Single Anastomosis Duodenal Switch versus Classic Duodenal Switch: Long-term Outcomes from a Prospective Comparative Cohort Study

PURPOSE

The literature on long-term outcomes of duodenal switch (DS) compared to single anastomosis duodenal switch (SADI-S) procedures is lacking. We evaluated the long-term outcomes of SADI-S compared to those after the classic DS procedure.

METHODS

This is a follow-up report from a single-institution prospective cohort study comparing long-term outcomes of SADI-S versus DS both as one- and two-stage procedures (ClinicalTrials.gov: NCT02792166). Data is depicted as count (percentage) or median (interquartile range).

RESULTS

Forty-two patients underwent SADI-S, of whom 11 had it as a second-stage procedure (26%). Of 20 patients who underwent DS, twelve had it as a second-stage procedure (60%). Both groups were similar at baseline. Median follow-up times for one-stage SADI-S and DS were 57 (24) and 57 (9) months, respectively (p = 0.93). Similar BMI reductions were observed after one-stage SADI-S (16.5 kg/m2 [8.5]) and DS (18.9 kg/m2 [7.2]; p = 0.42). At median follow-up of 51 (21) and 60 (15) months after second-stage SADI-S and DS, respectively (p = 0.60), surgical procedures yielded reductions in BMI of 20.5 kg/m2 (14.0) and 24.0 kg/m2 (13.9), respectively (p = 0.52). Follow-up rates were similar for one-stage (≥ 88%; p = 0.29) and second-stage procedures (≥ 83%; p = 0.16). Similar diabetes and hypertension remissions were found (p = 0.77; P = 0.54, respectively). Despite fat-soluble vitamin deficiencies at baseline, after supplementation, they were either eliminated or less prevalent long-term after SADI-S. Daily bowel movements were also less frequent.

CONCLUSIONS

Long-term weight and comorbidity outcomes after SADI-S are similar to those of DS both as one- and two-stage surgeries. SADI-S procedure may allow for similar beneficial outcomes with less burden from gastrointestinal symptoms and fat-soluble vitamin deficiencies.

Ambulatory sleeve gastrectomy: a prospective feasibility and comparative study of early postoperative morbidity

BACKGROUND

Given its short procedure time and low morbidity, there is enthusiasm to perform sleeve gastrectomy (SG) in an outpatient setting. However, most relevant studies include an overnight stay at a medical facility (≤ 24-h). Hence, we investigated the feasibility and safety of a same-day discharge (SDD) protocol for laparoscopic SG.

METHODS

In a prospective pilot study (02/01/2021-02/28/2022), all patients planned for SG were screened for eligibility. Patients met the inclusion criteria if they were ≤ 65 years old, without major comorbidity, and lived close to the hospital. Postoperatively, patients who met discharge criteria were sent home directly from the recovery room. Patients were called the same night and the next morning. Feasibility was defined as discharge on the day of surgery without emergency department (ED) visit or readmission within 24-h. Secondary outcomes, including 90-day morbidity, were compared to patients who met inclusion criteria but chose a same-day admission (SDA) approach during the same study period. Descriptive statistics are displayed as count (percentage) and median (interquartile range).

RESULTS

A total of 320 patients were planned for SG during the study period, 229 of whom met eligibility criteria and underwent SG with 56 agreeing to SDD-SG while 173 opted for SDA-SG. Baseline characteristics were all similar between both groups except for obstructive sleep apnea being more prevalent in SDA-SG group (38.2% vs. 16.1%; P < 0.001). Operative characteristics including procedure time were similar between both groups. Successful SDD-SG was achieved in 54(96%) of patients with a median of 6.0(1.0) hours of stay in the recovery room. Ninety-day morbidity was similar between SDD-SG and SDA-SG groups (1.8% vs. 6.9%, respectively; P = 0.196).

CONCLUSION

A SDD protocol for laparoscopic SG was feasible and safe in selected patients. Larger studies that evaluate patient reported outcomes and include bypass-type procedures may be needed to guide safe use of ambulatory bariatric surgery.

Esophageal cancer after sleeve gastrectomy: a population-based comparative cohort study

BACKGROUND

Sleeve gastrectomy (SG) is the most common bariatric surgery; however, this approach may induce gastroesophageal reflux disease (GERD). Both obesity and GERD are independent risk factors for esophageal cancer, however the impact of SG on risk of esophageal cancer remains unknown.

OBJECTIVE

To evaluate the risk of esophageal cancer after reflux-prone bariatric surgery.

SETTING

Population-level, provincial administrative healthcare database, Quebec, Canada.

METHODS

We identified a population-based cohort of all patients with obesity who underwent reflux-prone surgery (SG and duodenal switch [DS]) or reflux-protective Roux-en-Y gastric bypass (RYGB) during 01/2006-12/2012 in Quebec, Canada. For every surgical patient, 2-3 nonsurgical controls with obesity matched for age, sex, and geography were also identified. Crude incidence rate ratios (IRRs) for esophageal cancer were calculated using person-time analysis. Hazard ratios (HRs) were obtained using multivariate cox regression.

RESULTS

A total of 4121 patients had reflux-prone procedures and 852 underwent RYGB. At a mean follow-up of 7.6 years, 8 cases of esophageal cancer were identified after bariatric surgery. Compared with RYGB, IRR for esophageal cancer in reflux-prone group was 1.45 (95%CI: .19-65.5) and HR = .83 (95%CI: .10-7.27). The crude incidence rate of esophageal cancer in the reflux-prone group was higher than that of nonsurgical controls (n = 12,159; IRR = 3.46, 95%CI: 1.00-12.5), but after adjustment the difference disappeared (HR = 2.47, 95%CI: .82-7.45).

CONCLUSIONS

Long-term incidence of esophageal cancer after reflux-prone bariatric surgery is not greater than RYGB. While crude incidence of esophageal cancer after reflux-prone surgery is higher than in nonsurgical patients with obesity, such difference disappears after accounting for confounders. Given the low incidence of esophageal cancer and slow progression of dysplastic Barrett esophagus, studies with longer follow-up are needed.

Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S): short-term outcomes from a prospective cohort study

BACKGROUND

Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a modification of the classic duodenal switch (DS). These modifications are intended to address concerns about DS, including malnutrition, longer operative times, and technical challenges, while preserving the benefits.

OBJECTIVES

To evaluate safety and outcomes of SADI-S as it compares to classic DS procedure.

SETTING

Bariatric Surgery Center of Excellence, University Hospital, Montreal, Canada.

METHODS

In a single-institution prospective cohort study, we compared safety and outcomes of the SADI-S versus DS procedures (ClinicalTrials.gov: NCT02792166; registered: 06/2016). Data is depicted as count (percentage) or median (interquartile range).

RESULTS

There were 42 patients who underwent SADI-S, of whom 11 had it as a second-stage procedure (26%). There were 20 patients who underwent DS, of whom 12 had it as second-stage procedures (60%). Both groups were similar at baseline. The median age was 45 (14) years, 39 (63%) were female, the median body mass index (BMI) was 48.2 (7.7) kg/m², and 29 (47%) patients had diabetes. The operative time was shorter for 1-stage SADI-S versus DS surgery (211 [70] versus 250 [60] min, respectively; P = .05) but was similar for second-stage procedures (P = .06). The 90-day complication rates were 11.9% (N = 5/42) after SADI-S and 5.0% (N = 1/20) after DS surgery (P = .64). There were no mortalities. Median follow-ups for 1-stage SADI-S and DS were 17 (11) and 12 (24) months, respectively (P = .65). Similar BMI changes were observed after 1-stage SADI-S (17.9 kg/m² [8.7]) and DS (17.5 kg/m² [16]; P = .65). At median follow-ups of 10 (20) and 14 (16) months after second-stage SADI-S and DS, respectively (P = .53), surgical procedures yielded added 5.0 kg/m² (5.8) and 6.5 kg/m² (7.1) changes in BMI, respectively (P = .26). Complete remission rates for diabetes were 91% after SADI-S (n = 21/23) and 50% after DS (n = 3/6). Compared with the SADI-S procedure, DS surgery was associated with higher frequencies of deficiencies in some fat-soluble vitamins, especially vitamin D.

CONCLUSIONS

The SADI-S procedure is safe, and its short-term outcomes, including weight loss and the resolution of co-morbidities, are similar to those of DS. SADI-S surgery also has promising potential as a second-stage procedure after sleeve gastrectomy.

Surgeon and hospital volume outcomes in bariatric surgery: a population-level study

BACKGROUND

Outcomes after bariatric surgery are tied to surgical volume; however, this relationship is not clearly established for each procedure.

OBJECTIVES

To evaluate the impact of surgeon/hospital volumes on morbidity after bariatric surgery and identify volume cutoffs.

SETTING

Multi-centric population-level study, province of Quebec, Canada.

METHODS

We studied a population-based cohort of all morbidly obese patients who underwent bariatric surgery in Quebec, Canada during 2006 to 2012. We evaluated only the most common procedures in North America, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). Multilevel, cross-classified logistic regressions were used to test the effects of annual surgeon volume (SV) and hospital volume (HV) on a composite 90-day postoperative outcome. Receiver operator curve was used to identify volume thresholds.

RESULTS

Overall, 821 patients had RYGB and 1802 underwent SG by 34 surgeons in 15 centers. For RYGB, 10-case increase in SV was associated with adjusted odds ratio of .82 (95% confidence interval: .71-.94). Similar increase in HV resulted in odds ratio of .86 (95% confidence interval: .77-.96). Annual SV threshold of 21 RYGBs and HV of 25 cases were identified (area under the curve = .60 and .61, respectively). For SV, being in the higher volume category translated into an absolute risk reduction of 12.5% for 90-day major morbidity. For SG, annual 10-case increase in SV and HV was not significantly associated with a decrease in 90-day postoperative morbidity.

CONCLUSION

SV and HV are significant independent predictors of 90-day major morbidity after RYGB. This study further supports establishing minimum surgical volume requirements for more complex anastomotic procedures like RYGB. However, the role of volume targets in SG remains unclear.

Variability in Bariatric Surgical Care Among Various Centers: a Survey of All Bariatric Surgeons in the Province of Quebec, Canada

BACKGROUND

Despite an increase in bariatric surgery across Quebec, Canada, access is still limited. Furthermore, there are differences in resources and multidisciplinary capabilities of providing centers that may impact quality of care and outcomes.

METHODS

We performed an online survey of all bariatric surgeons in the province of Quebec, Canada, using the LimeSurvey software.

RESULTS

Forty-six surgeons from 15 centers were surveyed. Response rate was 87% (n = 40). Only 13 (35%) surgeons have any formal fellowship training in bariatric surgery and 74% perform > 50 cases/year. All surgeons perform sleeve gastrectomy, 34% do duodenal switch, and 44% provide major revisions. Thirty-one surgeons (77%) identified access to operating room as the main cause for surgical delays. While most surgeons (52%) considered < 6 months as an acceptable wait-time, only 33% achieved this in their practice. Majority (70%) favored a centralized provincial referral system. Patient's geographical convenience, procedural choice, and multidisciplinary capabilities of providing centers are identified as important determinants for centralized referrals (93, 78, and 55%, respectively). Virtually, all supported accreditation/designation of centers and creation of Quebec Bariatric Network for quality control and research (85 and 98%, respectively).

CONCLUSION

Bariatric surgical patterns vary among designated centers in Quebec, Canada. Access to multidisciplinary care and surgeon's fellowship training may be contributing factors for the observed variability. Wait-lists are long and timely access to surgery remains an issue. There is near consensus for establishing a centralized referral system, designation of referral vs. primary centers, and creating Quebec Bariatric Network for research and quality control.

Physical activity and sedentary behavior in bariatric patients long-term post-surgery

BACKGROUND

To measure sedentary behaviors and physical activity using accelerometry in participants who have undergone bariatric surgery 8.87 ± 3.78 years earlier and to compare these results with established guidelines.

METHODS

Participants' weight and height were measured, an ActivPAL™3 accelerometer and sleeping journal were used to determine day sedentary time, transitions from sitting to standing, as well as steps/day, and participants were asked to indicate if they felt that they were currently less, the same, or more active than before surgery.

RESULTS

Participants averaged 48 ± 15 transitions/day, 6375 ± 2690 steps/day, and 9.7 ± 2.3 h/day in sedentary positions. There was a negative correlation between steps/day and sedentary time (r = -.466, p ≤ .001), 11.27 % of participants achieved 10,000 steps/day. Participants who reported being more active prior to surgery averaged 6323.4 ± 2634.79 steps/day, which was not different from the other two groups of self-perceived change in level of physical activity (F (2, 68) = .941, p ≤ .05) from pre- to post-surgery.

CONCLUSIONS

Participants were inadequately active and overly sedentary compared to established guidelines and norms. Healthcare workers should be taking physical activity and sedentary time into account when creating post-surgical guidelines for this population to ensure the best long-term weight loss maintenance and health outcomes.

Precision of the iDXA for visceral adipose tissue measurement in severely obese patients

A new measurement tool, the automated software CoreScan, for the GE Lunar iDXA, has been validated for measuring visceral adipose tissue (VAT) against computed tomography in normal-weight populations. However, no study has evaluated the precision of CoreScan in measuring VAT among severely obese patients.

PURPOSE

The purpose of the study was to evaluate the precision of CoreScan for VAT measurements in severely obese adults (body mass index > 40 kg·m(-2)).

METHODS

A total of 55 obese participants with a mean age of 46 ± 11 yr, body mass index of 49 ± 6 kg·m(-2), and body mass of 137.3 ± 21.3 kg took part in this study. Two consecutive iDXA scans with repositioning of the total body were conducted for each participant. The coefficient of variation, the root-mean-square averages of SD of repeated measurements, the corresponding 95% least significant change, and intraclass correlations were calculated.

RESULTS

Precision error was 8.77% (percent coefficient of variation), with a root-mean-square SD of 0.294 kg and an intraclass correlation of 0.96. Bland-Altman plots demonstrated a mean precision bias of -0.08 ± 0.41 kg, giving a coefficient of repeatability of 0.82 kg and a bias range of -0.890 to 0.725 kg.

CONCLUSIONS

When interpreting VAT results with the iDXA in severely obese populations, clinicians should be aware of the precision error for this important clinical parameter.

Long-term incidence of symptomatic urolithiasis post-bariatric surgery

INTRODUCTION

The risk of urolithiasis post-Roux-en-Y gastric bypass (RYGB) surgery is higher when compared to the general population. Calcium and vitamin D supplementation is routinely prescribed to these patients, yet compliance with these supplements is unknown. The aim of this study was to assess the incidence of symptomatic de novo urolithiasis post-RYGB and compliance with calcium and vitamin D supplementation.

METHODS

A standardized telephone questionnaire was administered to patients who underwent RYGB between 1996 and 2011. Personal and medical histories were obtained with emphasis on episodes of symptomatic urolithiasis and calcium and vitamin D supplementation.

RESULTS

The response rate was 48% with 478 patients completing the telephone questionnaire. After a mean follow-up of 7.0 years (range: 1-15), the incidence of post-RYGB symptomatic urolithiasis was 7.3%, while the rate of de novo symptomatic urolithiasis was 5%. The overall median time to present with symptomatic urolithiasis was 3.1 years, with 3.3 years for de novo stone-formers, and 2.0 years for recurrent stone-formers (p = 0.38). In de novo stone-formers, 33% presented with symptomatic urolithiasis 4 to 14 years postoperatively. Compliance with calcium and vitamin D supplementation was 56% and 51%, respectively.

CONCLUSIONS

Despite recall bias and lack of confirmatory imaging studies, a high postoperative incidence of symptomatic urolithiasis was found in a large sample of post-RYGB patients. A third of patients with de novo stones, presented with symptomatic urolithiasis 4 to 14 years postoperatively. Compliance with postoperative calcium and vitamin D supplementation was poor and needs improvement.

In vivo precision of the GE lunar iDXA for the assessment of lumbar spine, total hip, femoral neck, and total body bone mineral density in severely obese patients

No study has evaluated the precision of the GE Lunar iDXATM (GE Healthcare) in measuring bone mineral density (BMD) among severely obese patients. The purpose of the study was to evaluate the precision of the GE Lunar iDXATM for assessing BMD, including the lumbar spine L1-L4, L2-L4, the total hip, femoral neck, and total body in a severely obese population (body mass index [BMI]>40 kg/m(2)). Sixty-four severely obese participants with a mean age of 46 ± 11 yr, BMI of 49 ± 6 kg/m(2), and a mean body mass of 136.8 ± 20.4 kg took part in this investigation. Two consecutive iDXA scans (with repositioning) of the total body (total body BMD [TBBMD]), lumbar spine (L1-L4 and L2-L4), total hip (total hip BMD [THBMD]), and femoral neck (femoral neck BMD [FNBMD]) were conducted for each participant. The coefficient of variation (CV), the root mean square (RMS) averages of standard deviations of repeated measurements, the corresponding 95% least significant change, and intraclass correlations (ICCs) were calculated. In addition, analysis of bias and coefficients of repeatability were calculated. The results showed a high level of precision for total body (TBBMD), lumbar spine (L1-L4), and total hip (THBMD) with values of RMS: 0.013, 0.014, and 0.011 g/cm(2); CV: 0.97%, 1.05%, and 0.99%, respectively. Precision error for the femoral neck was 2.34% (RMS: 0.025 g/cm(2)) but still represented high reproducibility. ICCs in all dual-energy X-ray absorptiometry measurements were 0.99 with FNBMD having the lowest at 0.98. Coefficients of repeatability for THBMD, FNBMD, L1-L4, L2-L4, and TBBMD were 0.0312, 0.0688, 0.0383, 0.0493, and 0.0312 g/cm(2), respectively. The Lunar iDXA demonstrated excellent precision for BMD measurements and is the first study to assess reproducibility of the GE Lunar iDXA with severely obese adults.

The effect of chewing lidocaine soaked gauze on intubation conditions during awake videolaryngoscopy: a randomised controlled trial in the morbidly obese

The increasing utilisation of the videolaryngoscope for awake tracheal intubation requires development and assessment of methods to decrease the gag reflex. We hypothesised that chewing gauze soaked with lidocaine would decrease the gag reflex during awake videolaryngoscope tracheal intubation. Twenty four morbidly obese patients assessed as having a potential difficult tracheal intubation were randomised to chew gauze soaked with 20 ml of 2% lidocaine or saline for 3 minutes. All patients then received 20 ml of aerosolised 2% lidocaine and underwent awake videolaryngoscope assisted tracheal intubation. Gagging scores, heart rate and blood pressure were assessed when best laryngeal view was obtained, when the tracheal tube was positioned at the cords, and when the tube was advanced into the trachea. In addition, serum lidocaine levels were measured. The primary outcome was the gagging score at best laryngeal visualisation, which was compared between groups with a Student's t-test. Gagging scores and hemodynamic parameters did not differ between groups, but the saline group had lower plasma levels of lidocaine after the intubation procedure. When used for awake videolaryngoscope assisted tracheal intubation of the morbidly obese, chewing lidocaine soaked gauze does not decrease the amount of gagging as compared to lidocaine aerosolisation, but does increase the plasma levels of lidocaine.

Validation of Obesity Surgery Mortality Risk Score in patients undergoing gastric bypass in a Canadian center

BACKGROUND

The Obesity Surgery Mortality Risk Score (OS-MRS) has been proposed as a user-friendly tool for the assessment and risk stratification of patients undergoing Roux-en-Y gastric bypass (RYGB). We assessed the validity of the OS-MRS in 2121 primary RYGB procedures performed at our center during a 25-year period.

METHODS

A retrospective study of the patients who had undergone primary RYGB since 1983 was performed. The 90-day mortality and all mortalities related to complications of the RYGB were determined. For every patient, we assigned the relevant risk score according to their co-morbidities and relevant demographics. Each patient was assigned to a class (A, B, or C) according to the OS-MRS. We used the Z test to estimate whether the difference between the actual and predicted risk using the OS-MRS was statistically significant.

RESULTS

We identified 2121 patients who had undergone primary RYGB, of which 1254 (59%) were open (ORYGB) and 867 (41%) were laparoscopic (LRYGB). The mean body mass index was 50.7 +/- 8.6 kg/m(2), and the mean age was 39.7 +/- 9.9 years. The mortality rate for ORYGB was 1% (13 patients) and for LRYGB was .4% (4 patients). The overall mortality rate was .8% (17 patients). Of the 2121 patients, 1385 (65%) were in class A, 671 (32%) were in class B, and 65 (3%) were in class C. The expected versus observed mortality rate was .3% versus .3% for class A, 1.9% versus 1.5% for class B, and 7.5% versus 3% for class C, respectively. The difference between the mortality expected from applying the OS-MRS in our cohort and the observed mortality was assessed for statistical significance using Flora's Z statistic. No significant difference was found between the observed and expected mortality, suggesting that the OS-MRS was a valid tool for predicting mortality in our cohort.

CONCLUSION

In our bariatric center with >25 years' experience, the OS-MRS accurately predicted the postoperative mortality for RYGB surgery. It appears to be a user-friendly scoring system that could facilitate the informed consent process. Before the system is unequivocally adopted, additional validation trials of a prospective nature are required.

Clinical review: Myocardial depression in sepsis and septic shock

Myocardial dysfunction frequently accompanies severe sepsis and septic shock. Whereas myocardial depression was previously considered a preterminal event, it is now clear that cardiac dysfunction as evidenced by biventricular dilatation and reduced ejection fraction is present in most patients with severe sepsis and septic shock. Myocardial depression exists despite a fluid resuscitation-dependent hyperdynamic state that typically persists in septic shock patients until death or recovery. Cardiac function usually recovers within 7-10 days in survivors. Myocardial dysfunction does not appear to be due to myocardial hypoperfusion but due to circulating depressant factors, including the cytokines tumor necrosis factor alpha and IL-1beta. At a cellular level, reduced myocardial contractility seems to be induced by both nitric oxide-dependent and nitric oxide-independent mechanisms. The present paper reviews both the clinical manifestations and the molecular/cellular mechanisms of sepsis-induced myocardial depression.