Thirteen-Year Experience of Laparoscopic Sleeve Gastrectomy: Surgical Risk, Weight Loss, and Revision Procedures

Greater durability of weight loss at ten years with gastric bypass compared to sleeve gastrectomy

INTRODUCTION

Sleeve gastrectomy (SG) and gastric bypass (GB) are the most commonly performed bariatric surgeries. However, there is insufficient data on which leads to greater long-term (10 year) weight loss.

METHODS

Subjects who underwent SG and GB from 2008-2013 were followed up at 2, 5, and 10 years post-operatively for weight and diabetes (DM) outcomes. Percentage total weight loss (%TWL), weight regain ( ≥ 20% from nadir) and DM remission rates were compared.

RESULTS

Subjects (n = 253) who underwent SG (60.9%) and GB (39.1%) were included. The mean age was 41.4 ± 10.6 y, 39.1% were male, and the mean body mass index was 42.1 ± 9.3 kg/m2 with no significant difference between groups. The GB group had a greater proportion of subjects with DM (83.8% vs 19.5%, p < 0.001). At 2 y, %TWL was comparable (GB: 22.3 ± 9.6%, SG: 22.6 ± 10.5%, p = 0.824). However, those who underwent GB had significantly higher %TWL at 5 y (GB: 21.5 ± 8.9%, SG 18.0 ± 11.3%, p = 0.029) and 10 y (GB: 21.0 ± 9.0%, SG: 15.4 ± 12.1%, p = 0.001). The rate of significant weight regain was higher amongst the SG group at both 5 y (SG: 14.7%, GB: 3.8%, p = 0.018) and 10 y (SG: 27.9%, GB: 13.7%, p = 0.037) post-operatively. On multiple linear regression, GB remained significantly associated with greater %TWL at 10 y compared to SG (b = 5.51; adjusted p-value = 0.013), after adjusting for age, sex, pre-operative BMI, pre-operative glycemic status, and surgery year. There was no difference in DM remission rates at 10 y (SG: 26.7%, GB: 19.1%, p = 0.385).

CONCLUSION

GB was able to produce greater %TWL and less weight regain than SG at 5 and 10 years post-operatively. There was no difference in long-term DM remission rates between the two surgeries.

Bariatric Surgery: Overview of Procedures and Outcomes

Bariatric surgery has been demonstrated to be the single most effective weight loss therapy available. These therapies are now very well standardized and the evidence demonstrating their efficacy is overwhelming. Advancements in minimally invasive surgery and overall surgical experience have led to a significant decrease in perioperative mortality, and the benefits of bariatric surgery on life expectancy are therefore likely to be even more positive today. Bariatric surgery has been shown to have comparable morbidity and mortality risks to other commonly performed procedures like cholecystectomy, hernia repairs, appendectomy, and hip arthroplasty.

Sleeve gastrectomy plus single anastomosis sleeve ileal bipartition versus sleeve gastrectomy alone: The role of bipartition

BACKGROUND

Sleeve gastrectomy (SG) with single anastomosis sleeve ileal bipartition (SASI) is a novel procedure for increasing the anti-metabolic efficacy of SG in severely people with obesity.

OBJECTIVES

This study aimed to compare 1-year results between SASI and SG, thereby assessing the role of bipartition.

SETTING

The study was conducted at the Medical University hospital.

METHODS

Between November 2021 and December 2022, 39 patients received an SG + SASI surgery, a total of 35 patients completed 1-year follow-up after the surgery. They were matched with a group of 70 patients with SG that were equal in age, sex, and body mass index (BMI). Operative risk, weight loss, and remission of comorbidities were evaluated after 12 months.

RESULTS

The operation time of the SASI group was significantly longer than the SG group (140.3 ± 22.8 vs. 114.9 ± 21.6 min; p < .001). At 12 months after surgery, the SASI group had better weight loss (total weight loss: 37.0% vs. 29.7%; p = .001) and achieved a lower BMI than SG (23.4 ± 2.6 kg/m2 vs. 24.6 ± 2.9 kg/m2; p = .046). Reduction of A1C and remission of T2D was greater in the SASI group. The SASI group had a higher reduction in uric acid, low-density lipoprotein, total cholesterol, and triglyceride levels after operation than the SG group. However, the SG group is superior to the SASI group in mean corpuscular volume, calcium, and iron levels.

CONCLUSIONS

In this study, adding an ileum bipartition to SG increases the weight loss, glycemic, and blood lipid control of SG only.

Increased staple line leak rates following re-sleeve: analysis comparing re-sleeve versus Roux-en-Y gastric bypass conversion and primary sleeve gastrectomy

BACKGROUND

Sleeve gastrectomy is the most common bariatric procedure and its long-term complications include inadequate weight loss, weight regain, and de novo GERD, often requiring revisional surgery. Revisions, notably re-sleeve and conversion to Roux-en-Y gastric bypass (RYGB), are frequently performed, but safety data is limited. Herein, we used the MBSAQIP database to compare 30 day outcomes of primary sleeve gastrectomy (SG) with re-sleeve (RS) and SG to RYGB conversion.

METHODS

Patients who underwent primary SG, RS, and SG to RYGB conversion within the MBSAQIP data registry from January 1, 2020 to December 31, 2022 were included in this study. Using Propensity Score Matching analysis, the cohorts were matched for 23 preoperative characteristics. We then compared 30 day postoperative outcomes and bariatric-specific complications between primary SG and RS (analysis 1) and between RS and SG to RYGB conversion (analysis 2).

RESULTS

A total of 302,961 were included. The matched cohorts in analysis 1 (n = 1630) and analysis 2 (n = 1633) had similar pre-operative characteristics. Propensity-matched outcomes in analysis 1 showed that patients in the RS group had significantly higher staple line leak (1.3% vs. 0.1%, p < 0.001) when compared to primary SG. Similarly, longer operative times (90.16 ± 51.90 min vs. 68.32 ± 37.54 min, p < 0.001) and higher rates of readmissions (5.5% vs. 2.1%, p < 0.001), reoperations (2.3% vs. 0.6%, p < 0.001), interventions (2.5% vs. 0.4%, p < 0.001) were found in those who underwent RS. In analysis 2, RS showed higher leak rates (1.3% vs. 0.5%, p = 0.015) when compared to conversion from SG to RYGB.

CONCLUSION

The RS group has a higher risk of staple line leaks compared to primary SG and conversion from SG to RYGB. In our study, there was a 2.6-fold increase in staple line leak after re-sleeve compared to RYGB conversion and a 13-fold increase compared to primary SG.

A superior approach? The role of robotic sleeve gastrectomy in patients with super super obesity using the 2019-2022 MBSAQIP database

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) in patients with BMI ≥ 60 presents technical challenges, that might be overcome by robotic surgery, but its effectiveness has not been rigorously evaluated. We compared the 30-day outcomes of LSG and robotic sleeve gastrectomy (RSG) in patients with BMI < 60 versus ≥ 60 and between LSG and RSG in patients with BMI ≥ 60.

METHODS

Patients aged 18-65 years who underwent sleeve gastrectomy were included using the 2019-2022 MBSAQIP database. We performed a Propensity Score Matching analysis, with 21 preoperative characteristics. We compared 30-day postoperative outcomes for patients with BMI < 60 versus ≥ 60 using either a laparoscopic (Analysis 1) or robotic approach (Analysis 2) and compared LSG versus RSG in patients with BMI ≥ 60 (Analysis 3).

RESULTS

297,250 patients underwent LSG and 81,008 RSG. Propensity-matched¸ outcomes in analysis 1 (13,503 matched cases), showed that patients with BMI ≥ 60 had higher rates of mortality (0.1% vs. 0.0%, p = 0.014), staple line leak (0.3% vs. 0.2%, p = 0.035), postoperative bleeding (0.2% vs 0.1%, p = 0.028), readmissions (3.5% vs. 2.4%, p < 0.001), and interventions (0.7% vs. 0.5%, p = 0.028) when compared to patients with BMI < 60. In analysis 2 (4350 matched cases), patients with BMI ≥ 60 demonstrated longer operative times, length of stay, and higher rates of unplanned ICU when compared to patients with BMI < 60. In analysis 3 (4370 matched cases), patients who underwent RSG had fewer readmissions (2.9% vs. 3.7%, p = 0.037), staple line leaks (0.1% vs. 0.3%, p = 0.029), and postoperative bleeding (0.1% vs. 0.3%, p = 0.045), compared to LSG. Conversely, a longer operative time (92.74 ± 38.65 vs. 71.69 ± 37.45 min, p < 0.001) was reported.

CONCLUSION

LSG patients with BMI ≥ 60 have higher rates of complications compared to patients with a BMI < 60. Moreover, some outcomes may be improved with the robotic approach in patients with BMI ≥ 60. These results underscore the importance of considering a robotic approach in this super super obese population.

Results of the national registry of patients diagnosed with inflammatory bowel disease candidates for bariatric surgery (ReNacEIBar)

BACKGROUND

Our aim is to carry out a national registry of patients with inflammatory bowel disease (IBD) who underwent bariatric surgery, as well as evaluate the results and management of this type of patients in the usual clinical practice.

METHODS

National multicentric observational retrospective study, including patients, previously diagnosed with IBD who underwent bariatric surgery from January 2000 to December 2022.

RESULTS

Forty-one patients have been included: 43,9% previously diagnosed with ulcerative colitis, 57,3% Crohn's disease, and an indeterminate colitis (2,4%). The preoperative BMI was 45.8 ± 6,1 kg/m2. Among the bariatric surgeries, 31 (75,6%) sleeve gastrectomy, 1 (2,4%) gastric bypass and 9 (22%) one anastomosis gastric have been carried out. During the postoperative period, 9.8% complications have been recorded. BMI was 29,5 ± 4,7 kg/m2 and percent total weight lost was 33,9 ± 9,1% at 12 months.

CONCLUSIONS

Bariatric surgery in patients with inflammatory bowel disease can be considered safe and effective.

Cost-effectiveness of endoscopic, surgical and pharmacological obesity therapies: a microsimulation and threshold analyses

OBJECTIVE

Weight loss interventions to treat obesity include sleeve gastrectomy (SG), lifestyle intervention (LI), endoscopic sleeve gastroplasty (ESG) and semaglutide. We aimed to identify which treatments are cost-effective and identify requirements for semaglutide to be cost-effective.

DESIGN

We developed a semi-Markov microsimulation model to compare the effectiveness of SG, ESG, semaglutide and LI for weight loss in 40 years old with class I/II/III obesity. Extensive one-way sensitivity and threshold analysis were performed to vary cost of treatment strategies and semaglutide adherence rate. Outcome measures were incremental cost-effectiveness ratios (ICERs), with a willingness-to-pay threshold of US$100 000/quality-adjusted life-year (QALY).

RESULTS

When strategies were compared with each other, ESG was cost-effective in class I obesity (US$4105/QALY). SG was cost-effective in class II obesity (US$5883/QALY) and class III obesity (US$7821/QALY). In class I/II/III, obesity, SG and ESG were cost-effective compared with LI. However, semaglutide was not cost-effective compared with LI for class I/II/III obesity (ICER US$508 414/QALY, US$420 483/QALY and US$350 637/QALY). For semaglutide to be cost-effective compared with LI, it would have to cost less than US$7462 (class III), US$5847 (class II) or US$5149 (class I) annually. For semaglutide to be cost-effective when compared with ESG, it would have to cost less than US$1879 (class III), US$1204 (class II) or US$297 (class I) annually.

CONCLUSIONS

Cost-effective strategies were: ESG for class I obesity and SG for class II/III obesity. Semaglutide may be cost-effective with substantial cost reduction. Given potentially higher utilisation rates with pharmacotherapy, semaglutide may provide the largest reduction in obesity-related mortality.

Long-Term Results of Laparoscopic Sleeve Gastrectomy: a Review of Studies Reporting 10+ Years Outcomes

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure worldwide. Systematic search of Pubmed, Cochrane, and Embase was performed in order to find all the articles reporting 10+ years of LSG results. Eleven studies including 1020 patients met the inclusion criteria. Overall weighted mean %TWL was 24.4% (17-36.9%), and remission rates from TD2M to HTN were 45.6% (0-94.7%) and 41.4% (0-78.4%), respectively. De novo GERD had an overall prevalence of 32.3% (21.4-58.4%), and five cases (0.5%) of Barrett's disease were reported. Revisional surgery was required for 19.2% (1-49.5%) of patients, Roux-en-Y gastric bypass being the most common secondary procedure.

Perioperative Morbidity and Mortality of Laparoscopic Sleeve Gastrectomy (LSG) in a Single-Surgeon Experience on 892 Patients Over 11 Years

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has been the most frequently performed bariatric procedure since 2014, with continually growing popularity. This study aimed to present our 30-day morbidity and mortality following LSG over a period of 11 years.

PATIENTS AND METHODS

This is a retrospective study that was based on prospectively collected data from patients undergoing LSG by the same surgeon from July 2011 to the end of August 2022. The LSG-associated 30-day morbidity and mortality and the risk factors for 30-day morbidity were assessed.

RESULTS

This study included 892 patients who underwent LSG over the course of 11 years. Early postoperative adverse events were encountered in 16 patients (1.79%). Overall, twelve patients (1.35%) required blood transfusions, and two patients (0.22%) required ICU admission. The re-operation rate was 0.9% (n = 8) and the mortality rate was 0.22% (n = 2). The patient's BMI, hypertension, and revisional surgery were marginally significant/significant predictors of early postoperative morbidity. The mean EBWL% was 63.8 ± 15.55 at the 6-month follow-up.

CONCLUSION

This study confirms the previously reported LSG's short-term safety in terms of a low rate of 30-day postoperative morbidity and mortality. Preoperative BMI, hypertension, and revisional surgery are risk factors for 30-day morbidity and mortality.

Long-Term Outcome of Laparoscopic Sleeve Gastrectomy (LSG) on Weight Loss in Patients with Obesity: a 5-Year and 11-Year Follow-Up Study

BACKGROUND

Bariatric surgery is the most efficient treatment for patients with clinically severe obesity who have failed to obtain satisfactory weight loss through lifestyle modification and medical treatments. This study aimed to present our long-term laparoscopic sleeve gastrectomy (LSG) efficacy in terms of weight loss and obesity-related complications resolution.

PATIENTS AND METHODS

This is a retrospective study that was based on prospectively collected data from patients undergoing LSG by the same surgeon from July 2011 to the end of August 2022. The LSG-associated short-term (at 3 months, 6 months, and 1 year postoperatively) and long-term (at 5 years and 11 years postoperatively) weight loss, and the short-term (6 months postoperatively) and long-term (5 and 11 years postoperatively) rates of obesity-related complications were assessed.

RESULTS

This study included 892 patients who underwent LSG over 11 years. At the 1-year follow-up, data on 860 patients were available, while at the 5-year and 11-year follow-ups, data on 193 patients and 48 patients, respectively, were available. The mean EBWL% was 84.57 ± 18.41%, 64.22 ± 15.53%, and 66.01 ± 8.66% at the 1-year, 5-year, and 11-year follow-ups, respectively.

CONCLUSION

This study adds new evidence concerning the short-term efficacy of LSG. The long-term assessment showed relatively sustainable weight loss and obesity-related complications resolution, with a regression of the short-term gains that was still far from the baseline burden.

Weight loss trend after bariatric surgery in a population of obese patients

BACKGROUND AND AIMS

Bariatric Surgery (BS) is a therapeutic option in patients with severe obesity whose non-surgical techniques have failed. No work has previously explored trajectories of weight loss and how long this was maintained. Aim of study is to describe effect of BS and nutritional intervention on body weight trend in patients with obesity.

METHODS

792 patients who underwent BS from 1996 to 2021 were included. The Protocol provides Laparoscopic Sleeve Gastrectomy (LSG), Vertical Gastroplasty (VBG) and Roux-en-Y Gastric Bypass (GB). %Total Weight Loss (%TWL) and %Excess Weight Loss (%EWL) were evaluated in three cohort of patients. Cumulative incidence of clinical goal after surgery was calculated at two and five years after BS.

RESULTS

At two years of follow-up, average %TWL and %EWL were 31.2% (95% CI = 29.0-33.4%) and 71% (95% CI = 65.4-76.5%) for VBG, 34.7% (95% CI = 33.8-35.6%) and 78.0% (95% CI = 75.9-89.1%) for GB and 33.8% (95% CI = 32.5-35.1%) and 68.8% (95% CI = 66.1-71.6%) for LSG. At two years from surgery the cumulative incidence of clinical goal was 70.7% (95% CI = 59.1-79.1%) for VBG, 86.4% (95% CI = 82.4-89.6%) for GB and 83.4% (95% CI = 76.0-87.1%) for LSG. At five years from surgery, average % TWL and % EWL were 22.5% (95% CI = 10.2-34.8%) and 58.2% (95% CI = 28.4-88.1%) for VBG, 31.8% (95% CI = 30.2-33.3%) and 70.8% (95% CI = 67.5-74.1%) for GB and 29.5% (95% CI = 26.2-32.8%) and 62.0% (95% CI = 53.4-70.6%) for LSG respectively. At five years after having reached clinical goal the share of people who were able to maintain their weight was 49.5% (95% CI = 30.8-79.6%) for VBG, 69.5% (95% CI = 58.3-82.8%) for GB and 55.9% (95% CI = 42.1-74.3%) for LSG. The median time of clinical goal maintaining was 4.8 years for VBG (95% CI lower limit = 4.1), 6.6 years for GB (95% CI lower limit = 6.2) and 5.3 years for LSG (95% CI lower limit = 4.8).

CONCLUSIONS

Our work confirm effectiveness of BS in patients with obesity and show that who do not reach clinical goal within 2 years, hardly will reach it later and suggest necessity for a medium and long-term follow-up to prevent weight regain.

Reduced risk of pneumonia and influenza infection after bariatric surgery: a retrospective cohort study among patients with nondiabetic obesity in Taiwan

BACKGROUND

Bariatric surgery is associated with significant improvements in immunity in individuals with obesity, but the exact efficacy in reducing pneumonia and influenza infections is unclear.

OBJECTIVE

To investigate the association between bariatric surgery and the risk of pneumonia and influenza infection.

SETTING

Nondiabetic patients who underwent bariatric surgery and matched controls were identified from the National Health Insurance Research Database of Taiwan.

METHODS

We identified 1648 nondiabetic patients who underwent bariatric surgery from the National Health Insurance Research Database of Taiwan in 2001-2009. These patients were matched by propensity score with 4881 nondiabetic patients with obesity who did not undergo bariatric surgery. We followed the surgical and control cohorts until death, any diagnosis of pneumonia or influenza, or December 31, 2012. The Cox proportional hazards regression model was used to calculate the relative risk of pneumonia and influenza infection in those who underwent bariatric surgery compared with those who did not.

RESULTS

Overall, there was a .87-fold (95% CI, .78-.98) reduced risk of pneumonia and influenza infection in the surgical group versus the control group. Four years after bariatric surgery, a sustainable effect of the surgery was observed, and the risk of pneumonia and influenza infection was .83-fold reduced in the surgical group (95% CI, .73-.95). Individuals with obesity who underwent bariatric surgery had a reduced risk of pneumonia and influenza infection compared with matched control individuals.

CONCLUSION

Individuals with obesity who underwent bariatric surgery had a reduced risk of pneumonia and influenza infection compared with matched control individuals.

Gastroesophageal reflux after sleeve gastrectomy: The dimension of the problem

Sleeve gastrectomy is a safe and effective bariatric surgery in terms of weight loss and longterm improvement or resolution of comorbidities. However, its achilles heel is the possible association with the development with the novo and/or worsening of pre-existing gastroesophageal reflux disease. The anatomical and mechanical changes that this technique induces in the esophagogastric junction, support or contradict this hypothesis. Questions such as «what is the natural history of gastroesophageal reflux in the patient undergoing gastric sleeve surgery?», «how many patients after vertical gastrectomy will develop gastroesophageal reflux?» and «how many patients will worsen their previous reflux after this technique?» are intended to be addressed in the present article.

Meta-analysis of Long-term De Novo Acid Reflux-Related Outcomes Following Sleeve Gastrectomy: Evidence Against the Need for Routine Postoperative Endoscopic Surveillance

OBJECTIVES

To evaluate the incidence of long-term de novo acid reflux-related complications following sleeve gastrectomy (SG) to determine whether routine postoperative surveillance endoscopy is necessary.

METHODS

A systematic search of Medline, Embase, CINAHL, CENTRAL, the Web of Science, and bibliographic reference lists was conducted. A proportion meta-analysis model was constructed to quantify the risk of the de novo gastro-oesophageal reflux disease (GORD), oesophagitis, and Barrett's oesophagus (BE) at least 4 years after SG. Random-effects modelling was applied to calculate pooled outcome data.

RESULTS

Thirty-two observational studies were included reporting a total of 7904 patients who underwent primary SG and were followed up for at least 4 years. The median follow-up period was 60 months (48-132). Preoperative acid-reflux symptoms existed in 19.1% ± 15.1% of the patients. The risk of development of de novo GORD, oesophagitis, and BE after SG was 24.8% (95% CI 18.6-31.0%), 27.9% (95% CI 17.7-38.1%), and 6.7% (95% CI 3.7-9.7%), respectively. The between-study heterogeneity was significant in all outcome syntheses. It was suspected that several of the included studies have not reported BE and oesophagitis because such events might not have happened in their cohorts.

CONCLUSIONS

Long-term risk of de novo GORD after SG seems to be comparable with those of the general population which questions the merit of surveillance endoscopy after SG in asymptomatic patients. De novo BE and oesophagitis after SG have not been reported by most of the available studies which may lead to overestimation of the rates of both outcomes in any evidence synthesis. We recommend endoscopic surveillance for symptomatic patients only.

Mid-Term Outcomes After Conversion Procedures Following Laparoscopic Sleeve Gastrectomy

PURPOSE

In the long term, laparoscopic sleeve gastrectomy (SG) may be associated with insufficient weight loss (IWL), gastroesophageal reflux disease (GERD), and persistence or relapse of associated medical problems. This study's objective is to present mid-term results regarding weight loss (WL), evolution of associated medical problems, and reoperation rate of patients who underwent a conversion after SG.

METHODS

Retrospective single-center analysis of patients with a minimal follow-up of 2 years after conversion.

RESULTS

In this series of 549 SGs, 84 patients (15.3%) underwent a conversion, and 71 met inclusion criteria. They were converted to short biliopancreatic limb Roux-en-Y gastric bypass (short BPL RYGB) (n = 28, 39.4%), biliopancreatic diversion with duodenal switch (BPD/DS) (n = 19, 26.8%), long biliopancreatic limb Roux-en-Y gastric bypass (long BPL RYGB) (n = 17, 23.9%), and re-sleeve gastrectomy (RSG) (n = 7, 9.9%). Indications were GERD (n = 24, 33.8%), IWL (n = 23, 32.4%), IWL + GERD (n = 22, 31.0%), or stenosis/kinking of the sleeve (n = 2, 2.8%). The mean pre-revisional body mass index (BMI) was 38.0 ± 7.5 kg/m2. The mean follow-up time after conversion was 5.1 ± 3.1 years. The overall percentage of total weight loss (%TWL) was greatest after BPD/DS (36.6%) and long BPL RYGB (32.9%) compared to RSG (20.0%; p = 0.004; p = 0.049). In case of GERD, conversion to Roux-en-Y gastric bypass (RYGB) led to a resolution of symptoms in 79.5%. 16.9% of patients underwent an additional revisional procedure.

CONCLUSION

In the event of IWL after SG, conversion to BPD/DS provides a significant and sustainable additional WL. Conversion to RYGB leads to a reliable symptom control in patients suffering from GERD after SG.

Management and outcomes of gastric leak after sleeve gastrectomy: results from the 2010-2020 national registry

BACKGROUND

Management of gastric leak after sleeve gastrectomy (SG) is challenging due to its unpredictable outcomes. We aimed to summarize the characteristics of SG leaks and analyze interventions and corresponding outcomes in a real-world setting.

METHODS

To retrospectively review of 15,721 SG procedures from 2010 to 2020 based on a national registry. A cumulative sum analysis was used to identify a fitting curve of gastric leak rate. The Kaplan-Meier method and log-rank tests were performed to calculate and compare the probabilities of relevant outcomes. The logistic regression analysis was conducted to determine the predictors of acute leaks.

RESULTS

A total of 78 cases of SG leaks were collected with an incidence of 0.5% (78/15,721) from this registry (6 patients who had the primary SG in non-participating centers). After accumulating 260 cases in a bariatric surgery center, the leak rate decreased to a stably low value of under 1.17%. The significant differences presented in sex, waist circumference, and the proportion of hypoproteinemia and type 2 diabetes at baseline between patients with SG leak and the whole registry population ( P = 0.005, = 0.026, <0.001, and = 0.001, respectively). Moreover, 83.1% (59/71) of the leakage was near the esophagogastric junction region. Leakage healed in 64 (88.9%, 64/72) patients. The median healing time of acute and non-acute leaks was 5.93 months and 8.12 months, respectively. Acute leak (38/72, 52.8%) was the predominant type with a cumulative reoperation rate >50%, whereas the cumulative healing probability in the patients who required surgical treatment was significantly lower than those requring non-surgical treatment ( P = 0.013). Precise dissection in the His angle area was independently associated with a lower acute leak rate, whereas preservation ≥2 cm distance from the His angle area was an independent risk factor.

CONCLUSIONS

Male sex, elevated waist circumference, hypoproteinaemia, and type 2 diabetes are risk factors of gastric leaks after SG. Optimizing surgical techniques, including precise dissection of His angle area and preservation of smaller gastric fundus, should be suggested to prevent acute leaks.

Long-Term Outcomes 10 Years after Laparoscopic Sleeve Gastrectomy: a Single Center Retrospective Analysis

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) is the most frequently performed bariatric procedure in the world. The aim of the study was to evaluate outcomes after 10 years.

METHODS

Patients who underwent LSG between 2005 and 2010 in a single center were retrospectively assessed, focusing mainly on the percentage of excess weight loss (%EWL) after 10 years. Inadequate weight loss was defined as a %EWL < 50% or the need to perform a revisional bariatric surgery.

RESULTS

Overall, 149 patients underwent LSG, with a median preoperative body mass index of 42.0 ± 6.5 kg/m2. Ten patients (6.7%) underwent previous bariatric procedure. Patients eating behavior was described as volume eaters in 73 (49%), sweet eaters in 11 (7.4%) and both volume and sweet eaters in 65 (43.6%). Six patients died during follow-up and 25 patients were lost to follow-up, leaving 118 (79%) patients who completed full follow-up. Thirty-five patients (23.5%) needed a revisional bariatric surgery. For the 83 remaining patients, the mean %EWL was 35.9% at 10 years, only 23 of 83 patients (27.7%) had a %EWL ≥ 50%. Thus 80.5% patients (95/118) experienced inadequate weight loss 10 years after LSG. A lower %EWL after 1 year was predictive for inadequate weight loss after 10 years.

CONCLUSION

Ten years after LSG, the rate of inadequate weight loss was high, reaching 80% of patients. Thirty percent of patients required a revisional bariatric procedure. New studies must try to identify patients who are good candidates for LSG and strategies to improve long-term outcomes.

The Effect of Revisional One Anastomosis Gastric Bypass After Sleeve Gastrectomy on Gastroesophageal Reflux Disease, Compared with Revisional Roux-en-Y Gastric Bypass: Symptoms and Quality of Life Outcomes

BACKGROUND

Gastroesophageal reflux disease (GERD) is common after sleeve gastrectomy (SG). We aimed to evaluate the effect of revisional one anastomosis gastric bypass (OAGB) on GERD, compared with revisional Roux-en-Y gastric bypass (RYGB) METHODS: A retrospective single-center study of a prospectively maintained patient registry (2018-2022). All patients with GERD undergoing OAGB and RYGB after SG were retrieved and included in the study.

RESULTS

Seventy-eight SG patients had conversion to OAGB (n=31) and RYGB (n=47). Baseline characteristics were similar except age (43.8±11.5 vs. 50.3±13.4 years; p=0.03), body mass index (39.9±8.8 vs. 30.6±6 kg/m2; p<0.001), time interval (8±2.7 vs. 6.4±3.4 years; p=0.01), and sleep apnea (29% vs 8.5%; p=0.01), respectively. There was no significant difference between groups in number of patients consuming proton pump inhibitors (70.1% vs. 72.3%; p=0.66), GERD-health-related quality of life (HRQL) score (9.6±7.2 vs. 13.1±8; p=0.06), and pathological endoscopic findings (48.4% vs. 46.8%; p=0.89). Major complication rates were 0% vs. 8.5% (p=0.09). At 32.4 months follow-up, total weight loss was 22%±12.9 and 4.4%±14.6 (p<0.001), GERD resolution 77.4% and 91.9% (p=0.03), HRQL scoring improved to 1.7±4.5 and 1.7±2.7; p=0.94 for OAGB and RYGB, respectively.

CONCLUSIONS

SG conversion to RYGB provides better chances for definitive treatment of GERD. OAGB results in good symptom resolution and improved quality of life and may be considered for post-SG GERD treatment. The most appropriate solution should be individualized to each patient.

Medium Term Outcomes of Revision Laparoscopic Sleeve Gastrectomy after Gastric Banding: A Propensity Score Matched Study

PURPOSE

Revision bariatric surgery may be undertaken after weight loss failure and/or complications following primary bariatric surgery. This study aims to compare the efficacy and safety of revision laparoscopic sleeve gastrectomy (RLSG) after gastric banding (GB) to those of primary laparoscopic sleeve gastrectomy (PLSG).

MATERIALS AND METHODS

A retrospective, propensity-score matched study was conducted to compare between PLSG (control) patients and RLSG after GB (treatment) patients. Patients were matched using 2:1 nearest neighbor propensity score matching without replacement. Patients were compared on weight loss outcomes and postoperative complications for up to five years.

RESULTS

144 PLSG patients were compared against 72 RLSG patients. At 36 months, PLSG patients had significantly higher mean %TWL than RLSG patients (27.4 ± 8.6 [9.3-48.9]% vs. 17.9 ± 10.2 [1.7-36.3]%, p < 0.01). At 60 months, both groups had similar mean %TWL (16.6 ± 8.1 [4.6-31.3]% vs. 16.2 ± 6.0 [8.8-22.4)]%, p > 0.05). Early functional complication rates were slightly higher with PLSG (13.9% vs. 9.7%), but late functional complication rates were comparatively higher with RLSG (50.0% vs. 37.5%). The differences were not statistically significant (p > 0.05). Both early (0.7% vs 4.2%) and late (3.5% vs 8.3%) surgical complication rates were lower in PLSG patients compared to RLSG patients but did not reach statistical significance (p > 0.05).

CONCLUSION

RLSG after GB has poorer weight loss outcomes than PLSG in the short-term. Although RLSG may carry higher risks of functional complications, the safety of RLSG and PLSG are overall comparable.

Outcomes of laparoscopic revisional conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: Diff erent strategies for obese and non-obese Asian patients

BACKGROUND

Sleeve gastrectomy (SG) is the most performed bariatric procedure now. Some patients would necessitate a revision to Roux-en-Y gastric bypass (RYGB) as a salvage procedure for intractable gastroesophageal reflux disease (GERD). However, outcome of the revision in Asians with co-existed obesity and those non-obese is not clear.

METHODS

We retrospectively reviewed the data of patients who underwent revisional laparoscopic RYGB after SG between 2007 and 2019 for intractable GERD with data of one year follow-up. Pre-operative clinical data, perioperative outcomes, GERD symptoms, weight loss and medication details were analyzed. Patients were classified into those with body mass index (BMI) ≥ 25 and < 25 kg/m².

RESULTS

Fifty-five patients (44 women, 11 men; mean age 42.5 years) were included. Mean interval from the initial SG to revision surgery was 51.2 months (range, 5-132). Mean body mass index before SG was 34.6 kg/m², whereas that before revision surgery was 27.6 kg/m². All the patients required continue proton pump inhibitor (PPI) to control the GERD symptoms before surgery. Among them, 36 (65.4%) patients in the obese group received long BP limb (>100 cm) RYGB for associated obesity but the common channel was assured to ≥ 400 cm or 70% of small bowel length, the other 19 (34.6%) patients in the non-obese group received standard BP limb (<100 cm) RYGB. There was no difference in basic characters between the two groups before revision surgery except a higher mean BMI (30.0 vs. 22.2 kg/m², p < 0.001), blood pressure and triglyceride in obese group. One year after revision surgery, all the patients had improved GERD symptoms but only 33 (60%) can completely wave PPI, without difference between the 2 groups. Obese group with a long BP limb RYGB had a significant higher % total weight loss (TWL) than non-obese group (%TWL 9.1% vs. -3.1%, p = 0.005).

CONCLUSION

Laparoscopic revision to RYGB is a safe and effective treatment for patients with intractable GERD after SG but some patients may still have residual GERD symptoms. Using a modified RYGB technique in revision surgery may help in weight reduction for obese Asian patients.

A case-control comparative study between Toupet-Sleeve and conventional sleeve gastrectomy in patients with preoperative gastroesophageal reflux

INTRODUCTION

The aim of that study was to compare outcomes after Toupet-Sleeve (T-Sleeve) and sleeve gastrectomy (SG) as primary bariatric procedures in obese patients presenting with preoperative gastro-esophageal reflux disease (GERD).

MATERIAL AND METHODS

The outcomes of 19 consecutive patients operated between 2017 and 2019 by T-Sleeve were compared to the outcomes of 38 patients operated in 2014 by SG. The two groups were matched by age, sex, ASA classification, BMI, food habits and severity of esophagitis. Postoperative weight loss and evolution of GERD symptoms were the study end-points.

RESULTS

The preoperative BMI was 43 ± 5 in the T-Sleeve and 42 ± 5 in the SG group (NS). All the procedures were completed by laparoscopy. The operative time was higher in the T-Sleeve group: 89 ± 18 vs. 68 ± 12 min. (p < 0.001). A lower weight loss was observed in the T-Sleeve group. Respectively 1 and 2 years after surgery, the mean BMI were: 32 ± 6 and 34 ± 6 in the T-Sleeve vs. 28 ± 5 (p < 0.006) and 30 ± 6 (p < 0.05) in the SG group and the mean %EWL were: 61 ± 23 and 54 ± 26% in the T-Sleeve vs. 86 ± 25 (p < 0.002) and 75 ± 28% (p < 0.03) in the SG group. Better control of GERD was noted in the T-Sleeve group: the number of patients with complete resolution of GERD symptoms was 17 (89%) vs. 13 (34%) in the SG group (p < 0.001).

CONCLUSION

T-Sleeve was an effective procedure for GERD treatment but, the weight loss was significantly much lower than after conventional SG. Studies with longer follow-up are mandatory to validate the T-Sleeve procedure.

Ten-Year Results of Laparoscopic Sleeve Gastrectomy: a Retrospectively Designed Study of a Single Tertiary Center

PURPOSE

Laparoscopic sleeve gastrectomy (SG) is the most popular bariatric surgery. Nonetheless, only a few studies have reported its long-term outcomes. This study aimed to evaluate changes in weight and body mass index (BMI) parameters, resolution of comorbidities, and frequency of re-operations in a follow-up period of at least 10 years.

MATERIALS AND METHODS

Data was available from 180 patients' records who underwent SG between 2008 and 2011 in the Tel Aviv Sourasky Medical Center. Eighty patients agreed to partake in a follow-up assessment that was completed via a phone call questionnaire and hospital computed registry.

RESULTS

Patients' mean preoperative BMI was 43.86 ± 6.36 kg/m² which was significantly higher when compared to mean nadir BMI and last follow-up BMI (29.44 ± 7.12 and 36.34 ± 9.7; p < 0.001). Mean percentage of excess weight loss (%EWL) at 10 years was 42.65 ± 36.02% and mean percentage of total weight loss was 19.33 ± 16.73%. Twenty-eight patients (35%) maintained at least 50% EWL. Twenty-seven (33.75%) patients underwent at least one surgical procedure following SG. Eleven patients (13.75%) underwent a conversion to Roux-en-Y gastric bypass and six patients (7.5%) underwent conversion to one anastomosis gastric bypass. Resolution of type 2 diabetes (T2D), hypertension, and hypercholesterolemia occurred in 47%, 43.7%, and 48.4%, respectively. De-novo cases of gastroesophageal reflux (GERD) were present in 40%.

CONCLUSION

SG shows high long-term failure rates. One of every three patients will undergo another surgical procedure within a 10-year period.

Incidence of Abnormalities of the Gastric Tube Following Sleeve Gastrectomy and Its Role on Esophagitis Progression

PURPOSE

The purpose of this study is to determine the incidence of gastric tube abnormalities after SG and its relationship with esophagitis progression.

METHODS

Retrospective study which included 459 patients in the postoperative period of SG who underwent an esophagogastroduodenoscopy in both pre- and postoperative periods. The main studied variables were presence of gastric tube abnormalities (dilation, neofundus, twist, and hiatal hernia) and esophagitis progression.

RESULTS

Among the 459 patients who underwent SG, 393 (85.6%) were women, and 66 (14.4%) men, with mean age of 40.4 years. Mean preoperative BMI was 39.70 kg/m². In total, 20.3% of the sample presented progression of esophagitis after surgery. Among the whole sample, 130 (28.3%) presented with an abnormality of the remnant gastric tube. The most common alteration was gastric dilation, which occurred in 16.1% of the patients, followed by gastric twist (10.7%), neofundus (7.4%), and hiatal hernia (0.2%). Patients who presented with any abnormality of the gastric tube were significantly prone to presenting esophagitis progression (p = 0.013). When analyzing each morphological abnormality isolated, there was no statistically significant correlation.

CONCLUSION

Abnormalities of the gastric tube are not uncommon after SG and seems to contribute partially to the relevant rates of GERD and esophagitis after this surgery.

A Shared Decision-making Process may Affect Bariatric Procedure Selection and Alter Surgical Outcomes: a Single-unit Retrospective Study

PURPOSE

A shared decision-making (SDM) process centered on the patient perspective may increase understanding and treatment satisfaction. This study aimed to investigate whether SDM would increase the acceptance of bariatric/metabolic surgeries, change treatment decisions, and affect 1-year results.

MATERIALS AND METHODS

This retrospective analysis enrolled 315 consecutive patients with a body mass index between 32.5 and 50 kg/m² and aged 20-65 years who underwent consultation for a primary bariatric/metabolic procedure within 2 years before (pre-SDM) or after (post-SDM) SDM program implementation to assist in the decision to undergo Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) surgery. Consent rate, procedure choice, weight loss, comorbidity remission, etc., were compared between periods and procedures. Statistical tests were two-sided, with p < 0.05 considered significant.

RESULTS

More eligible patients underwent metabolic/bariatric procedures post-SDM than pre-SDM (115/159 [72%] vs. 106/156 [68%]; p = 0.395), and a stronger preference for RYGB post-SDM was observed (71% vs. 62%; p = 0.153). Significantly more patients with diabetes (28 [34.1%] vs. 5 [15.2%]; p = 0.041) chose RYGB over SG post-SDM. Patients who underwent RYGB had a higher diabetes remission rate both pre-SDM (70.0% vs. 58.3%; p = 0.571) and post-SDM (76.2% vs. 66.7%; p = 0.712) than those who underwent SG. While 1-year weight loss was similar between procedures, adherence to nutritional supplementation did not appear to be broadly enhanced post-SDM.

CONCLUSION

SDM influenced procedure selection toward RYGB, which was more popular than SG among patients with diabetes. Higher diabetes remission was achieved with RYGB, although the results of other effects deserve further study.

Long-term (11 + years) efficacy of sleeve gastrectomy as a stand-alone bariatric procedure: a single-center retrospective observational study

INTRODUCTION

Sleeve gastrectomy (SG) is currently the most commonly performed bariatric procedure worldwide. The aim of the present study was to evaluate the long-term efficacy of SG as a stand-alone bariatric procedure.

METHODS

A single-center retrospective analysis of 104 patients who underwent SG as a stand-alone bariatric procedure between January 2005 and December 2009. Weight loss, weight regain, remission or improvement of comorbidities and the new onset of comorbidities were the main outcomes of the study.

RESULTS

The percent excess body weight loss (%EBWL), percent excess body mass weight (BMI) loss (%EBMIL), and percent total body weight loss (%TBWL) were 59 ± 25, 69 ± 29, and 29 ± 12, respectively, after a mean follow-up of 13.4 years. At the last follow-up, nearly two thirds of patients (67.3%) had an %EBWL greater than 50. The percentage of patients who experienced significant weight regain ranged from 47 to 64%, depending on the definition used for weight regain. The rate of improvement or remission of hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, and degenerative joint disease at a mean follow-up of 13.4 years was 40%, 94.7%, 70%, 100%, and 42.9%, respectively. The new onset of gastroesophageal reflux disease (GERD) symptoms in the same period was 43%.

CONCLUSION

Our data supports that SG results in long-lasting weight loss in the majority of patients and acceptable rates of remission or improvement of comorbidities. Weight regain and GERD may be issues of particular concern during long-term follow-up after SG.

Gastroesophageal reflux after sleeve gastrectomy. Fact or fiction?

BACKGROUND

One of the most controversial issues surrounding laparoscopic sleeve gastrectomy is the development of gastroesophageal reflux disease following surgery. The aim of the study was to evaluate the occurrence of gastroesophageal reflux disease after laparoscopic sleeve gastrectomy and to analyze patients' weight loss, comorbidities, and quality of life after surgery.

METHODS

The clinical records of 52 patients submitted to laparoscopic sleeve gastrectomy between January and November 2018, with 3 years of follow-up, were retrospectively reviewed. At the end of the follow-up period, the patients underwent screening endoscopy, and those with postoperative esophagitis were submitted to endoscopic biopsies and pH-impedance monitoring (MII-pH). The presence of gastroesophageal reflux disease symptoms was assessed using the modified clinical DeMesteer score questionnaire. The Bariatric Analysis and Reporting Outcome System score and 36-Item Short Form Health Survey were used to assess the postoperative quality of life.

RESULTS

In the preoperative work-up, only 7.6% of patients had signs of esophagitis at esophagogastroduodenoscopy, whilst at 3-year follow-up, 50% of them had endoscopic signs of gastroesophageal reflux disease. Twenty-one out of 26 patients with signs of esophagitis agreed to undergo MII-pH. The median DeMesteer score questionnaire was 4.5, with only 4 patients (19%) exhibiting a value greater than the pH cut-off value (14.72), indicative of gastroesophageal reflux disease. MII-pH data analysis showed the presence of gastroesophageal reflux disease in 5 patients. An excellent outcome on the Bariatric Analysis and Reporting Outcome System score was reported in 50% of patients, and all 8 domains from the 36-Item Short Form Health Survey improved significantly.

CONCLUSION

This study showed an improvement in these patients' quality of life and the limited refluxogenic nature of laparoscopic sleeve gastrectomy at 3-year follow-up when diagnosis of gastroesophageal reflux disease is based on the Lyon consensus.

Gastroesophageal Reflux Disease as an Indication of Revisional Bariatric Surgery-Indication and Results-a Systematic Review and Metanalysis

This systematic review evaluates the indications and results of revisional bariatric surgery (RBS) in gastroesophageal reflux disease (GERD). A systematic literature search and meta-analysis was performed for articles published by April 1, 2021. After examining 722 papers involving 17,437 patients, 48 studies were included (n = 915 patients). RBS for GERD was mostly reported after sleeve gastrectomy (n = 796, 87%) and one anastomosis gastric bypass (n = 62, 6.8%) and was performed due to intractable GERD (71.6%), GERD and weight issues (16%), and biliary reflux (6.2%). Mean follow-up of the studies was 31.5 (3-84) months. Pooled estimation of a meta-analysis of studies reported 7% of GERD following primary surgery needing RBS, in which 99% of the patients experienced remission.

Reference Values for Weight Loss During 1 Year After Sleeve Gastrectomy: a Multicenter Retrospective Study in Japan

INTRODUCTION

This study aimed to provide reference values for the percentage total weight loss during 1 year after laparoscopic sleeve gastrectomy associated with primary response in Japan.

METHODS

This multicenter retrospective study comprised 248 patients with severe obesity who underwent laparoscopic sleeve gastrectomy at five institutions in Japan. A percentage total weight loss < 20% at 1 year was defined as primary non-response. Parsimonious predictive models were developed based on the results of multiple regression analyses. A receiver operating characteristic curve analysis was used to assess the discriminative performance for primary non-response.

RESULTS

The median age, initial body mass index, and percentage total weight loss at 1 year were 41 years, 41.4 kg/m², and 30.1%, respectively. There were 28 (11.3%) primary non-responders. For discriminating primary non-responders, the areas under the receiver operating characteristic curve of the parsimonious model and actual percentage of total weight loss at 3 months after laparoscopic sleeve gastrectomy were 0.846 and 0.803, respectively. Cutoffs for the predicted percentage total weight loss using the model and actual value of percentage total weight loss at 3 months attaining 80% sensitivity were 30% and 22%, and those attaining 98% specificity were 22% and 15%, respectively.

CONCLUSIONS

Reference values for the percentage total weight loss at 3 months were obtained using the predictive model and actual value of percentage total weight loss at 3 months. Patients at risk for primary non-response can be determined at 3 months with these values, which can help in considering earlier interventions.

Evaluation of the effectiveness of weight loss and the return of lost weight after sleeve gastrectomy in the long term follow-up period

Sleeve gastrectomy, originally proposed as part of a two-stage operation, more than 15 years ago, is recognized as an independent, effective intervention for the treatment of obesity. The purpose of this review was to evaluate the effectiveness of sleeve gastrectomy based on data on long-term follow-up of patients. A search was performed in two databases, 33 literary sources were selected based on the results of the selection. In this review, the authors evaluated some parameters characterizing the effectiveness of sleeve gastrectomy in the long term after surgery. The percentage of follow-up of patients in the long-term period (follow up, %) varied from 5,6% to 97%, the expected decrease in % follow up over time did not occur. The authors have suggested similar results due to the heterogeneity of the data of the analyzed sources. By the five-year period, the detected average % of follow-up did not correspond to the optimal recommended level of follow-up for operated patients by this time. The most common criterion for assessing the return of weight is an increase in body weight by more than 10 kg from the lowest achieved. The prevalence of this phenomenon ranged from 26.3% to 44%. Among the reasons predisposing to weight loss are the initial high BMI, old age, dilatation of the formed stomach. In the absence of a universal definition of various terms (follow up, unsatisfactory result of surgery, weight loss, etc.), the results among the same patients when using different definitions will differ, there is a need to adopt standards when describing these phenomena. Despite the likelihood of weight loss after longitudinal resection, this operation is relatively simple from a technical point of view, safer, it can be used to improve the course of concomitant pathology (diabetes mellitus, hypertension), improve the quality and increase the life expectancy of patients.

Gastroesophageal Reflux Disease, Esophagitis, and Barrett's Esophagus 3 to 4 Years Post Sleeve Gastrectomy

BACKGROUND

Sleeve gastrectomy (SG) has become the most popular bariatric procedure worldwide. However, SG is associated with de novo gastroesophageal reflux (GERD) and esophagitis, with concerns for progression into Barrett's esophagus (BE). The purpose of this study is to assess the clinical and endoscopic progression of GERD, esophagitis, and BE 3 to 4 years after SG.

METHODS

Fifty-eight patients (pts) were assessed with endoscopy preoperative and at 3 to 4 years post SG, representing 44.9% follow-up. Endoscopy was offered to all SG pts regardless of symptoms. Outcomes including percent total weight loss (%TWL), PPI use, esophagitis progression, de novo reflux, and BE formation.

RESULTS

At post-op follow-up, the %TWL was 23%. The average BMI dropped from 49.07 to 37.5. De novo reflux developed in 13 pts (30.9%). Of the 16 pts with GERD pre-op, 37.5% improved, 25% had stable disease, and 37.5% had worsening symptoms. The rate of esophagitis nearly doubled from 37.9% pre-op to 70.6% post-op. A majority of post-op pts had mild esophagitis (87.8%), with 12.1% with LA classes C and D. Asymptomatic esophagitis was found in 68.2% of post-op pts. The incidence of BE was 12.7% post-op, with de novo BE developing in 4 pts, representing 7.2%.

CONCLUSION

SG is associated with increased rates of asymptomatic esophagitis and de novo reflux at 3 to 4 years post-op. De novo BE was detected as well, highlighting the importance of post-op screening. The majority of pts with GERD pre-op have stable disease or improve.

Progress in understanding of influence of bariatric surgery on reflux esophagitis

In today's society, as the number of obese people increases year by year, the incidence of gastroesophageal reflux disease (GERD) continues to rise. Although bariatric surgery has brought good news to these patients who are unable to lose weight on their own, it is still unclear whether it is effective in relieving GERD, or even inducing or aggravating GERD. In this article, we will review and provide evidence of the effect of bariatric surgery on GERD.

Weight Loss Outcomes and Lifestyle Patterns Following Sleeve Gastrectomy: an 8-Year Retrospective Study of 212 Patients

PURPOSE

Sleeve gastrectomy (SG) is an effective treatment for extreme obesity; however, long-term weight loss outcomes remain largely understudied. We aimed to examine the long-term weight changes following SG and patient characteristics and lifestyle patterns related to weight loss outcomes.

MATERIALS AND METHODS

Data from medical records of patients operated in a tertiary university medical center between 2008 and 2014 were reviewed, along with information derived from a telephone questionnaire. Information included the following: current medical status, medications, side effects, behavior, lifestyle habits, and weight changes.

RESULTS

A total of 212 patients (69.3% females) were included, with a median follow-up duration of 8 years post-SG. Mean age and baseline body mass index (BMI) of participants were 39.7 ± 12.0 years and 42.2 ± 4.9 kg/m², respectively. Mean BMI, percentage excess weight loss, and percentage total body weight loss were 33.1 ± 6.1, 55.5 ± 27.5%, and 21.7 ± 10.7%, respectively. Higher baseline BMI was found to be the strongest independent predictor for insufficient weight loss (OR = 0.90, P = 0.001, 95% CI 0.85, 0.96). Sweetened beverage intake, usage of psychiatric medications, higher initial BMI, and lower age were significant predictors for increased weight gain from nadir weight (P < 0.0001, P = 0.005, P = 0.035, and P < 0.0001, respectively).

CONCLUSIONS

SG patients were found to maintain a notable long-term weight loss. Nevertheless, weight regain and insufficient weight loss were prevalent in the long-term post-operative period, and were related to certain lifestyle patterns. Clinical practice should emphasize the relationship between post-operative weight loss outcomes and specific behaviors. Efforts should be made to educate patients on the need for lifelong follow-up and support.

Metabolic surgery in China: present and future

Obesity and its related complications comprise a serious public health problem worldwide, and obesity is increasing in China. Metabolic surgery is a new type of treatment with unique advantages in weight loss and obesity-related metabolic complications. The pathogenesis of obesity is complex and not yet fully understood. Here, we review the current efficacy and safety of metabolic surgery, as well as recent progress in mechanistic studies and surgical procedures in China. The exciting and rapid advances in this field provide new opportunities for patients with obesity and strike a balance between long-term effectiveness and safety.

Fifteen Years After Sleeve Gastrectomy: Weight Loss, Remission of Associated Medical Problems, Quality of Life, and Conversions to Roux-en-Y Gastric Bypass-Long-Term Follow-Up in a Multicenter Study

Purpose

Since 2014, sleeve gastrectomy (SG) has been the most frequently performed bariatric-metabolic operation worldwide (2018: 386,096). There are only a few studies reporting a long-term follow-up (up to 11 years) available today. The aim of this study was to evaluate the long-term outcome of SG with a follow-up of at least 15 years regarding weight loss, remission of associated medical problems (AMP), conversions, and quality of life (QOL).

Setting

Multicenter cross-sectional study; university hospital.

Methods

This study includes all patients who had SG before 2005 at the participating bariatric centers. History of weight, AMP, conversions, and QOL were evaluated by interview at our bariatric center.

Results

Fifty-three patients met the inclusion criteria of a minimal follow-up of 15 years. Weight and body mass index at the time of the SG were 136.8kg and 48.7kg/m². Twenty-six patients (49.1%) were converted to Roux-en-Y gastric bypass (RYGB) for weight regain and gastroesophageal reflux within the follow-up period. Total weight loss after 15 years was 31.5% in the non-converted group and 32.9% in the converted group. Remission rates of AMP and QOL were stable over the follow-up period.

Conclusion

Fifteen years after SG, a stable postoperative weight was observed at the cost of a high conversion rate. Patients converted to RYGB were able to achieve further weight loss and preserve good remission rates of AMP. SG in patients without the need of a conversion to another bariatric-metabolic procedure may be considered effective. Careful preoperative patient selection is mandatory when performing SG.

Graphical abstract

Long-Term Efficacy of Bariatric Surgery for the Treatment of Super-Obesity: Comparison of SG, RYGB, and OAGB

BACKGROUND

The most appropriate procedure for the treatment of super obesity (BMI > 50 kg/m²) is unknown. We aimed to evaluate the safety, long-term (> 5 years) weight loss, and adverse events between three commonly performed procedures, sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and one anastomosis gastric bypass (OAGB) in super-obese patients.

METHODS

Between January 2002 and December 2015, 498 successive patients with super morbid obesity (BMI > 50), who underwent SG or RYGB or OAGB, were recruited. Surgical outcome, weight loss, resolution of co-morbidities, and late complications were followed and compared between the 3 groups. All data derived from a prospective bariatric database and a retrospective analysis was conducted.

RESULTS

The average patient age was 32.1 ± 10.4 years, with a mean body mass index (BMI) of 56.0 ± 6.7 kg/m². Of them, 190 (38.9%) underwent SG, 62 (12.4%) RYGB, and 246 (49.4%) OAGB. There was no difference in basic characters between the 3 groups except SG had fewer diabetic patients. RYGB group had higher intraoperative blood loss, longer operating time, and hospital stay than the other 2 groups. RYGB had a higher 30-days post-operative major complication rate (4.8%) than SG (0.5%) and OAGB (0.8%). The follow-up rate at 1 and 5 years was 89.4% and 52.0%. At post-operative 5 years, OAGB had a higher total weight loss (40.8%) than SG (35.1%), but not RYGB (37.2%). SG had a lower remission rate in dyslipidemia comparing to OAGB and RYGB, but T2DM remission rate was no different between the groups. The overall revision rate is 5.4% (27/498) of the whole group, and SG had a lower revision rate (2.6%) than RYGB (8.1%) and OAGB (6.9%).

CONCLUSION

SG is an effective and durable primary bariatric procedure for the treatment of super obesity and metabolic disorders. OAGB had a similar operation risk to SG but resulted in a better weight loss than SG.

Indications and Long-Term Outcomes of Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass

PURPOSE

Long-term results on sleeve gastrectomy (SG) with more than 10 years report patients needing sleeve revision for weight loss failure, de novo gastroesophageal reflux (GERD), or sleeve complications. The aim of this study was to analyze the results of laparoscopic conversion of failed SG to Roux-en-Y gastric bypass (RYGB).

MATERIALS AND METHODS

Retrospective review of a prospectively institutional maintained database to identify patients who underwent conversion of SG to RYGB between 2012 and June 2020.

RESULTS

Sixty patients(50 females) underwent conversion to RYGB. Average time to conversion was 5.6 years (2-11). Mean %WL and TWL after SG were respectively 26±8.8% and 33.2±14.1kg. Mean BMI at the time of RYGB was 38.1±7.1 kg/m². Mean follow-up was 30.4±16.8 months (6-84). Available patients at each time of follow-up: 1 year 59 (98.3%); 2 years 47 (78.3%); 3 years 39 (71.6%); and 5 years 33 (55%). Patients were divided according to indication for revision in weight regain/insufficient weight loss (30 patients) group 1 and GERD/complications (25 patients) group 2. Percentage of excess weight loss at 1, 3, and 5 years follow-up after bypass was for group 1 40.3±17.6, 34.3±19.5, and 23.2±19.4 and for group 2 90.4±37, 62.6±28.2, and 56±35.02. Total weight loss at last follow-up since sleeve was respectively 31kg in group 1 and 46.7kg in group 2 (p=0.002). No mortality was observed. Thirty-day complication rate was 3.3%.

CONCLUSION

RYGB after SG is a safe and effective revisional procedure to manage weight regain and de novo GERD, to address complications, and to improve comorbidities.

Midterm Outcome of Laparoscopic Sleeve Gastrectomy in Asians: a Systematic Review and Meta-analysis

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a commonly performed bariatric surgery. Studies have suggested that LSG can provide effective and sustainable weight loss although most of them were conducted in Western populations. Our aim was to characterize the midterm outcome of LSG in Asians with obesity.

METHODS

MEDLINE and EMBASE were searched through August 2019 for studies that reported % total body weight loss (TBWL) and/or % excess weight loss (EWL) at 3 and/or 5 years among adult Asians with obesity who underwent LSG. Data on complications and surgical revision rate were also extracted. The pooled effect size and 95% confidence interval (CI) were calculated using a random effects model.

RESULTS

A total of 19 studies involving 6235 patients were included. The pooled mean %EWLs were 72.6% (95% CI 67.2-78.0, I² = 97%); 67.1% (95% CI 61.7-72.6, I² = 95%); and 59.1% (95% CI 48.8-69.4, I² = 94%) at 1, 3, and 5 years, respectively. The pooled mean %TBWLs were 32.1%, 29.0%, and 25.5% at 1, 3, and 5 years, respectively. The pooled rates of revision due to gastroesophageal reflux disease and weight regain were 1.9% and 2.5%, respectively.

CONCLUSIONS

Our meta-analysis suggests that LSG is an effective procedure for weight reduction that offers durable response for up to 5 years among Asians with obesity. The longer-term data is needed.

Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy in Terms of Efficacy and Safety: a Comparative Study During 11-Year Experience

PURPOSE

This cohort study was designed to compare the efficacy and safety of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) for the management of morbid obesity during the 11-year experience.

MATERIALS AND METHODS

This study was conducted between July 2006 and August 2019. Annually we recorded data about the weight, body mass index (BMI), percentage of excess weight loss (%EWL), percentage of weight loss (%WL), weight regain, and postoperative complications into a prospectively collected database.

RESULTS

A total of 1146 patients (LRYGB=396 and LSG=750) aged >18 years old were included in the study. Over the first 7 years after surgery, the weight loss rate was significantly higher in the LRYGB-treated group than the LSG-treated group, and weight regain was significantly lower in the LRYGB-treated group in comparison with the LSG-treated group. Our results revealed that statistically, but not clinically, the efficacy of LRYGB and LSG is equivalent in terms of %WL, %EWL, and weight regain within 8 years and more. Besides, there were no significant differences in surgery-related mortality and severe complications between the two procedures.

CONCLUSION

Our study's results indicated that the clinical efficacy of LRYGB in the management of obesity is better than LSG during the 11-year experience. But the differences in weight loss and weight regain were not statistically relevant at 8 years and more after the surgery. Also, a comparison of severe complications did not indicate significant differences between the two groups.

Laparoscopic Vertical Sleeve Gastrectomy as a Treatment Option for Adults with Diabetes Mellitus

Obesity is a major factor in the worldwide rise in the prevalence of type 2 diabetes mellitus. The obesity "epidemic" will require novel, effective interventions to permit both the prevention and treatment of diabetes caused by obesity. Laparoscopic vertical sleeve gastrectomy is a newer bariatric surgical procedure with a lower risk of complications (compared to Roux-en-Y gastric bypass surgery). Based in part on restriction of daily caloric intake, sleeve gastrectomy has a major role in inducing significant weight loss and weight loss is maintained for at least 10 years. Prior studies have supported the utility of the vertical sleeve gastrectomy for the treatment and management of subgroups of individuals with diabetes mellitus. There are reports of 11% to 76.9% of obese individuals discontinuing use of diabetic medications in studies lasting up to 8 years after vertical sleeve gastrectomy. Major ongoing issues include the preoperative determination of the suitability of diabetic patients to undergo this bariatric surgical procedure. Understanding how this surgical procedure is performed and the resulting anatomy is important when vertical sleeve gastrectomy is being considered as a treatment option for diabetes. In the postoperative periods, specific macronutrient goals and micronutrient supplements are important for successful and safer clinical results. An understanding of immediate- and long term- potential complications is important for reducing the potential risks of vertical sleeve gastrectomy. This includes the recognition and treatment of postoperative nutritional deficiencies and disorders. Vertical sleeve gastrectomy is a component of a long term, organized program directed at treating diabetes related to obesity. This approach may result in improved patient outcomes when vertical sleeve gastrectomy is performed to treat type 2 diabetes in obese individuals.

Revisional Surgeries of Laparoscopic Sleeve Gastrectomy

Bariatric surgery has become increasingly common due to the worldwide obesity epidemic. A shift from open to laparoscopic surgery, specifically, laparoscopic sleeve gastrectomy (LSG), has occurred in the last two decades because of the low morbidity and mortality rates of LSG. Although LSG is a promising treatment option for patients with morbid obesity due to restrictive and endocrine mechanisms, it requires modifications for a subset of patients because of weight regain and tough complications, such as gastroesophageal reflux, strictures, gastric leak, and persistent metabolic syndrome., Revision surgeries have become more and more indispensable in bariatric surgery, accounting for 7.4% in 2016. Mainstream revisional bariatric surgeries after LSG include Roux-en-Y gastric bypass, repeated sleeve gastrectomy, biliopancreatic diversion, duodenal switch, duodenal-jejunal bypass, one-anastomosis gastric bypass, single anastomosis duodeno-ileal bypass (SAID) and transit bipartition. This review mainly describes the revisional surgeries of LSG, including the indication, choice of surgical method, and subsequent effect.

Ten-year outcomes after primary vertical sleeve gastrectomy for morbid obesity: a monocentric cohort study

OBJECTIVE

To assess the 10-year outcomes after sleeve gastrectomy (SG). Primary end-points were the long-term weight loss and the need for conversion and one of the secondary end-points was the incidence of gastroesophageal reflux (GERD).

MATERIALS AND METHODS

Between 2006 and 2008, 40 consecutive patients had a primary SG. A retrospective analysis of our database and telephone interview of patients who defaulted clinic follow-up was conducted. Success of surgery was defined as percentage of excess weight loss (%EWL) > 50% and no need for conversion.

RESULTS

Thirty-four patients (85%) achieved a 10-year follow-up. There were 11 men and 23 women with a mean preoperative body mass index (BMI) of 44 ± 4 kg/m² and a mean age of 42 ± 8 years. Optimal weight loss was reached after a follow-up of 12 months: the mean BMI was 31 ± 5 kg/m² and %EWL 70 ± 21%. A progressive weight regain was observed over time. With a median follow-up of 11 years (range 7-12), the mean BMI and %EWL were respectively 36 ± 8 kg/m² (p < 0.005) and 42 ± 37% (p < 0.001). With a median delay of 9 years (range 7-9), 6 patients (18%) were converted to gastric bypass because of weight regain. On total, SG was successful only in 14 patients (41%). Success rate was particularly high in patients who had a 1-year %EWL > 75%: 10/12 (83%) vs. 4/22 (17%) (p < 0.001). Those 12 patients were only characterized by a lower preoperative BMI: 41 ± 2 vs. 45 ± 4 (p < 0.002). Besides, 22 patients (65%) had long-term GERD requiring medical treatment: the incidence of de novo GERD was 41% (6/14) and of persisting GERD 80% (16/20).

CONCLUSIONS

Our 10-year success rate after SG was 41% and the incidence of GERD 65%. SG should preferably be proposed to selected patients. Patients with low preoperative BMI and without preoperative symptoms of GERD appeared as the best candidates for SG.

Standardized reporting of co-morbidity outcome after bariatric surgery: low compliance with the ASMBS outcome reporting standards despite ease of use

BACKGROUND

Despite the publication of the American Society for Metabolic and Bariatric Surgery (ASMBS) Outcome Reporting Standards in 2015, there is still a great variety in definitions used for reporting remission of co-morbidities after bariatric surgery. This hampers meaningful comparison of results.

OBJECTIVE

To assess compliance with the ASMBS standards in current literature, and to evaluate use of the standards by applying them in a report on the outcomes of 5 co-morbidities after bariatric surgery.

SETTING

Two clinics of the Dutch Obesity Clinic, location Den Haag and Velp, and three affiliated hospitals: Haaglanden Medical Center in Den Haag, Groene Hart Hospital in Gouda, and Vitalys Clinic in Velp.

METHODS

A systematic search in PubMed was conducted to identify studies using the ASMBS standards. Besides, the standards were applied to a cohort of patients who underwent a primary bariatric procedure between November 2016 and June 2017. Outcomes of co-morbidities were determined at 6 and 12 months after surgery.

RESULTS

Ten previous studies applying ASMBS definitions were identified by the search, including 6 studies using portions of the definitions, and 4 using complete definitions for 3 co-morbidities or in a small population. In this study, the standards were applied to 1064 patients, of whom 796 patients (75%) underwent Roux-en-Y gastric bypass and 268 patients (25%) underwent sleeve gastrectomy. At 12 months, complete remission of diabetes (glycosylated hemoglobin <6%, off medication) was reached in 63%, partial remission (glycosylated hemoglobin 6%-6.4%, off medication) in 7%, and improvement in 28% of patients (n = 232/248, 94%). Complete remission of hypertension (normotensive, off medication) was noted in 8%, partial remission (prehypertensive, off medication) in 23% and improvement in 63% (n = 397/412, 96%). Remission rate for dyslipidemia (normal nonhigh-density lipoprotein, off medication) was 57% and improvement rate was 19% (n = 129/133, 97%). Resolution of gastroesophageal reflux disease (no symptoms, off medication) was observed in 54% (n = 265/265). Obstructive sleep apnea syndrome improved in 90% (n = 157/169, 93%).

CONCLUSIONS

Compliance with the ASMBS standards is low, despite ease of use. Standardized definitions provided by the ASMBS guideline could be used in future research to enable comparison of outcomes of different studies and surgical procedures.

Sleeve gastrectomy as a rescue of failed gastric banding: comparison of 1- and 2-step approaches

BACKGROUND

Series comparing gastric banding (GB) removal and sleeve gastrectomy (SG) when procedures are performed as a 1- or a 2-step approach are contradictory in their outcomes. No series comparing these approaches with midterm weight loss is available.

OBJECTIVES

Compare the outcomes and weight loss of SG performed as 1- and 2-step approaches as a revisional procedure for GB failure.

SETTING

University Hospital, France, public practice.

METHODS

Between February 2006 and January 2017, all patients undergoing SG with a previous history of implementation of GB (n = 358) were included in this 2-center, retrospective, observational study. Revisional surgery was proposed in patients with insufficient excess weight loss (excess weight loss ≤50%) or weight regain after GB. A 1-step (1-step group, n = 270) or 2-step (2-step group, n = 88) approach was decided depending on patient's choice and/or surgeon's preference. The primary efficacy endpoint was the comparison of weight loss in the 1- and 2-step groups at the 2-year follow-up. The secondary efficacy endpoints were short-term outcomes (overall mortality and morbidity at postoperative day 30, specific morbidity, reoperation, length of hospital stay, and readmission).

RESULTS

In the 1-step group, the mean preoperative body mass index before SG was 40.5 kg/m² (27.0-69.0), while in the 2-step group, the mean preoperative body mass index was 43.5 kg/m² (31.5-61.7). Mean operating time was 109 minutes (50-240) in the 1-step group and 78.7 minutes (40-175) in the 2-step group (P = .22). In the 1-step group, 6 conversions to laparotomy occurred, while in the 2-step group, 2 conversions to laparotomy occurred (P = .75). One death (.2%, in the 2-step group) and 39 complications (30 in the 1-step group [11.1%] and 9 in the 2-step group [10.2%]) also occurred. The mean length of hospital stay was 6.2 days in the 1-step group and 4.1 days in the 2-step group. At 2-year follow-up, mean body mass index was 32.4 kg/m² in the 1-step group and 33.2 kg/m² in the 2-step group (P = .15), representing excess weight losses of 61.9 and 50.1 (P = .05), respectively. The rates of revisional surgery were .7% and 2.2%, respectively.

CONCLUSIONS

SG after previous GB is efficient with similar outcomes depending on the 1- or 2-step approach. The 1-step approach seems to have increased weight loss compared with the 2-step approach.

The Effects of Bariatric Surgery and Endoscopic Bariatric Therapies on GERD: An Update

PURPOSE OF REVIEW

Bariatric surgery and endoluminal bariatric therapies (EBTs) form an increasingly utilized therapeutic approach to treat obese patients but may worsen gastroesophageal reflux disease (GERD). In this updated article, we review the evidence on the effects of bariatric procedures on GERD.

FINDINGS

Recent evidence implicates sleeve gastrectomy with the highest rates of de novo GERD and Barrett's esophagus (BE), whereas malabsorptive-restrictive procedures such as Roux-en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB) were shown to have significantly lower reported rates. The intragastric balloon (IGB) has been associated with increased likelihood of GERD, whereas insufficient evidence exists linking endoscopic sleeve gastroplasty (ESG) to GERD.

SUMMARY

Gastroesophageal reflux disease may be treated with some bariatric procedures but is often developed de novo as a result of the change in anatomy. Patients set to undergo bariatric surgery may benefit from pre-procedural endoscopy to choose the more suitable therapy. Further studies with objective measurements of GERD post procedure may provide more insight into the effects of bariatric therapies on reflux, especially more novel ones such as ESG.