Esophageal function and non-acid reflux evaluated by impedance-24 h-pH-metry, high-resolution manometry, and gastroscopy after one-anastomosis gastric bypass-outcomes of a prospective mid-term study

BACKGROUND

One-Anastomosis Gastric Bypass (OAGB) is the third most common bariatric operation for patients with obesity worldwide. One concern about OAGB is the presence of acid and non-acid reflux in a mid- and long-term follow-up. The aim of this study was to objectively evaluate reflux and esophagus motility by comparing preoperative and postoperative mid-term outcomes.

SETTING

Cross-sectional study; University-hospital based.

METHODS

This study includes primary OAGB patients (preoperative gastroscopy, high-resolution manometry (HRM), and impedance-24 h-pH-metry) operated at Medical University of Vienna before 31st December 2017. After a mean follow-up of 5.1 ± 2.3 years, these examinations were repeated. In addition, history of weight, remission of associated medical problems (AMP), and quality of life (QOL) were evaluated.

RESULTS

A total of 21 patients were included in this study and went through all examinations. Preoperative weight was 124.4 ± 17.3 kg with a BMI of 44.7 ± 5.6 kg/m², total weight loss after 5.1 ± 2.3 years was 34.4 ± 8.3%. In addition, remission of AMP and QOL outcomes were very satisfactory in this study. In gastroscopy, anastomositis, esophagitis, Barrett´s esophagus, and bile in the pouch were found in: 38.1%, 28.3%, 9.5%, and 42.9%. Results of HRM of the lower esophageal sphincter pressure were 28.0 ± 15.6 mmHg, which are unchanged compared to preoperative values. Nevertheless, in the impedance-24 h-pH-metry, acid exposure time and DeMeester score decreased significantly to 1.2 ± 1.2% (p = 0.004) and 7.5 ± 8.9 (p = 0.017). Further, the total number of refluxes were equal to preoperative; however, the decreased acid refluxes were replaced by non-acid refluxes.

CONCLUSION

This study has shown decreased rates of acid reflux and increased non-acid reflux after a mid-term outcome of primary OAGB patients. Gastroscopy showed signs of chronic irritation of the gastrojejunostomy, pouch, and distal esophagus, even in asymptomatic patients. Follow-up gastroscopies in OAGB patients after 5 years may be considered.

The faith of non-surveilled pancreatic cysts: a bicentric retrospective study

BACKGROUND

Incidental discovery of pancreatic cystic neoplasms (PCLs) is a common and steadily increasing occurrence. The aim of this study was to investigate a cohort of patients presenting with incidentally detected PCLs which were not included in a surveillance protocol, and to compare their risk of malignant evolution with that of systematically surveilled lesions.

MATERIALS AND METHODS

A population of PCLs which did not receive surveillance over a period >10 years (population A) was selected at the Medical University of Vienna. A group of "low risk" branch duct intraductal papillary mucinous neoplasm ≤15 mm in size upon diagnosis undergoing a regular follow-up of at least 5 years at the University of Verona was selected as control (population B). The incidence of pancreatic cancer (PC), cumulative risk of PC and disease-specific survival were compared.

RESULTS

Overall, 376 patients with non-surveilled PCLs were included in study group A and compared to 299 patients in group B. This comparison resulted in similar incidence rates of PC (1.6% vs 1.7%, p = 0.938), a strong similarity in terms of disease-specific mortality rates (1.3% vs 0.3%, p = 0.171) and the 5- and 10-year cumulative risk of PC (≅ 1% and 2%, p = 0.589) and DSS (≅ 100% and 98%, p = 0.050).

CONCLUSION

The "price to pay" for a negligence-based policy in the population of non-surveilled PCLs was reasonable, and the incidence of PC was comparable to that reported for a population of low-risk cysts enrolled to a standardized surveillance protocol.

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.

Management of nutritional deficiencies following one anastomosis gastric bypass (OAGB): a single-center experience

BACKGROUND

Metabolic/bariatric surgery (MBS) remains the most effective and long-lasting treatment for obesity and its complications. Apart from any surgical complications, the often less obvious but possibly severe side-effects of nutritional deficiencies have become of interest in recent years. OAGB is known to come with the need for thorough supplementation.

SETTING

Retrospective study; university-hospital based.

AIM

Assessing nutritional issues and their management in a real-life cohort of patients undergoing OAGB.

METHODS

Patients that underwent OABG between 01/2018 and 08/2019 were retrospectively assessed. Laboratory values (gained from electronic patients charts) were analyzed for nutritional issues (parathyroid hormone, vitamin A, E, D, B12, folic acid, albumin, ferritin, iron, and transferrin saturation) as well as postoperative complications and reoperations. Furthermore, weight development, improvement/remission of obesity-related complications, and regular intake of multivitamin supplementation (MVS) were assessed.

RESULTS

120 patients underwent OAGB; 89 were female. A follow-up was available for 101 patients. Mean length of follow-up was 27.8 ± 20.9 months. OAGB led to a %TWL of 36.7 ± 9.5% and %EWL of 86.8 ± 25.5%. Preoperative deficiencies were vitamin D (53.3%), followed by folic acid (16.7%) and vitamin A (6.7%). During follow-up, every patient developed at least one deficiency, hypovitaminosis D and A were predominant (74.3% and 41.0%), and 31 suffered from folic acid deficiency (30.7%). Hypovitaminosis B12 and calcium deficiency was observed in three patients (2.9%). Although advised to, only 45.5% opted for the intake of specialized MVS, whereas 10% did not take any MVS at all. More than half of all patients (53.5%) took additional supplements. Nineteen patients underwent reoperations associated with the initial OAGB.

CONCLUSION

Two conclusions can be drawn: First, there is a general need for bypass patients to get assessed for a broad array of deficiencies over time. Second, MVS is essential for patients that had bypass surgery. Additionally, compliance needs to be promoted by educating patients as well as other treating physicians.

Update on esophageal function, acid and non-acid reflux after one-anastomosis gastric bypass (OAGB): high-resolution manometry, impedance-24-h pH-metry, and gastroscopy in a prospective mid-term study

BACKGROUND

One-anastomosis gastric bypass (OAGB) is the third most common metabolic/bariatric procedure worldwide. A point for discussion regarding OAGB is acid and non-acid reflux in mid- and long-term follow-up. The aim of this study was to objectively evaluate reflux and esophagus motility by comparing pre- and postoperative results of 24-h pH-metry, high-resolution manometry (HRM), and gastroscopy.

SETTING

Cross-sectional study and university hospital based.

METHODS

This study includes primary OAGB patients operated at the Medical University of Vienna before 31st December 2022. After a mean follow-up of 4.1 ± 2.9 years, the preoperative examinations were repeated. Additionally, history of weight, remission of obesity-related complications (ORC), and quality of life (QOL) were evaluated.

RESULTS

A total of 50 patients were included in this study and went through all examinations. Preoperative weight was 125.5 ± 21.0 kg with a BMI of 44.6 ± 5.4 kg/m2 and total weight loss after 4.1 ± 2.9 years was 37.1 ± 8.1%. Remission of ORC and QOL outcomes was successful in all categories. Gastroscopy showed anastomositis, esophagitis, Barrett's esophagus, and bile in the pouch in 38.0%, 34.0%, 6.0%, and 48.0%, respectively. In HRM, the postoperative lower esophageal sphincter pressure was 29.6 ± 15.1 mmHg (unchanged to preoperative). The total number of refluxes was equal to preoperative, whereas decreased acid refluxes were replaced by increasing non-acid refluxes. Impedance-24-h pH-metry showed that acid exposure time of the esophagus and DeMeester score decreased significantly to 1.6 ± 1.4% (p = 0.001) and 10.3 ± 9.6 (p = 0.046).

CONCLUSION

This study has shown decreased rates of acid reflux and increased rates of non-acid reflux after a mid-term outcome of primary OAGB patients. Gastroscopy showed significant signs of chronic reflux exposure of the anastomosis, the pouch, and the distal esophagus, even in asymptomatic patients. General follow-up visits in patients after OAGB should be considered.