in preoperative weight loss (13.00 ± 11.69 kg and 15.22 ± 15.96 kg respectively, p = 0.619). During the 1-year follow-up, the weight loss was similar to the non-ESKD group. In the first 3 months, faster weight loss in ESKD was observed. Initial and follow-up BMI values did not differ significantly between groups. We demonstrated that obese patients with ESKD can lose weight as effectively as non-ESKD patients.

Conclusion

Morbidly obese ESKD patients have an equal weight loss to patients without ESKD. Bariatric surgery could improve access to kidney transplantation and may potentially improve transplantation outcomes of obese patients with ESKD.

Sleeve gastrectomy or gastric bypass: a "post-code" lottery? A comprehensive national analysis of the utilization of bariatric surgery in Switzerland between 2011-2017

BACKGROUND

Sleeve gastrectomy (SG) recently became the most frequently performed bariatric surgery (BS) worldwide, overtaking the long-time standard Roux-en-Y gastric bypass (RYGB). Main indications for one or the other procedure show large inter-center variations and warrant further investigations.

OBJECTIVES

The aim of this study was to identify the influencers of primary BS selection in Switzerland.

SETTING

Switzerland.

METHODS

Retrospective analysis of all hospitalizations in Switzerland January 1, 2011 through December 31, 2017 with anonymized data provided by the Swiss Federal Statistical Office. BS procedures were identified based on ICD-10 and national surgical codes. Statistical analyses were performed with R.

RESULTS

During the study period 27,375 BS were performed. The annual BS caseload doubled over time, whereas inpatient complications decreased (∼-33%). RYGB was the prevailing procedure, although its annual proportion decreased from 80% to 70% over 7 years. Meanwhile, use of SG increased from 14% to 23%. Primary RYGB and SG had similar rates of inpatient mortality (∼.05%) and morbidity (8.0 versus 7.4%, P =.148), with the exception of higher ileus rates following RYGB (.7 versus .1%, P < .001). Patient-related factors favoring the indication of SG were male sex, extremes of age, and metabolic co-morbidities , while gastroesophageal reflux disease and private insurance-favored RYGB. Strikingly, differences between geographic regions outweighed patient-related factors in procedure selection: inhabitants of German- and Italian-speaking areas had higher likelihood (OR 4.6; 3.9, P < .001) to receive SG than those in French-speaking areas.

CONCLUSION

Geographic differences in primary BS procedure selection indicate a lack of objective rationales. Long-term risk-benefit and cost-effectiveness analyses are needed to assist evidence-based decision making.

The yield, effectiveness and safety of gastroscopy in management of early postbariatric upper gastrointestinal pain

BACKGROUND

Upper gastrointestinal (GI) symptoms are prevalent among patients after -bariatric surgeries. Gastroscopy is an important procedure to investigate symptoms. Our primary aim was to evaluate the yield, effectiveness and safety of gastroscopy procedure obtained in a 3-months period after bariatric operation for exploring upper GI symptoms origin.

METHODS

Single center, retrospective study at the EMMS Nazareth Hospital from 2010 to 2018. All patients who underwent gastric-bypass (either Roux-en-Y[R-en-Y] or Mini-gastric bypass [MGB]) and who experienced early upper GI symptoms were included in the study.

RESULTS

A total of 428 were included in the study. Among them, 154 patients (36%) underwent R-en-Y surgery and 274 (64%) underwent MGB. Baseline characteristics were similar in the two groups. The mean age in the R-en-Y group was 42.3±10.8 vs. 42.8±11.2 in the MGB group. Thirty-nine patients underwent gastroscopy, more in the R-en-Y group compared to MGB group (11.6% vs. 7.6%, P<0.005). In the MGB group, more patients had normal surgical anatomy (23.1%) vs. 12.8% in the R-en-Y group, and the prevalence of erosive esophagitis was 14.2% in the MBG group vs. 5.5% in the R-en-Y group, P<0.005. On the other hand, marginal ulcer was more frequent after R-en-Y than MGB surgery (16.6% vs. 9.5%, P<0.005). No procedural related complication was observed in both groups.

CONCLUSIONS

Upper GI symptoms in the early postbariatric surgery period are common with most endoscopic examination revealing normal postsurgical anatomy. In this setting, gastroscopy is safe, without procedural related complications.