Randomized Controlled Trials in Bariatric Surgery

Banded Sleeve Gastrectomy and One Anastomosis Gastric Bypass/Mini-gastric Bypass for Treatment of Obesity: a Retrospective Cohort Comparative Study with 6 years follow-up

BACKGROUND

Banded sleeve gastrectomy (BSG), a modification of the laparoscopic sleeve gastrectomy (SG), and one anastomotic gastric bypass/mini-gastric bypass (OAGB/MGB), a modification to the Roux-en-Y gastric bypass (RYGB), have been reported to enhance weight loss and minimize significant weight regain when compared with the SG and RYGB respectively. However, there has not been any report or study comparing these two operations.

OBJECTIVE

We did a retrospective cohort study comparing these two operations and present a review and analysis with follow-up for 6 years.

METHOD

A review of all the operations performed at MBRSC in 2011 from a prospectively maintained database was done. Patients who had either a BSG or OAGB/MGB were identified. Data on the patients' profile, co-morbid conditions, perioperative complications, late complications, weight loss, resolution of comorbidities, and changes in quality of life (QLF) were collected reviewed and analyzed.

RESULT

Sixty-eight patients were identified who had a primary BSG and 55 who had an OAGB/MGB in 2011. The follow-up rate, the age, BMI, and gender composition were similar in both groups. There were more patients with type 2 diabetes (T2D) in the BSG group than in the OAGB/MGB group (44.1% vs. 27.2%). The incidences of hypertension (HTN) and obstructive sleep apnea (OSA) were higher in the OAGB/MGB group (62% vs. 36% and 96.3% vs. 2.9% respectively). The weight loss was faster in the OAGB/MGB group in the first year, but by the sixth year, the weight loss was slightly higher in the BSG group (84% vs. 79%). Resolution rate of T2D and HTN was higher after the OAGB/MGB group, 86.6% vs. 75.7% and 85.3% vs. 64.0% respectively. There was a 20% incidence of nutrient deficiencies in OAGB/MGB group and none in the BSG group.

CONCLUSION

Both operations produced excellent weight loss and maintenance in the short to intermediate term. There was better resolution of T2D and HTN after OAGB/MGB at the expense of a higher incidence of nutrient deficiency and some protein caloric malnutrition. There is need for prospective and larger series studies to confirm these findings.

Impact of self-efficacy on risk aversion in the context of surgical weight loss decision scenarios

Obesity is prevalent among a third of US adults and a leading indicator for many chronic diseases. Self-efficacy is important for non-surgical weight loss interventions, but there is less information about the role of self-efficacy in the candidacy phase when there are discussions of side effects and decisions for uptake. This study conducted an experiment set within an online survey assessing risk aversion towards bariatric surgery as a weight loss intervention. The survey asked about hypothetical weight loss scenarios for bariatric surgery among a national probability-based sample of US adults aged 18 years and older. Participants answered their willingness to achieve different weight loss amounts within the context of bariatric surgery in varying risk scenarios. The analysis utilized a repeated-measures linear mixed model. A three-way interaction demonstrated that participants were more willing to take risks under ideal weight loss conditions even with the risk of death, particularly when considering self-efficacy (𝛽 = 1.20, P = .05). Margin projections showed that those with lower self-efficacy were more likely to take risks overall. This trend was significant for those with a body mass index of 30 and above in scenarios presenting one's ideal weight as the outcome of bariatric surgery. Adding a measure of self-efficacy within patient assessments could identify those eligible patients who are most likely to adopt bariatric surgery, particularly among those who may have negative post-surgical outcomes due to low self-efficacy levels. Addressing self-efficacy by way of providing support resources in tandem with candidacy consultations may enhance quality of life and post-surgical outcomes.

Increased Gastrointestinal Surgical Hospital Burden After Laparoscopic Gastric Bypass for Obesity: A Nationwide 5-years Follow-up Study

OBJECTIVE

To study long-term gastrointestinal surgical hospital burden (hospital readmissions and gastrointestinal surgical procedures) after laparoscopic gastric bypass.

BACKGROUND

Little is known about gastrointestinal surgical hospital burden after laparoscopic gastric bypass.

METHODS

Danish patients undergoing laparoscopic gastric bypass (BMI >35-50) from January 1, 2005 to December 31, 2013 were included (100% follow-up). The nonsurgical reference group were individuals with BMI of ≥ 30 drawn from The Danish National Health Surveys from 2005 to 2013. The primary outcome was gastrointestinal surgical hospital burden. Secondary outcome was mortality. Age, body mass index (BMI), gender, and calendar time (time of surgery and nonsurgical survey), diabetes status was adjusted for in a multivariate Poisson regression model.

RESULTS

13,582 bariatric surgical patients and 45,948 reference individuals were included with a mean follow-up time of 4.7 years (SD 2.4). The incidence rate ratio (IRR) for hospital re-re-admission was 2.17 higher in the intervention group (95% CI 2.04-2.31). Sensitivity analysis showed that patients operated before 2010 had a higher incidence for re-re-admission than after. IRR for surgical gastrointestinal procedures was 6.56 (CI 6.15-6.99) and 3.04 (CI 3.51-4.17) after 1 and 5 years for the intervention group compared with the reference group. Surgery for internal hernia was the most common abdominal procedure. The mortality odds ratio was 0.84 (CI 0.65-0.96).

CONCLUSIONS

Gastrointestinal surgical hospital burden was significantly higher in the first 5 years after gastric bypass compared with a matched nonsurgical reference group of obese citizens.

[Quality indicators for metabolic and bariatric surgery in Germany : Evidence-based development of an indicator panel for the quality of results, indications and structure]

An expert committee was appointed by the German Society for General and Visceral Surgery to develop a panel of appropriate quality indicators to collate the quality of results, indications and structure in metabolic and bariatric surgery. This entailed assimilating the available evidence (systematic literature search), results from the national registry of the society (StuDoQ|MBE) and specific socioeconomic aspects (e. g. severely limited access to metabolic and bariatric surgery in Germany). These quality parameters were to be incorporated into the national guidelines and the rules of procedure for certification in the future. The committee concluded that mortality, MTL30 and severe complications needing intervention (Clavien-Dindo ≥ 3b) are suitable indicators to measure surgical outcome quality due to their relevance, scientific soundness and practicability. As a systematic follow-up is mandatory after bariatric surgery, a minimum follow-up quota is now required using reported quality of life data as an indicator of process quality. As intestinal bypass procedures have been shown to be superior in the treatment of type 2 diabetes, these procedures should be offered to eligible patients and also be performed. The proposed threshold values based on the results of the available literature and StuDoQ registry are to be considered as preliminary and need to be validated and adjusted if necessary in the future. The StuDoQ|MBE is considered a valuable tool to gather this information and also represents the appropriate infrastructure for the collation of relevant risk adjustors.

Recent advancements in bariatric/metabolic surgery

Obesity and type 2 diabetes mellitus (T2DM) are currently two pan‐endemic health problems worldwide and are associated with considerable increase in morbidity and mortality. Both diseases are closely related and very difficult to control by current medical treatment, including diet, drug therapy and behavioral modification. Bariatric surgery has proven successful in treating not just obesity but also in significantly decreasing overall obesity‐associated morbidities as well as improving quality of life in severely obese patients (body mass index [BMI] >35 kg/m²). A rapid increase in bariatric surgery started in the 2000s when the laparoscopic surgical technique was introduced into this field. Many new procedures had been developed and changed the face of modern bariatric surgery. Recently, bariatric surgery played as gastrointestinal metabolic surgery has been proposed as a new treatment modality for obesity‐related T2DM for patients with BMI >35 kg/m². Strong evidence has demonstrated that bariatric/metabolic surgery is an effective and durable treatment for obese T2DM patients. Bariatric/metabolic surgery is now becoming an important surgical division. The present article examines and discusses recent advancements in bariatric/metabolic surgery and covers four major fields: (i) the rapid increase in numbers and better safety; (ii) new procedures with better outcomes; (iii) from bariatric to metabolic surgery; and (iv) understanding the mechanisms and personalized treatment.

Skin changes after bariatric surgery

Today, obesity is considered an epidemic all over the world and it is recognized as one of the major public health problems. Bariatric surgery is considered an appropriate therapeutic option for obesity with progressively increasing demands. The changes resulting from massive weight loss after bariatric surgery are related to numerous complications. This article will present the dermatological alterations that can be found after bariatric surgery. They will be subdivided into dermatoses that are secondary to metabolic and nutritional disorders, those derived from cutaneous structural modifications after major weight loss and the influence the latter may have in improving of certain dermatoses.

Surgery for weight loss in adults

BACKGROUND

Bariatric (weight loss) surgery for obesity is considered when other treatments have failed. The effects of the available bariatric procedures compared with medical management and with each other are uncertain. This is an update of a Cochrane review first published in 2003 and most recently updated in 2009.

OBJECTIVES

To assess the effects of bariatric surgery for overweight and obesity, including the control of comorbidities.

SEARCH METHODS

Studies were obtained from searches of numerous databases, supplemented with searches of reference lists and consultation with experts in obesity research. Date of last search was November 2013.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing surgical interventions with non-surgical management of obesity or overweight or comparing different surgical procedures.

DATA COLLECTION AND ANALYSIS

Data were extracted by one review author and checked by a second review author. Two review authors independently assessed risk of bias and evaluated overall study quality utilising the GRADE instrument.

MAIN RESULTS

Twenty-two trials with 1798 participants were included; sample sizes ranged from 15 to 250. Most studies followed participants for 12, 24 or 36 months; the longest follow-up was 10 years. The risk of bias across all domains of most trials was uncertain; just one was judged to have adequate allocation concealment.All seven RCTs comparing surgery with non-surgical interventions found benefits of surgery on measures of weight change at one to two years follow-up. Improvements for some aspects of health-related quality of life (QoL) (two RCTs) and diabetes (five RCTs) were also found. The overall quality of the evidence was moderate. Five studies reported data on mortality, no deaths occurred. Serious adverse events (SAEs) were reported in four studies and ranged from 0% to 37% in the surgery groups and 0% to 25% in the no surgery groups. Between 2% and 13% of participants required reoperations in the five studies that reported these data.Three RCTs found that laparoscopic Roux-en-Y gastric bypass (L)(RYGB) achieved significantly greater weight loss and body mass index (BMI) reduction up to five years after surgery compared with laparoscopic adjustable gastric banding (LAGB). Mean end-of-study BMI was lower following LRYGB compared with LAGB: mean difference (MD) -5.2 kg/m² (95% confidence interval (CI) -6.4 to -4.0; P < 0.00001; 265 participants; 3 trials; moderate quality evidence). Evidence for QoL and comorbidities was very low quality. The LRGYB procedure resulted in greater duration of hospitalisation in two RCTs (4/3.1 versus 2/1.5 days) and a greater number of late major complications (26.1% versus 11.6%) in one RCT. In one RCT the LAGB required high rates of reoperation for band removal (9 patients, 40.9%).Open RYGB, LRYGB and laparoscopic sleeve gastrectomy (LSG) led to losses of weight and/or BMI but there was no consistent picture as to which procedure was better or worse in the seven included trials. MD was -0.2 kg/m² (95% CI -1.8 to 1.3); 353 participants; 6 trials; low quality evidence) in favour of LRYGB.  No statistically significant differences in QoL were found (one RCT). Six RCTs reported mortality; one death occurred following LRYGB. SAEs were reported by one RCT and were higher in the LRYGB group (4.5%) than the LSG group (0.9%). Reoperations ranged from 6.7% to 24% in the LRYGB group and 3.3% to 34% in the LSG group. Effects on comorbidities, complications and additional surgical procedures were neutral, except gastro-oesophageal reflux disease improved following LRYGB (one RCT). One RCT of people with a BMI 25 to 35 and type 2 diabetes found laparoscopic mini-gastric bypass resulted in greater weight loss and improvement of diabetes compared with LSG, and had similar levels of complications.Two RCTs found that biliopancreatic diversion with duodenal switch (BDDS) resulted in greater weight loss than RYGB in morbidly obese patients. End-of-study mean BMI loss was greater following BDDS: MD -7.3 kg/m² (95% CI -9.3 to -5.4); P < 0.00001; 107 participants; 2 trials; moderate quality evidence). QoL was similar on most domains. In one study between 82% to 100% of participants with diabetes had a HbA1c of less than 5% three years after surgery. Reoperations were higher in the BDDS group (16.1% to 27.6%) than the LRYGB group (4.3% to 8.3%). One death occurred in the BDDS group.One RCT comparing laparoscopic duodenojejunal bypass with sleeve gastrectomy versus LRYGB found BMI, excess weight loss, and rates of remission of diabetes and hypertension were similar at 12 months follow-up (very low quality evidence). QoL, SAEs and reoperation rates were not reported. No deaths occurred in either group.One RCT comparing laparoscopic isolated sleeve gastrectomy (LISG) versus LAGB found greater improvement in weight-loss outcomes following LISG at three years follow-up (very low quality evidence). QoL, mortality and SAEs were not reported. Reoperations occurred in 20% of the LAGB group and in 10% of the LISG group.One RCT (unpublished) comparing laparoscopic gastric imbrication with LSG found no statistically significant difference in weight loss between groups (very low quality evidence).  QoL and comorbidities were not reported. No deaths occurred. Two participants in the gastric imbrication group required reoperation.

AUTHORS' CONCLUSIONS

Surgery results in greater improvement in weight loss outcomes and weight associated comorbidities compared with non-surgical interventions, regardless of the type of procedures used. When compared with each other, certain procedures resulted in greater weight loss and improvements in comorbidities than others. Outcomes were similar between RYGB and sleeve gastrectomy, and both of these procedures had better outcomes than adjustable gastric banding. For people with very high BMI, biliopancreatic diversion with duodenal switch resulted in greater weight loss than RYGB. Duodenojejunal bypass with sleeve gastrectomy and laparoscopic RYGB had similar outcomes, however this is based on one small trial. Isolated sleeve gastrectomy led to better weight-loss outcomes than adjustable gastric banding after three years follow-up. This was based on one trial only.  Weight-related outcomes were similar between laparoscopic gastric imbrication and laparoscopic sleeve gastrectomy in one trial. Across all studies adverse event rates and reoperation rates were generally poorly reported. Most trials followed participants for only one or two years, therefore the long-term effects of surgery remain unclear.

Acute gastric remnant dilatation, a rare early complication of laparoscopic mini-gastric bypass

Several thousands of laparoscopic mini-gastric bypass have been performed globally by a number of surgeons. There is growing evidence that mini-gastric bypass is a safe and effective procedure. We report a rare case of massive gastric remnant dilation in a 45-year-old man after laparoscopic mini-gastric bypass. Acute gastric dilatation is a surgical emergency. In our case, a triad of clinical suspicion, laboratory profile, and emergency radiologic investigation were essential for early diagnosis and management. Image-guided gastrostomy tube placement provides an effective decompression of the gastric remnant. A literature review revealed no previous reports of similar complications in mini-gastric bypass.