Excessive weight loss after sleeve gastrectomy: a systematic review. Obes Surg. 2012;22:721-731. [PMID: 22411568 DOI: 10.1007/s11695-012-0616-1]

Randomized controlled trial comparing laparoscopic greater curvature plication versus laparoscopic sleeve gastrectomy

BACKGROUND

Laparoscopic greater curvature plication (LGCP) is a new restrictive bariatric procedure, which has a similar restrictive mechanism like laparoscopic sleeve gastrectomy (LSG) without potential risk of leak. Aim of the study was to compare 2-year outcomes of LSG and LGCP.

METHODS

Multicenter prospective randomized trial was started in 2010. A total of 54 patients with morbid obesity were allocated either to LGCP group (n = 25) or LSG group (n = 27). Main exclusion criteria were: ASA > III, age > 75 and BMI > 65 kg/m(2). There were 40 women and 12 men, and the mean age was 42.6 ± 6.8 years (range 35-62). Data on the operation time, complications, hospital stay, body mass index loss, percentage of excess weight loss (%EWL), loss of appetite and improvement in comorbidities were collected during the follow-up examinations.

RESULTS

All procedures were completed laparoscopically. The mean operative time was 92.0 ± 15 min for LSG and 73 ± 19 min for LGCP (p > 0.05). The mean hospital stay was 4.0 ± 1.9 days in the LSG group and 3.8 ± 1.7 days in LGCP group (p > 0.05). One year after surgery, the mean %EWL was 59.5 ± 15.4 % in LSG group and 45.8 ± 17 % in LGCP group (p > 0.05). After 2 years, mean %EWL was 78.9 ± 20 % in the LSG group and 42.4 ± 18 % in the LGCP group (p < 0.01). After 3 years, mean %EWL was 72.8 ± 22 in the LSG group and only 20.5 ± 23.9 in the LGCP group (p < 0.01). Loss of feeling of hunger after 2 years was 25 % in LGCP group and 76.9 % in the LSG group (p < 0.05). The comorbidities including diabetes, sleep apnea and hypertension were markedly improved in the both groups after surgery.

CONCLUSION

The short-term outcomes demonstrated equal effectiveness of the both procedures, but 2-year follow-up showed that LGCP is worse than LSG as a restrictive procedure for weight loss.

Long-term results after laparoscopic sleeve gastrectomy in a large monocentric series

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) has gained great popularity as a stand-alone bariatric procedure because short- and mid-term outcomes in terms of weight loss and resolution of co-morbidities have been very positive. However, long-term results from large series still are sparse.

OBJECTIVES

To evaluate the long-term clinical outcomes of SG in a large series of patients undergoing SG as a stand-alone procedure.

SETTING

University hospital in Italy.

METHODS

A retrospective analysis of prospectively collected data from 182 patients undergoing SG between 2006 and 2008 in the authors' institution. Long-term outcomes at 6 and 7 years were analyzed in terms of weight loss and co-morbidities resolution.

RESULTS

Mean initial body mass index (BMI) was 45.9±7.3 kg/m(2). Major postoperative complications occurred in 8 patients (5.4%): 4 leaks, 2 bleeding, 1 abdominal collection, and 1 dysphagia. All complications were managed conservatively. One hundred forty-eight patients (81.4%) completed the 72-month (6-year) follow-up. Thirty-seven patients (25%) reached a follow-up of 84 months. At year 6 follow-up the mean BMI and the mean percentage of excess weight loss (%EWL) were 30.2 kg/m(2) and 67.3%, respectively. Mean total body weight loss was 44.9 kg, while a %EWL >50 was registered in 123 patients (83.1%). Preoperative BMI did not significantly influence postoperative %EWL. Remission of type 2 diabetes mellitus, arterial hypertension, obstructive sleep apnea syndrome, and gastroesophageal reflux disease symptoms occurred in 83.8%, 59.7%, 75.6%, and 64.7% of patients, respectively.

CONCLUSION

%EWL and resolution of co-morbidities appear to be sustained 6 and 7 years after SG. Preoperative BMI is not predictive for weight loss outcomes.

Malabsorption as a Therapeutic Approach in Bariatric Surgery

Background

The increasing prevalence of obese patients will lead to a more frequent use of bariatric procedures in the future. Compared to conservative medical therapy, bariatric procedures achieve greater weight loss and superior control of comorbidities, resulting in improved overall mortality.

Methods

A search for current literature regarding mechanisms, indications, and outcomes of bariatric surgery was performed.

Results

In order to care for patients after bariatric surgery properly, it is important to understand its mechanisms of action and effects on gastrointestinal physiology. Recent investigations indicate that the beneficial effects of bariatric procedures are much more complex than simply limiting food intake or an associated malabsorption. Changes in gastrointestinal hormone secretion, energy expenditure, intestinal bacterial colonization, bile acid metabolism, and epigenetic modifications resulting in altered gene expression are likely responsible for the majority of the beneficial effects of bariatric surgery. Malabsorptive bariatric procedures divert the flow of bile and pancreatic enzymes from food and therefore limit the digestion and absorption of nutrients, resulting in reduced calorie intake and subsequent weight loss. Essential micronutrients such as vitamins and trace elements are also absorbed to a lesser extent, potentially leading to severe side effects.

Conclusion

To prevent malnutrition, dietary supplementation and regular control of micronutrient levels are mandatory for patients undergoing malabsorptive bariatric procedures, in whom the fat-soluble vitamins A and D are commonly deficient.

Comparison of laparoscopic sleeve gastrectomy and laparoscopic gastric plication: One year follow-up results

OBJECTIVE

Various different surgical methods are used for obesity surgery. Among them, laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric plication (LGP) have been both successfully performed in recent years. In this study, we compared the treatment results of patients who underwent LGP, a method that was introduced later consisting of plication of gastric greater curvature to achieve volume reduction, with results of patients who underwent LSG.

MATERIAL AND METHODS

We analyzed data on morbid obese patients who underwent bariatric surgery with either LSG or LPG in Konya Beyhekim Hospital between 2009 and 2012. Demographic features including age and sex, preoperative blood biochemistry, body mass index (BMI) before and after operation, duration of hospital stay, morbidity, mortality and complications were analyzed.

RESULTS

Fifty-five patients who were operated for obesity between 2009 and 2012 were included in the study. 29 patients underwent LGP, and 26 patients LSG. The BMI in the LGP and LSG groups was 41.4±3 kg/m(2) and 42.0±3.1 kg/m(2), respectively. There was no significant difference between two groups in terms of BMI. Two groups were also similar in terms of age and gender. In the LGP group, one patient had postoperative necrosis of the suture line. One patient in the LSG group was re-operated due to bleeding. Another patient in this group had leakage at the suture line. Postoperative BMI assessment of groups revealed significantly lower BMI levels in the LSG group. Length of hospital stay was significantly shorter in the LGP group. There was no significant difference in complication rates between two groups.

CONCLUSION

In this study, we obtained similar results in patients who were treated with LGP or LSG. Moreover, LSG was more efficient in decreasing BMI in morbid obesity surgery when compared to LGP. However, duration of hospital stay was significantly shorter in LGP group. We concluded that both methods could be effectively and safely used in the surgical management of morbid obesity.

Predictors of weight loss 2 years after laparoscopic sleeve gastrectomy

INTRODUCTION

Despite the rapidly increasing popularity of laparoscopic sleeve gastrectomy (LSG), there is limited data examining weight loss more than 1 year after the procedure. There have also been few studies examining baseline predictors of weight loss after LSG. We aimed to examine the percentage of excess weight loss (%EWL) in patients 2 years after LSG and identify baseline predictors of %EWL.

METHODS

Electronic records from university hospitals were available for 292 patients who underwent LSG (205 women; mean age, 41.5 ± 11.1 years; mean weight, 126.5 ± 27.5 kg; mean BMI, 45.5 ± 7.5 kg/m(2) ). Variables assessed for predictive effect were baseline age, sex, BMI, presence of comorbidities (diabetes, hypertension, or obstructive sleep apnea), the amount of weight loss induced by a very low-calorie diet before surgery, and the number of clinic appointments attended over the 2 years. We performed linear regression and mixed model analyses between predictor variables and %EWL at 2 years.

RESULTS

Adjusted %EWL was 31% at 2 weeks, 49% at 3 months, 64% at 6 months, 70% at 9 months, 76% at 12 months, 79% at 18 months, and 79% at 2 years. Multivariate analysis showed that lower baseline BMI, absence of hypertension, and greater clinic attendance predicted better %EWL (r(2)  = 0.11).

CONCLUSION

Longer-term follow-up studies of weight loss post LSG are required to assist with patient care and management.

Efficacy of laparoscopic sleeve gastrectomy and intensive medical management in obese patients with type 2 diabetes mellitus

BACKGROUND

There are a dearth of studies comparing laparoscopic sleeve gastrectomy (LSG) and intensive medical treatment (IMT) in obese type 2 diabetes mellitus (T2DM) patients. This study compares these modalities in terms of weight loss, metabolic parameters and quality of life (QOL) score.

METHODS

We evaluated the efficacy of LSG (n = 14) vs. IMT (n = 17) comprising of low calorie diet, exenatide, metformin and if required insulin detemir in 31 obese T2DM patients with BMI of 37.9 ± 5.3kg/m(2) and target HbA1c < 7 %. The mean (±SD) age of the patients was 49.6 ± 11.9 years and 74 % were women. The mean duration of diabetes was 8.5 ± 6.1 years and mean HbA1c was 8.6 ± 1.3 %. Primary end point was excess body weight loss (EBWL) at the final follow-up.

RESULTS

The mean duration of follow-up was 12.5 ± 5.0 (median 12) months. EBWL was 61.2 ± 17.6 % and 27.4 ± 23.6 % in LSG and IMT group respectively (p < 0.001). Glycemic outcomes improved in both with mean HbA1c of 6.6 ± 1.5 % in LSG and 7.1 ± 1.2 % in IMT group. In LSG group, there was resolution of diabetes and hypertension in 36 and 29 % of patients respectively while none in the IMT group. HOMA-IR, hsCRP, ghrelin and leptin decreased while adiponectin increased significantly in LSG compared to IMT group. QOL score improved in LSG as compared to IMT.

CONCLUSIONS

In obese T2DM patients, LSG is superior to IMT in terms of weight loss, resolution of comorbidities and QOL score.

BariSurg trial: Sleeve gastrectomy versus Roux-en-Y gastric bypass in obese patients with BMI 35-60 kg/m(2) - a multi-centre randomized patient and observer blind non-inferiority trial

Background

Roux-en-Ygastric bypass (RYGB) and sleeve gastrectomy (SG) rank among the most frequently applied bariatric procedures worldwide due to their positive risk/benefit correlation. A systematic review revealed a similar excess weight loss (EWL) 2 years postoperatively between SG and RYGB. However, there is a lack of randomized controlled multi-centre trials comparing SG and RYGB, not only concerning EWL, but also in terms of remission of obesity-related co-morbidities, gastroesophageal reflux disease (GERD) and quality of life (QoL) in the mid- and long-term.

Methods

The BariSurg trial was designed as a multi-centre, randomized controlled patient and observer blind trial. The trial protocol was approved by the corresponding ethics committees of the centres. To demonstrate EWL non-inferiority of SG compared to RYGB, power calculation was performed according to a non-inferiority study design. Morbidity, mortality, remission of obesity-related co-morbidities, GERD course and QoL are major secondary endpoints. 248 patients between 18 and 70 years, with a body mass index (BMI) between 35–60 kg/m² and indication for bariatric surgery according to the most recent German S3-guidelines will be randomized. The primary and secondary endpoints will be assessed prior to surgery and afterwards at discharge and at the time points 3–6, 12, 24, 36, 48 and 60 months postoperatively.

Discussion

With its five year follow-up, the BariSurg-trial will provide further evidence based data concerning the impact of SG and RYGB on EWL, remission of obesity-related co-morbidities, the course of GERD and QoL.

Trial registration

The trial protocol has been registered in the German Clinical Trials Register DRKS00004766.

To band or not to band--early results of banded sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is the procedure with the fastest growing numbers worldwide. Although excellent weight loss can be achieved, one major obstacle of LSG is weight regain due to sleeve dilatation. Banded sleeve gastrectomy (BLSG) has been described as an option to counteract sleeve dilatation and ameliorate weight loss over time. In a retrospective study, we analysed 25 patients who underwent BLSG using a MiniMizer® ring. Twenty five patients who had previously undergone a conventional LSG were selected for matched-pair analysis. Patient follow-up was 12 months in both groups. Mean preoperative BMI was 56.1 ± 7.2 kg/m(2) for BLSG and 57.0 ± 6.3 kg/m(2) for LSG, P = 0.522. Operative time was significantly shorter for BLSG (53 ± 27 min vs. 68 ± 20 min, P = 0.0025). Excess weight loss (%EWL) was equal in both groups with %EWL at 12 months of 58.0 ± 14.6 % for BSLG patients vs. 58.4 ± 19.2 % for LSG patients. There was no procedure-related mortality in either group. At 12 months postoperative, vomiting was significantly increased in BSLG patients (OR 6.75, P = 0.035). New onset reflux was equal in both groups (OR 0.67, P = 0.469). Ring implantation does not increase the duration of surgery or early surgical complications. Weight loss in the first follow-up year is not influenced, but the incidence of vomiting is raised after 12 months when patients start to increase eating volume.

Metabolic changes induced by the biliopancreatic diversion in diet-induced obesity in male rats: the contributions of sleeve gastrectomy and duodenal switch

The mechanisms underlying the body weight and fat loss after the biliopancreatic diversion with duodenal switch (BPD/DS) remain to be fully delineated. The aim of this study was to examine the contributions of the two main components of BPD/DS, namely sleeve gastrectomy (SG) and duodenal switch (DS), on energy balance changes in rats rendered obese with a high-fat (HF) diet. Three different bariatric procedures (BPD/DS, SG, and DS) and three sham surgeries were performed in male Wistar rats. Sham-operated animals fed HF were either fed ad libitum (Sham HF) or pair weighed (Sham HF PW) by food restriction to the BPD/DS rats. A group of sham-operated rats was kept on standard chow and served as normal diet control (Sham Chow). All three bariatric surgeries resulted in a transient reduction in food intake. SG per se induced a delay in body weight gain. BPD/DS and DS led to a noticeable gut malabsorption and a reduction in body weight and fat gains along with significant elevations in plasma levels of glucagon-like peptide-1(7-36) and peptide YY. BPD/DS and DS elevated energy expenditure above that of Sham HF PW during the dark phase. However, they reduced the volume, oxidative metabolism, and expression of thermogenic genes in interscapular brown adipose tissue. Altogether the results of this study suggest that the DS component of the BPD/DS, which led to a reduction in digestible energy intake while sustaining energy expenditure, plays a key role in the improvement in the metabolic profile led by BPD/DS in rats fed a HF diet.

Short-term outcomes of sleeve gastrectomy for morbid obesity: does staple line reinforcement matter?

Background

Stand-alone laparoscopic sleeve gastrectomy (LSG) has been found to be effective in producing weight loss but few large, one-center LSG series have been reported. Gastric leakage from the staple line is a life-threatening complication of LSG, but there is controversy about whether buttressing the staple line with a reinforcement material will reduce leaks. We describe a single-center, 518-patient series of LSG procedures in which a synthetic buttressing material (GORE® SEAMGUARD® Bioabsorbable Staple Line Reinforcement) was used in the most recently treated patients.

Methods

We retrospectively reviewed the medical records of all patients who underwent LSG in our unit between September 2007 and December 2011. Patients treated before August 2009 did not receive the staple line reinforcement material (n = 186), whereas all patients treated afterward did (n = 332).

Results

The percentages of excess weight loss in the 518 patients (mean age, 41 years; 82 % female; mean preoperative body mass index, 44 kg/m²) were 67 % (79 % follow-up rate) at 6 months postoperatively, 81 % (64 %) at 1 year, and 84 % (30 %) at 2 years. Type 2 diabetes resolved in 71 % of patients (91/128). Patients given reinforcement material had baseline characteristics similar to those in the no-reinforcement-material group, but had no postoperative staple line leaks or bleeding. The no-reinforcement group had three leaks (p = 0.045) and one case of bleeding.

Conclusions

LSG resulted in substantial short-term weight loss. Use of the bioabsorbable staple line reinforcement material may decrease leaks after LSG.

Laparoscopic vertical sleeve gastrectomy significantly improves short term weight loss as compared to laparoscopic adjustable gastric band placement in morbidly obese adolescent patients

BACKGROUND

Bariatric surgery has shown to be an effective weight loss treatment in morbidly obese adolescents. We compared outcomes of laparoscopic adjustable gastric band (LAGB) to laparoscopic vertical sleeve gastrectomy (VSG).

METHODS

A single institution, retrospective evaluation of a prospectively collected database of LAGB and VSG patients.

RESULTS

174 morbidly obese patients underwent bariatric surgery at our institution between 2006 and 2013. 137 patients underwent LAGB and 37 underwent VSG. There were no significant differences between LAGB vs. VSG groups on day of surgery for age, gender, ethnicity, weight, and BMI. At 24-month follow up, patients who underwent VSG vs. LAGB displayed significantly greater percent excess weight loss (70.9±20.7 vs. 35.5±28.6, P=0.004) and percent preoperative BMI loss (32.3±11.0 vs. 16.4±12.7, P=0.004). Both VSG and LAGB significantly improved levels of HDL, HgA1c, and fasting glucose. LAGB patients had more complications than VSG patients.

CONCLUSION

Bariatric surgery is an effective treatment strategy in morbidly obese adolescents who have failed medical management. VSG results in greater short term weight and BMI loss when compared to LAGB. Longer follow up with more patients will be required to confirm the long term safety and efficacy of VSG in adolescent patients.

Body shape expectations and self-ideal body shape discrepancy in women seeking bariatric surgery: a cross-sectional study

Background

Postoperative body shape expectations (BSE) of bariatric surgery candidates remain relatively unexplored, and may have important implications for weight loss outcomes, treatment satisfaction, and education.

Methods

The ‘Silhouette Figure Rating Scale’ was administered to 69 consecutive female candidates. Self-perceived current and goal body shape and postoperative BSE in four categories; “dream, “happy”, “acceptable”, and “disappointed” were examined.

Results

The mean age and BMI of the sample was 43.4 ± 8.9 years and 48.8 ± 7.0 kg/m². Self-ideal body shape discrepancy of 4.1 ± 1.3 silhouettes was reported, indicating body image dissatisfaction. 53% incorrectly identified the silhouette associated with their actual BMI. Goal body shape (4.3 ± 0.8 silhouettes) corresponded to a BMI figure 23.1 kg/m²- 26.2 kg/m². The postoperative “dream” (4.1 ± 1.0 silhouettes), “happy” (5.0 ± 0.8 silhouettes), “acceptable” (5.3 ± 1.0 silhouettes), and “disappointed” (6.9 ± 1.0 silhouettes) BSE corresponded to silhouettes that were thinner than the thinnest silhouette clinically expected based on a 56.1% excess weight loss 1-year after laparoscopic sleeve gastrectomy (LSG) or a 22.3% to 47.2% total body weight loss.

Conclusions

Women seeking bariatric surgery experience body image dissatisfaction and misperceive their actual body size. BSE do not correspond with evidence-based LSG weight loss outcomes.

[Challenges in building a surgical obesity center]

BACKGROUND

It is estimated that approximately 1 million adults in Germany suffer from grade III obesity. The aim of this article is to describe the challenges faced when constructing an operative obesity center.

METHODS

The inflow of patients as well as personnel and infrastructure of the interdisciplinary Diabetes and Obesity Center in Heidelberg were analyzed. The distribution of continuous data was described by mean values and standard deviation and analyzed using variance analysis.

RESULTS

The interdisciplinary Diabetes and Obesity Center in Heidelberg was founded in 2006 and offers conservative therapeutic treatment and all currently available operative procedures. For every operative intervention carried out an average of 1.7 expert reports and 0.3 counter expertises were necessary. The time period from the initial presentation of patients in the department of surgery to an operation was on average 12.8 months (standard deviation SD ± 4.5 months). The 47 patients for whom remuneration for treatment was initially refused had an average body mass index (BMI) of 49.2 kg/m(2) and of these 39 had at least the necessity for treatment of a comorbidity. Of the 45 patients for whom the reason for the refusal of treatment costs was given as a lack of conservative treatment, 30 had undertaken a medically supervised attempt at losing weight over at least 6 months. Additionally, 19 of these patients could document participation in a course at a rehabilitation center, a Xenical® or Reduktil® therapy or had undertaken the Optifast® program. For the 20 patients who supposedly lacked a psychosomatic evaluation, an adequate psychosomatic evaluation was carried out in all cases.

CONCLUSIONS

The establishment of an operative obesity center can last for several years. A essential prerequisite for success seems to be the constructive and targeted cooperation with the health insurance companies.

Perforated small bowel diverticulitis after gastric bypass

This report details the management of a patient with perforated acute diverticulitis of the Roux-en-Y loop 4 years after bariatric surgery.

We report a rare case of complicated jejunal diverticulitis in a patient with previous bariatric surgery. Small bowel diverticulosis is generally considered an inoffensive disease. In this report we describe a case of small bowel perforation in an obese subject who had undergone laparoscopic Roux-en-Y gastric bypass.

Revisions after failed gastric band: sleeve gastrectomy and Roux-en-Y gastric bypass

INTRODUCTION

Laparoscopic gastric band is an appealing bariatric operation due to its simplicity and good short-term outcomes; however, it is associated with complications (slippage, erosion, prolapse) and failure in reaching target weight loss. This study describes our experience with failed gastric bands that required a revisional procedure.

MATERIALS AND METHODS

This single-center retrospective analysis includes all consecutive patients who underwent a gastric band removal and revisional surgery in our hospital from January 2008 to June 2014. A total of 81 patients were identified and divided in three groups: Group one included patients who just had the gastric band removed (43), group two consisted of patients who underwent a conversion to sleeve gastrectomy (SG) (26), and group three included patients who required a conversion to Roux-en Y gastric bypass (RYGB) (12). Patient demographics, date of gastric band placement, indications for revision, postoperative morbidity and mortality, operating time, blood loss, length of stay, and % excess weight loss (%EWL) were recorded. Perioperative and clinical outcomes were compared between conversions to SG and RYGB.

RESULTS

In group two (n = 26), 21 conversions to SG were performed in concurrence with the band removal as a one-stage operation, while five procedures were performed in two-stages. There were no complications and no case was converted to open. Patients who underwent a one-stage procedure had a longer operative time, although it did not reach statistical significance. In group three, 12 patients underwent a conversion to RYGB as a revisional operation; 11 were performed as a one-stage procedure and only one patient underwent a two-stage procedure.

CONCLUSIONS

SG and RYGB are safe options to revise a failed gastric band. Both groups who received either a SG or RYGB had a low complication rate and acceptable %EWL with no statistical difference between the two.

Laparoscopic Magenstrasse and Mill gastroplasty. First results of a prospective study

BACKGROUND

The Magenstrasse and Mill (M&M) procedure is a vertical gastroplasty creating a tubular pouch extending from the cardia to the antrum. This "incomplete sleeve" avoids gastric resection or band placement. In this paper, we report our experience of the laparoscopic approach of the technique in a selected obese population excluding prominent grazer and/or sweet eaters.

MATERIAL AND METHODS

One hundred patients (39 males, 61 females) underwent the procedure in a prospective trial. Mean age was 40 years (range 18-68). Mean preoperative BMI was 43.2 kg/m(2) (range 35-62).

RESULTS

The procedure was performed by laparoscopy starting with the creation of a circular opening at the junction of antrum and corpus followed by a vertical stapling to the angle of Hiss. Mean duration of the procedure was 67 (range 40-122) min. No intraoperative complication occurred. Mean hospital stay (SD) was 2.5 (0.9) days. The single postoperative complication consisted in a mild stenosis that responded to endoscopic dilatation. After a mean follow-up of 15 months (range 9-24), mean percentage of excess body weight loss (SD) was 48(14), 59(18) and 68(24)%, respectively at 3, 6, and 12 months. Quality of life appeared satisfactory with a low incidence of gastroesophageal reflux. The procedure was associated with improvement or resolution of diabetes, arterial hypertension, and dyslipemia at 1 year.

CONCLUSIONS

Our experience demonstrated that the M&M procedure could be performed safely laparoscopically. The satisfactory results on weight loss, obesity-associated mordities, and quality of life will need to be confirmed on longer follow-up.

Postoperative complications in bariatric surgery using age and BMI stratification: a study using ACS-NSQIP data

BACKGROUND

Bariatric surgery results in long-term weight loss and significant morbidity reduction. Morbidity and mortality following bariatric surgery remain low and acceptable. This study looks to define the trend of morbidity and mortality as it relates to increasing age and body mass index (BMI) in patients undergoing bariatric surgery.

METHODS

We queried the ACS/NSQIP 2010-2011 Public Use File for patients who underwent elective laparoscopic adjustable banding (LAGB), sleeve gastrectomy (LSG) and gastric bypass (LGBP). Total morbidity and 30-day mortality were evaluated. Logistic regression models were created to estimate the effect of increasing age and BMI on morbidity for these bariatric procedures.

RESULTS

A total of 20,308 laparoscopic bariatric procedures were reviewed (11617 LGBP, 3069 LSG and 5622 LAGB). Overall mortality and morbidity rates were 0.11 and 3.84%, respectively. The odds of postoperative complications increased by 2% with each additional year of age (OR 1.02, 95% CI 1.02-1.03) and every point increase in BMI (OR 1.02, 95% CI 1.01-1.03). Multiple logistic regression identified COPD, Diabetes, Hypertension, and Dyspnea as major risk factors for postoperative morbidity. Postoperative complications were three times more likely after LGBP (OR 2.87, 95% CI 2.31-3.57) and two times more likely after LSG (OR 2.06, 95% CI 1.57-2.72) when compared to patients undergoing LAGB.

CONCLUSION

Morbidity and mortality increase on a predictable trend with increasing age and BMI. There is increased risk of morbidity for stapling procedures when compared to gastric banding, but this must be considered in context of surgical efficacy when choosing a bariatric procedure. These data can be used in preoperative counseling and evaluation of surgical candidacy of bariatric surgical patients.

Weight loss expectations of laparoscopic sleeve gastrectomy candidates compared to clinically expected weight loss outcomes 1-year post-surgery

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) results in significant, sustainable weight loss in obese individuals (body mass index (BMI) ≥ 40 kg/m(2) or BMI 35.0-39.9 kg/m(2) with major comorbidity). Average clinically expected % excess weight loss (%EWL) has been reported to be 56.1 % 1 year after LSG. Unrealistic weight loss expectations are purported to negatively impact treatment adherence and weight loss outcomes. This study examined the weight loss expectations of LSG candidates in Newfoundland and Labrador, Canada.

METHODS

The Goals and Relative Weights Questionnaire was administered before the start of a bariatric surgery education session to 84 consecutive LSG candidates. Patients reported postoperative weight loss expectations in four categories: "dream", "happy", "acceptable", and "disappointed".

RESULTS

Participants included 69 women and 15 men with an average age and weight of 43.7 years and 136.7 kg. The patients reported average postoperative "dream" and "happy" weights as 71.1 and 80.0 kg, respectively. Patients reported a weight of 86.2 kg as "acceptable" but would be "disappointed" with a weight of 105.6 kg. To achieve the desired amount of weight loss for each category, patients would have to achieve %EWLs of 88.7, 76.4, 68.2, and 40.6 %, respectively.

CONCLUSIONS

Patients have higher weight loss expectations than those that are clinically expected within 1 year after LSG.

Significant weight loss and rapid resolution of diabetes and dyslipidemia during short-term follow-up after laparoscopic sleeve gastrectomy

BACKGROUND

Bariatric surgery has been established as the best option of treatment for morbid obesity. Recently, laparoscopic sleeve gastrectomy (SG) has become very popular because of good postoperative weight loss and low morbidity. The aim of this study was to report our single-center experience with SG regarding feasibility, morbidity, and outcome.

METHODS

From January 2006 to December 2011, 93 patients (68 female) with a median age of 46 years underwent laparoscopic SG at our department. Thirteen patients had a history of gastric banding with insufficient weight loss or band-related complications. Clinical outcome and laboratory findings were analyzed.

RESULTS

The mean preoperative and postoperative body mass index (BMI) was 44.1 ± 6.9 and 33.4 ± 6.8 kg/m(2), respectively (p < 0.001). The mean excessive body weight loss after a median follow-up of 11.9 months was 55.7 % ± 24.9 %. Three bleedings, two staple line leakages, and a deep wound infection required conversion to laparotomy (n = 1), reoperation (n = 4), or endoscopic stent implantation (n = 2). Resolution of diabetes and dyslipidemia was seen in 85 and 50 % of patients, respectively. Blood test results of HbA1c, cholesterols, triglycerides, and leptin showed significant postoperative improvement.

CONCLUSIONS

Laparoscopic SG represents a feasible bariatric procedure with good short-term weight loss, low morbidity rate, and efficient resolution of diabetes and dyslipidemia, especially in patients with lower BMI. The significant decrease of leptin necessitates further studies to understand the ambiguous role of leptin in bariatric surgery.

The effects of sleeve gastrectomy on hormonal regulation of glucose metabolism in Goto-Kakizaki rats

BACKGROUND

The antidiabetic effect of sleeve gastrectomy (SG) has been interpreted as a conceivable result of surgically induced weight loss in the obese type 2 diabetes mellitus (T2DM) subjects. However, the blood glucose control often occurs within days, before significant weight loss has been reached. This work aims to investigate the major mechanism and persistence regarding how SG improves glucose metabolism in nonobese T2DM rats.

METHODS

These Goto Kakizaki rats (n = 21) were randomly assigned into three groups: SG, sham SG, and pair-fed (PF) group, whose weight, food intake, oral glucose tolerance test, insulin tolerance test, plasma insulin, homeostasis model assessment for insulin resistance (HOMA-IR), ghrelin, and glucagon-like peptide-1 (GLP-1) were measured.

RESULTS

According to the experiment, from the 2nd week until the 24th week, the fasting blood glucose of the rats in the SG group had significantly decreased with the improved glucose tolerance. At the 2nd week postoperation, the area under the blood glucose concentration curve (AUC) received a distinct reduction of 28.1 % (P < 0.0001). The ghrelin secretion of the SG group was significantly decreased (P < 0.005). The GLP-1 had increased (P < 0.0001), while the HOMA-IR values decreased (P < 0.05) throughout the experimental period. These effects were not seen in the sham-SG and PF groups despite similar changes of weight loss or food intake.

CONCLUSIONS

The above results suggest that SG can conduct a direct control on T2DM instead of secondarily to weight loss or food intake around the whole experimental period. The changes of the gastrointestinal hormones may be the major mechanism of the antidiabetic effect.

Laparoscopic re-sleeve gastrectomy as a treatment of weight regain after sleeve gastrectomy

AIM: To evaluate laparoscopic re-sleeve gastrectomy as a treatment of weight regain after Sleeve.

METHODS: Laparoscopic sleeve gastrectomy is a common bariatric procedure. Weight regain after long-term follow-up is reported. Patients were considered for laparoscopic re-sleeve gastrectomy when we observed progressive weight regain and persistence of comorbidities associated with evidence of dilated gastric fundus and/or antrum on upper gastro-intestinal series. Follow-up visits were scheduled at 1, 3, 6 and 12 mo after surgery and every 6 mo thereafter. Measures of change from baseline at different times were analyzed with the paired samples t test.

RESULTS: We observed progressive weight regain after sleeve in 11 of the 201 patients (5.4%) who had a mean follow-up of 21.1 ± 9.7 mo (range 6-57 mo). Three patients started to regain weight after 6 mo following Sleeve, 5 patients after 12 mo, 3 patients after 18 m. Re-sleeve gastrectomy was always performed by laparoscopy. The mean time of intervention was 55.8 ± 29.1 min. In all cases, neither intra-operative nor post-operative complications occurred. After 1 year follow-up we observed a significant (P < 0.05) mean body mass index reduction (-6.6 ± 2.7 kg/m²) and mean % excess weight loss (%EWL) increase (+31.0% ± 15.8%). An important reduction of antihypertensive drugs and hypoglycemic agents was observed after re-sleeve in those patients affected by hypertension and diabetes. Joint problems and sleep apnea syndrome improved in all 11 patients.

CONCLUSION: Laparoscopic re-sleeve gastrectomy is a feasible and effective intervention to correct weight regain after sleeve.

A new endoscopically implantable device (SatiSphere) for treatment of obesity--efficacy, safety, and metabolic effects on glucose, insulin, and GLP-1 levels

BACKGROUND

The endoluminal mechanical device SatiSphere is a new endoscopically implantable device designed to delay transit time of nutrients through the duodenum. It consists of a 1-mm nitinol wire with pigtail ends and several mesh spheres mounted along its course, released in the duodenum and gastric antrum to conform to the duodenal C loop configuration and thereby self-anchor.

METHODS

The objective is to test the safety, efficacy, and effect on body weight in a 2:1 randomized study, as well as incretin secretion in a subgroup.

RESULTS

Of 31 included cases (11 men, mean age 42.9 years, mean BMI 41.3 kg/m2), 21 patients treated with endoscopic device insertion with scheduled device removal after 3 months were compared with 10 controls. In 10 of 21 patients, device migration occurred, in two cases necessitating emergency surgery, which led to termination of the trial. Weight loss after 3 months was 6.7, 4.6, and 2.2 kg in the groups completing therapy, all treatment cases using intention to treat (ITT) analysis and controls. Excess weight loss was significantly increased by endoluminal mechanical device insertion (18.4, 12.2, and 4.4% in completers, ITT analysis group and controls; p = 0.02 for completers vs. controls). Measuring glucose, insulin, and glucagon-like peptide 1 (GLP-1) following a mixed-meal test with the device in place and after removal (n = 7), the device delayed glucose absorption and insulin secretion and altered kinetics in GLP-1 levels.

CONCLUSIONS

The device might be short-term effective in reducing body weight, which might be mediated through alterations in incretin metabolism. However, frequent device migration necessitates device modifications.

Laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy as revisional procedure after adjustable gastric band--a systematic review

The adjustable gastric band (L)AGB gained popularity as a weight loss procedure. However, long-term results are disappointing; many patients need revision to laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG). The purpose of this study was to assess morbidity, mortality, and results of these two revisional procedures. Fifteen LRYGB studies with a total of 588 patients and eight LSG studies with 286 patients were included. The reason for revision was insufficient weight loss or weight regain in 62.2 and 63.9% in LRYGB and LSG patients. Short-term complications occurred in 8.5 and 15.7% and long-term complications in 8.9 and 2.5%. Reoperation was performed in 6.5 and 3.5%. Revision to LRYGB or LSG after (L)AGB is feasible and relatively safe. Complication rate is higher than in primary procedures.

Laparoscopic sleeve gastrectomy for morbid obesity: 5-year results

BACKGROUND

Data concerning the long-term efficacy of laparoscopic sleeve gastrectomy in the treatment of morbid obesity remain scarce. In this retrospective, the authors present 5-year follow-up of 30 patients having undergone laparoscopic sleeve gastrectomy.

METHODS

Since 2004, 30 patients underwent laparoscopic sleeve gastrectomy and completed 5 years of follow-up. Five patients were subsequently subjected to laparoscopic Roux-en-Y gastric bypass and were excluded from further analysis. The remaining 25 patients comprised the study population.

RESULTS

Mean excess weight loss was 65.2 ± 6.1%, 64.7 ± 5.6%, 62 ± 4.9%, 58.2 ± 5.5%, and 56.4 ± 5.8% for the first 5 years, respectively. There were no deaths, nor any major morbidity. Remission of comorbidities was observed in 40% to 80.9% of cases.

CONCLUSIONS

Laparoscopic sleeve gastrectomy is a safe and effective means of treatment of morbid obesity both in the short and in the long term. More research is needed to better predict which patient will benefit most from this operation.

Laparoscopic gastric bypass vs. sleeve gastrectomy in the super obese patient: early outcomes of an observational study

BACKGROUND

Super obesity [body mass index (BMI) > 50 kg/m2] can yield to higher morbidity/mortality in bariatric surgery, this could be related to patient's characteristics and/or surgeon's experience. In morbid obesity, both techniques proved to have a positive impact and sometimes comparable outcomes during the first 2 years. This has not been clearly analyzed in the super obese patient.

METHODS

Retrospective study comparing the records of 77 consecutive super obese patients (BMI: 50-59.9 kg/m2) submitted to either laparoscopic gastric bypass (LGBP, n = 32) or laparoscopic sleeve gastrectomy (LSG, n = 45) between 2010 and 2012 at a single institution. The primary objective was to analyze baseline demographics, comorbidities, operative outcomes, and early complications (<30 days). Secondarily, weight loss [BMI and % excess weight loss (%EWL)] was also described and compared during the first year.

RESULTS

Female sex comprised 72.7 % of all cases. Both groups had comparable BMI (52.7 ± 2.1 kg/m2 for LGBP vs. 53.87 ± 2.8 kg/m2 for LSG; p = 0.087) and homogeneous baseline characteristics. Operative time was lower for the LSG group (113.1 ± 35.3 vs. 186.9 ± 39 min for LGBP; p ≤ 0.001). Overall, early complications were observed in 16.8% of patients (LGBP 9% vs. LSG 22%; p = 0.217). There were four major complications (two in each group), with two reinterventions. Weight loss (%EWL) at 6, 9, and 12 months was significantly higher in the LGBP group (51.6 ± 12.9%, 56.5 ± 13%, 63.9 ± 13.3%, respectively) than in the LSG group (40 ± 12.8%, 45.1 ± 15.5%, 43.9 ± 10.4%, respectively).

CONCLUSIONS

Just like in morbid obesity, LGBP and LSG are effective and safe procedures in super obese patients. LGBP had better weight loss at 1 year.

Iatrogenic oesophageal transection during laparoscopic sleeve gastrectomy

Laparoscopic sleeve gastrectomy has been hailed as an easy and safe procedure when compared with other bariatric operations. However, it may be associated with well-recognised early complications such as leaks and bleeding, as well as late ones such as stenosis and weight regain. Iatrogenic complete oesophageal transection has never been reported before as a complication. We report a case of complete oesophageal transection during laparoscopic sleeve gastrectomy that was not recognised intraoperatively. The repair of this iatrogenic injury was staged, with the final stage carried out some 3 months after the initial procedure. This case report highlights the possible occurrence of complete oesophageal transection during laparoscopic sleeve gastrectomy, and suggests steps to avoid and correct such complications.

Systematic review on reoperative bariatric surgery: American Society for Metabolic and Bariatric Surgery Revision Task Force

BACKGROUND

Reoperative bariatric surgery has become a common practice in many bariatric surgery programs. There is currently little evidence-based guidance regarding specific indications and outcomes for reoperative bariatric surgery. A task force was convened to review the current evidence regarding reoperative bariatric surgery. The aim of the review was to identify procedure-specific indications and outcomes for reoperative procedures.

METHODS

Literature search was conducted to identify studies reporting indications for and outcomes after reoperative bariatric surgery. Specifically, operations to treat complications, failed weight loss, and weight regain were evaluated. Abstract and manuscript reviews were completed by the task force members to identify, grade, and categorize relevant studies.

RESULTS

A total of 819 articles were identified in the initial search. After review for inclusion criteria and data quality, 175 articles were included in the systematic review and analysis. The majority of published studies are single center retrospective reviews. The evidence supporting reoperative surgery for acute and chronic complications is described. The evidence regarding reoperative surgery for failed weight loss and weight regain generally demonstrates improved weight loss and co-morbidity reduction after reintervention. Procedure-specific outcomes are described. Complication rates are generally reported to be higher after reoperative surgery compared to primary surgery.

CONCLUSION

The indications and outcomes for reoperative bariatric surgery are procedure-specific but the current evidence does support additional treatment for persistent obesity, co-morbid disease, and complications.

Comparison of short-term outcome of laparoscopic sleeve gastrectomy and gastric bypass in the treatment of morbid obesity: A prospective randomized controlled multicenter SLEEVEPASS study with 6-month follow-up

BACKGROUND AND AIMS

The long-term efficacy of laparoscopic Roux-en-Y gastric bypass in the treatment of morbid obesity has already been demonstrated. Laparoscopic sleeve gastrectomy has shown promising short-term results, but the long-term efficacy is still unclear. The aim of this prospective randomized multicenter study is to compare the results of Roux-en-Y gastric bypass and sleeve gastrectomy.

MATERIAL AND METHODS

A total of 240 morbidly obese patients were randomized to undergo either Roux-en-Y gastric bypass or sleeve gastrectomy. The primary end point of study was weight loss, and the secondary end points were resolution of comorbidities and morbidity. The short-term results at 6 months were analyzed.

RESULTS

The mean excess weight loss at 6 months was 49.2% in the sleeve gastrectomy group and 52.9% in the Roux-en-Y gastric bypass group (p = 0.086). Type 2 diabetes was resolved or improved in 84.3% of patients in the sleeve gastrectomy group and 93.3% in the Roux-en-Y gastric bypass group (p = 0.585). The corresponding results for arterial hypertension were 76.8% and 81.9% (p = 0.707) and for hypercholesterolemia 64.1% and 69.0% (p = 0.485). There was no mortality at 6 months. There was one major complication following sleeve gastrectomy and two after Roux-en-Y gastric bypass (p = 0.531). Eight sleeve gastrectomy patients and 11 Roux-en-Y gastric bypass patients had minor complications (p = 0.403).

CONCLUSION

The short-term results of sleeve gastrectomy and Roux-en-Y gastric bypass regarding weight loss, resolution of obesity-related comorbidities and complications were not different at 6 months.

Surgical management of obesity in patients with morbid obesity and nonalcoholic fatty liver disease

Most patients with severe complex obesity presenting for bariatric-metabolic surgery have nonalcoholic fatty liver disease (NAFLD). NAFLD is associated with central obesity, insulin resistance, type 2 diabetes, hypertension, and obesity-related dyslipidemia. Weight loss should be a primary therapy for NAFLD. However, evidence supporting intentional weight loss as a therapy for NAFLD is limited. Bariatric-metabolic surgery provides the most reliable method of achieving substantial sustained weight loss and the most commonly used procedures are associated with reduced steatosis and lobular inflammatory changes, but there are mixed reports regarding fibrosis. Surgery should complement treatment of obesity-related comorbidity, but not replace established therapy.

Laparoscopic removal of poor outcome gastric banding with concomitant sleeve gastrectomy

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) has a significant incidence of long-term failure, which may require an alternative revisional bariatric procedure to remediate. Unfortunately, there is few data pinpointing which specific revisional procedure most effectively addresses failed gastric banding. Recently, it has been observed that laparoscopic sleeve gastrectomy (LSG) is a promising primary bariatric procedure; however, its use as a revisional procedure has been limited. This study aims to evaluate the safety and efficacy of LSG performed concomitantly with removal of a poor-outcome LAGB.

METHODS

A retrospective review was performed on patients who underwent LAGB removal with concomitant LSG at King Saud University in Saudi Arabia between September 2007 and April 2012. Patient body mass index (BMI), percentage of excess weight loss (%EWL), duration of operation, length of hospital stay, complications after LSG, and indications for revisional surgery were all reviewed and compared to those of patients who underwent LSG as a primary procedure.

RESULTS

Fifty-six patients (70 % female) underwent conversion of LAGB to LSG concomitantly, and 128 (66 % female) patients underwent primary LSG surgery. The revisional and primary LSG patients had similar preoperative ages (mean age 33.5 ± 10.7 vs. 33.6 ± 9.0 years, respectively; p = 0.43). However, revisional patients had a significantly lower BMI at the time of surgery (44.4 ± 7.0 kg/m(2) vs. 47.9 ± 8.2; p < 0.01). Absolute BMI postoperative reduction at 24 months was 14.33 points in the revision group and 18.98 points in the primary LSG group; similar %EWL was achieved by both groups at 24 months postoperatively (80.1 vs. 84.6 %). Complications appeared in two (5.5 %) revisional patients and in nine (7.0 %) primary LSG patients. No mortalities occurred in either group.

CONCLUSIONS

Conversion of LAGB by means of concomitant LSG is a safe and efficient procedure and achieves similar outcomes as primary LSG surgery alone.

Two lessons from a 5-year follow-up study of laparoscopic sleeve gastrectomy: persistent, relevant weight loss and a short surgical learning curve

INTRODUCTION

Like Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy (LSG) has been validated as a bariatric surgery procedure in its own right. However, the few studies of the long-term outcomes of LSG have only featured small patient populations. The objective of the present study was to evaluate weight loss 5 years after LSG and assess the surgical learning curve for this procedure.

METHODS

We performed a retrospective, single-center study of a prospective database including all consecutive patients having undergone LSG at Amiens University Medical Center between November 2004 and July 2007. Data (weight, body mass index [BMI], percentage of excess weight loss [EWL], percentage of excess BMI loss, and percentage weight loss [PWL]) were collected during follow-up (particularly after 5 years).

RESULTS

The study population comprised 118 patients (100 females [85%]; mean ± SD age, 40 ± 11 years; mean preoperative weight, 131 ± 22 kg; mean preoperative BMI, 47.7 ± 7 kg/m(2)). LSG was performed after failure of gastric banding in 23 cases (19%) and after failure of an intragastric balloon in 1 (0.8%). In all, 95 patients (81%) were analyzed ≥60 months after the LSG (mean follow-up period, 71 ± 9 months). The PWL and EWL were 25 ± 14% and 46 ± 26%, respectively. Eleven patients had undergone a second bariatric operation within 5 years of the LSG. Concerning the 84 patients in whom only LSG was the only operation, the PWL and EWL were 23 ± 14% and 43 ± 25%, respectively. The EWL was >50% in 35 of these 84 patients (42%) and between 25 and 50% in 30 cases (36%). Optimal weight results were achieved after only 28 LSG had been performed, which testifies to a shorter learning curve than for most other bariatric surgery techniques.

CONCLUSION

Isolated LSG is a quickly mastered bariatric surgery technique with a short learning curve. It enables a mean PWL of >25% and an EWL of >50% in >40% of cases.

Gastric bypass leads to improvement of diabetic neuropathy independent of glucose normalization--results of a prospective cohort study (DiaSurg 1 study)

OBJECTIVE

Surprisingly, 40% to 95% of patients with type 2 diabetes mellitus (T2DM) show early remission of hyperglycemia after obesity surgery. It is unknown to what extent other diabetes-associated comorbidities such as distal peripheral neuropathy (DPN) might be influenced by obesity surgery. This pilot study aimed at providing further evidence for the impact of Roux-en-Y gastric bypass (RYGB) on both glycemic control and DPN in non-severely obese patients with insulin-dependent T2DM.

METHODS

In the present prospective cohort study, 20 patients with long-standing, insulin-dependent T2DM and a body mass index (BMI) between 25 and 35 kg/m underwent laparoscopic RYGB. Body mass index, glycosylated hemoglobin (HbA1c), and DPN [quantified by the Neuropathy Symptom Score (NSS) and the Neuropathy Deficit Score (NDS)] were investigated.

RESULTS

Six months after surgery, the preoperative BMI of 32.8 ± 2.1 kg/m (mean ± standard deviation) dropped to 25.6 ± 2.5 kg/m (P < 0.001). Preoperative HbA1c levels decreased from 8.5 ± 1.2% to 7.1 ± 1.2% (P < 0.001), with 15% of patients having a normalized HbA1c level lower than 6.2%. Of 12 patients with documented DPN, the median NSS was 8 (range, 0-10) preoperatively and 0 (range, 0-9) postoperatively (P = 0.004), with 8 patients scoring an NSS of 0. The median NDS was 6 (range, 2-8) preoperatively and 4 (range, 0-8) postoperatively (P = 0.027), with 1 patient scoring an NDS of 0. All patients had an improvement or normalization in either 1 or both scores.

CONCLUSIONS

As expected, BMI and HbA1c levels improved significantly after RYGB. More interestingly, neuropathy scores, such as NSS and NDS, improved significantly early after surgery. Symptomatic neuropathy was completely reversible in 67% of the patients. These findings add further evidence to the fact that RYGB might be a valuable treatment option not only for improving glycemic control but also for reducing diabetes-associated comorbidities, such as DPN. This points to a complex metabolic effect of RYGB that exceeds glucose normalization. However, the results still need to be confirmed in controlled trials.

Robotic sleeve gastrectomy: experience of 134 cases and comparison with a systematic review of the laparoscopic approach

BACKGROUND

Robotic technology has recently emerged in different surgical specialties, but the experience with robotic sleeve gastrectomy (RSG) is scarce in the literature. The purpose of this study is to compare our preliminary experience with RSG versus the descriptive results of a systematic review of the laparoscopic approach.

METHODS

Data from our RSG experience were retrospectively collected. Two surgeons performed all the cases in one single surgery center. Such information was compared with a systematic review of 22 selected studies that included 3,148 laparoscopic sleeve gastrectomy (LSG) cases. RSG were performed using the daVinci Surgical System.

RESULTS

This study included 134 RSG vs. 3,148 LSG. Mean age and mean BMI was 43 ± 12.6 vs. 40.7 ± 11.6 (p = 0.022), and 45 ± 7.1 vs. 43.6 ± 8.1 (p = 0.043), respectively. Leaks were found in 0 RSG vs. 1.97% LSG (p = 0.101); strictures in 0 vs. 0.43% (p = 0.447); bleeding in 0.7 vs. 1.21% (p = 0.594); and mortality in 0 vs. 0.1% (p = 0.714), respectively. Mean surgical time was calculated in 106.6 ± 48.8 vs. 94.5 ± 39.9 min (p = 0.006); and mean hospital length of stay was 2.2 ± 0.6 vs. 3.3 ± 1.7 days (p = <0.005), respectively. Four (2.9%) complications were found in our robotic series.

CONCLUSIONS

Our series shows that RSG is a safe alternative when used in bariatric surgery, showing similar results as the laparoscopic approach. Surgical time is longer in the robotic approach, while hospital length of stay is lower. No leaks or strictures were found in the robotic cases. However, further studies with larger sample size and randomization are warranted.

Effects of laparoscopic sleeve gastrectomy on attentional processing of food-related information: evidence from eye-tracking

BACKGROUND

Weight loss after laparoscopic sleeve gastrectomy (LSG) might be associated partially with changes in reward system functioning and altered appetitive responses to food cues. Food cue processing refers to motivational, affective, and cognitive responses to stimuli that are associated with food. We investigated if food cue processing is altered 6 months after weight loss that is induced by LSG. We expected patients after LSG to show reduced appetitive responses to food cues.

METHODS

In an experimental longitudinal exploratory study, 17 severely obese patients (body mass index [BMI]: 48.3 ± 6.5 kg/m²) were investigated presurgery and 6 months postsurgery. We used eye-tracking to assess attentional biases during free viewing of food versus nonfood cues, assessed pleasantness ratings of food cues, and self-reported food craving.

RESULTS

After LSG, the mean BMI of patients was 36.4 ± 6.0 kg/m², and the percentage of excess weight loss (%EWL) was 46.6% ± 14.0%. Six months after LSG, patients showed an attentional bias toward nonfood cues compared with presurgery, reported lower food craving, and rated presented food stimuli as less pleasant.

CONCLUSION

Evidence of altered food cue processing was found in patients after LSG, which may be interpreted as reduced food reward associated with increased cognitive control. Surgery-induced physiologic, cognitive-motivational, and behavioral changes may lead to a desensitization of the reward system and enhanced cognitive control.

Laparoscopic sleeve gastrectomy compared with other bariatric surgical procedures: a systematic review of randomized trials

BACKGROUND

The evidence regarding the effectiveness and safety of laparoscopic sleeve gastrectomy (LSG) has been mostly based on the data derived from nonrandomized studies. The objective of this study was to evaluate the outcomes of LSG and to present an up-to-date review of the available evidence based on the recent publications of new randomized, controlled trials (RCTs).

METHODS

PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched until November 2012 for RCTs on LSG.

RESULTS

Fifteen RCTs, comprising a total of 1191 patients, of whom 795 had undergone LSG, were included. No patient required conversion to open surgery for LSG, laparoscopic gastric bypass (LGB), or laparoscopic adjustable gastric banding (LAGB) procedures. There were no deaths, and the complication rate was 12.1% (range 10%-13.2%) in the LSG group versus 20.9% (range 10%-26.4%) in the LGB group, and 0% in the LAGB group (only 1 RCT). The complications included leakage, bleeding, stricture, and reoperation that occurred with rates of .9%, 3.3%, 0%, and 2.1%, respectively, in the LSG group and rates of 0%, 5%, 0%, and 4%, respectively, in the LGB group. The average operating time in the LSG group was 106.5 minutes versus 132.3 minutes in the LGB group. The percentage of excess weight loss (%EWL) ranged from 49% to 81% in the LSG group, from 62.1% to 94.4% in the LGB group, and from 28.7% to 48% in the LAGB group, with a follow-up ranging from 6 months to 3 years. The type 2 diabetes mellitus (T2DM) remission rate ranged from 26.5% to 75% in the LSG group and from 42% to 93% in the LGB group.

CONCLUSIONS

LSG is a well-tolerated, feasible procedure with a relatively short operating time. Its effectiveness in terms of weight loss is confirmed for short-term follow-up (≤ 3 years). The role of LSG in the treatment of T2DM requires further investigation.

Obesity, adiposity, and dyslipidemia: a consensus statement from the National Lipid Association

The term "fat" may refer to lipids as well as the cells and tissue that store lipid (ie, adipocytes and adipose tissue). "Lipid" is derived from "lipos," which refers to animal fat or vegetable oil. Adiposity refers to body fat and is derived from "adipo," referring to fat. Adipocytes and adipose tissue store the greatest amount of body lipids, including triglycerides and free cholesterol. Adipocytes and adipose tissue are active from an endocrine and immune standpoint. Adipocyte hypertrophy and excessive adipose tissue accumulation can promote pathogenic adipocyte and adipose tissue effects (adiposopathy), resulting in abnormal levels of circulating lipids, with dyslipidemia being a major atherosclerotic coronary heart disease risk factor. It is therefore incumbent upon lipidologists to be among the most knowledgeable in the understanding of the relationship between excessive body fat and dyslipidemia. On September 16, 2012, the National Lipid Association held a Consensus Conference with the goal of better defining the effect of adiposity on lipoproteins, how the pathos of excessive body fat (adiposopathy) contributes to dyslipidemia, and how therapies such as appropriate nutrition, increased physical activity, weight-management drugs, and bariatric surgery might be expected to impact dyslipidemia. It is hoped that the information derived from these proceedings will promote a greater appreciation among clinicians of the impact of excess adiposity and its treatment on dyslipidemia and prompt more research on the effects of interventions for improving dyslipidemia and reducing cardiovascular disease risk in overweight and obese patients.

To Sleeve or NOT to Sleeve in Bariatric Surgery?

Morbid obesity has become a global epidemic during the 20th century. Until now bariatric surgery is the only effective treatment for this disease leading to sustained weight loss and improvement of comorbidities. The sleeve gastrectomy is becoming a promising alternative for the gold standard the gastric bypass and it is gaining popularity as a stand-alone procedure. The effect of the laparoscopic sleeve gastrectomy is based on a restrictive mechanism, but a hormonal effect also seems to play an important role. Similar results are achieved in terms of excess weight loss and resolution of comorbidities compared to the gastric bypass. Inadequate weight loss or weight regain can be treated by revisional surgery. Complication rates after LSG appear to be lower compared with gastric bypass. General guidelines recommend bariatric surgery between the age of 18 and 65. However bariatric surgery in the elderly seems safe with respect to weight loss and resolution of comorbidities. At the same time weight loss surgery is more often performed in adolescent patients failing weight loss attempts. Even though more studies are needed describing long-term effects, there is already enough evidence that this technique is an effective single procedure for a considerable proportion of obese patients.

Gastrectomy and risk of pancreatic cancer: systematic review and meta-analysis of observational studies

PURPOSE

To investigate the association between gastrectomy and risk of pancreatic cancer (PaC).

METHODS

We identified eligible studies in Medline and EMBASE up to 11 February 2012 and the reference lists of original studies and review articles on this topic. Summary relative risks with their 95 % confidence intervals were calculated with a random-effects model. Between-study heterogeneity was assessed using Cochran Q and I (2) statistics.

RESULTS

Fifteen studies (11 case-control studies and 4 cohort studies) met eligibility criteria. The current data suggest that gastrectomy is associated with a 54 % excess risk of PaC (SRRs = 1.54; 95 % CI, 1.25-1.90; test for heterogeneity Q = 17.94, p < 0.001, I (2) = 22 %). There was no publication bias in the present meta-analysis.

CONCLUSION

A significant increased risk of PaC exists in patients who have undergone gastrectomy, particularly those receiving Billroth II resection with a long postoperative interval.

Laparoscopic sleeve gastrectomy for mildly obese patients (Body Mass Index of 30 <35 kg/m²): operative outcome and short-term results

BACKGROUND

Data concerning laparoscopic sleeve gastrectomy (LSG) in mild obesity are under investigation.

AIM/OBJECTIVE

May 2010 to May 2012, 122 consecutive patients with preoperative body mass index (BMI) of 33 ± 2.5 kg/m² (range 30-34.9) undergoing LSG were studied. Mean age was 33 ± 10 years (range 15-60), and 105 (86%) were women. Mean preoperative weight was 91 ± 9.7 kg (range 66-121), and preoperative excess weight was 30 ± 6.7 kg (range 19-43). Comorbidities were detected in 44 (36%) patients.

RESULTS

Mean operative time was 58 ± 15 min (range 40-95), and postoperative stay was 1.8 ± 0.19 days (range 1.5-3). There were no admissions to intensive care unit and no deaths within 30 days of surgery. The rates of leaks and strictures were 0%, and of hemorrhage 1.6%. At 12 months, BMI decreased to 24.7 ± 2, and the percentage of excess weight loss (% EWL) reached 76.5%. None of the patients had a BMI below 20 kg/m². Comorbidities resolved in 70.5% or improved in 29.5%. Patient satisfaction scoring (1-5) at least 1 year after was 4.6 ± 0.8 for body image and 4.4 ± 0.6 for food tolerance.

CONCLUSION

LSG for mildly obese patients has proved to be technically relatively easy, safe, and benefic in the short term.