A decade of bariatric surgery. What have we learned? Outcome in 520 patients from a single institution

Advancements in Bariatric Surgery: A Comparative Review of Laparoscopic and Robotic Techniques

This article examines the evolution of bariatric surgery, with a focus on emerging technologies such as robotics and laparoscopy. In the case of gastric bypass, no significant differences have emerged between the two techniques in terms of hospitalization duration, weight loss, weight regain, or 30-day mortality. Robotic surgery, while requiring more time in the operating room, has been associated with lower rates of bleeding, mortality, transfusions, and infections. In revisional bariatric surgery, the robotic approach has shown fewer complications, shorter hospital stays, and a reduced need for conversion to open surgery. In the case of sleeve gastrectomy, robotic procedures have required more time and longer postoperative stays but have recorded lower rates of transfusions and bleeding compared to laparoscopy. However, robotic surgeries have proven to be more costly and potentially more complex in terms of postoperative complications. The review has also addressed the topic of the single-anastomosis duodeno-ileal switch (SADIS), finding comparable results between robotic and laparoscopic techniques, although robotic procedures have required more time in the operating room. Robotic technology has proven to be safe and effective, albeit with slightly longer operative times in some cases.

One anastomosis gastric bypass vs sleeve gastrectomy as a revisional bariatric surgery for weight loss failure after primary restrictive procedure

INTRODUCTION

Weight loss failure after restrictive bariatric procedures initiated the debate about the choice of an adequate revisional intervention, a question still unanswered. While many surgeons went for a conversion to gastric bypass, others opted for re-trying a revisional restrictive procedure to avoid the side effects of gastric bypass. The objective of our study was to compare weight loss outcome between revisional laparoscopic sleeve gastrectomy (re-LSG) and revisional one anastomosis gastric bypass (re-OAGB) for insufficient weight loss or weight regain following primary restrictive bariatric surgery.

MATERIALS AND METHODS

We included 20 obese patients, with a history of weight regain or insufficient weight loss after primary restrictive surgery, who underwent re-LSG (eight patients) or re-OAGB (12 patients) between January 2018 and January 2021. Patients were followed up 2 years after their revisional intervention. Statistics were performed using IBM® SPSS® software for Windows version 21.

RESULTS

In the re-LSG group, the average body mass index (BMI) before primary restrictive procedure was 43.7 kg/m2 . The average period between the primary and revisional surgery was 12.6 years. Patients had a nadir BMI of 33.2 kg/m2 during that period and reached a mean BMI of 40.6 kg/m2 before re-LSG. Two years after re-LSG, the average BMI was 31.5 kg/m2 with a percent of excess weight loss (%EWL) of 54% and percent of excess BMI loss (%EBMIL) of 66.6%. In the re-OAGB group, the average BMI before primary restrictive procedure was 39 kg/m2 . The average period between the primary and revisional surgery was 10.7 years. Patients had a nadir BMI of 30.5 kg/m2 during that period and reached a mean BMI of 36.5 kg/m2 before re-OAGB. Two years after re-OAGB, the average BMI was 27 kg/m2 with a %EWL of 86.7% and %EBMIL of 92.6%.

CONCLUSION

For patients with insufficient weight loss or weight regain following primary restrictive bariatric surgery, re-OAGB has a better effectiveness in weight reduction compared with re-LSG after a 2-year follow up.

Safety and efficacy of OAGB/MGB during the learning curve: setting a benchmark in a bariatric center of excellence

Very little has been published on the learning curve (LC) of the One Anastomosis /Mini Gastric Bypass (OAGB/MGB). Aim of this study was to compare perioperative outcomes of OABG/MGBs performed during the LC of an experienced laparoscopic surgeon to global benchmark cut-offs. First 200 patients undergoing OAGB/MGB at our university hospital from 2010 to 2016 were retrospectively included in this study. LC of the surgeon was divided in two groups of 100 consecutive patients each and perioperative outcomes were compared to abovementioned global benchmarks for LSG and RYGB. A cumulative sum (CUSUM) analysis was performed for operative time and hospital stay. Uneventful postoperative recovery was recorded in 95% of patients. All benchmark values for RYGB were met in group 2. Comparison with cut-offs for LSG showed longer hospital stay and operative time in both groups but postoperative rate of complications resulted lower even for Group 1. CUSUM graph of the operative time runs randomly above the predetermined limit till the 40th cases but reaches the plateau after the 115th operation. CUSUM curve of the hospital stay reaches the plateau after the 57th case. OAGB/MGB confirms to be a feasible procedure, which can be safely and effectively performed during the learning curve. However, at least 100 hundred cases are required to reduce operative time and hospital stay.

Multisite study of Titan SGS stapler in longitudinal gastric resection

Background

Standardization of the laparoscopic sleeve gastrectomy procedure is needed to improve patient outcomes. A single-fire 23 cm stapler was developed to streamline the operation. Comparative testing conducted on excised human tissue has demonstrated the superiority of the novel Titan SGS stapler to two commonly utilized commercial devices in both staple line integrity and burst pressure. We hypothesized that the stapler would be safe and effective in creating longitudinal gastric resections in human patients.

Methods

61 patients were enrolled to undergo gastric resection with the Titan SGS stapler. Perioperative interventions and post-operative adverse events were recorded. Upper GI study was completed on post-operative day 1, and patients were followed for 6 weeks post-operatively to determine any subacute device-related adverse events.

Results

Surgeon feedback for intraoperative device utilization and post-operative gastric pouch shape were positive. Adverse events were found to be mild, limited, and generally well-known effects of bariatric surgery. One episode of post-operative hemorrhage required surgical takeback, with no criminal bleeding vessel identified.

Conclusion

The Titan SGS stapler is both safe and effective in sleeve gastrectomy pouch creation.

Ten-Year Results of Laparoscopic Sleeve Gastrectomy: Retrospective Matched Comparison with Laparoscopic Adjustable Gastric Banding-Is There a Significant Difference in Long Term?

Background

The laparoscopic sleeve gastrectomy (LSG) is the most common bariatric procedure performed worldwide while the laparoscopic adjustable gastric banding (LAGB) has been almost abandoned. Aim of this study was to retrospectively assess 10-year outcomes of LSG through a matched comparison with LAGB.

Materials and Methods

Retrospective search of prospectively maintained database of our university was carried out to find all patients that underwent LSG before December 2010. Each subject with LSG was matched one-to-one with a patient that had undergone LAGB in the same period with correspondent preoperative age, BMI, and sex.

Results

A total of 76 patients underwent LSG before 2010 and were all included in this study; a matched group of 76 out of 178 LAGB patients with 10-year follow-up was retrieved from our database. Comparison between the two groups showed better outcomes after LSG at 1 and 5 years but weight loss was comparable with the LAGB group at 10 years (%TWL 22.2 ± 13 vs 21.2 ± 16.1; p = 0.89). No significant difference was found in conversion/removal rate (15.8% vs 18.4%; p = 0.67).

Conclusion

LSG is an effective stand-alone bariatric procedure with better outcomes than LAGB in medium term, but results are comparable at 10 years. Subjects undergoing LSG should be informed that conversion to RYGB or OAGB may be necessary to achieve further weight loss or to treat reflux.

Graphical abstract

Effect of bariatric surgery on in vitro fertilization in infertile men with obesity

BACKGROUND

Obesity has previously been related to reduced female fertility, with prolonged waiting time to pregnancy among women with a body mass index (BMI) >35 kg/m² but there are few studies investigating the relationship between high BMI, bariatric surgery, and male fertility.

OBJECTIVES

The primary objective of this article was to investigate the effect of bariatric surgery on in vitro fertilization (IVF) outcomes in a cohort of men with morbid obesity who underwent sleeve gastrectomy (SG).

SETTING

University hospital, bariatric surgery unit.

METHODS

Pre- and postsurgery data on patient age, body mass index (BMI), and variables related to male fertility (semen volume, concentration, progressively motile sperm count, and sperm morphology) were collected; assisted reproductive technology outcomes before and after bariatric surgery were measured by the number of metaphase II oocytes; the number of top-quality oocytes and embryos; the number of fertilized oocytes; the number of transferred embryo; the implantation rate; the pregnancy rate; the live birth rate and the miscarriage rate.

RESULTS

Thirty-five men with obesity and idiopathic infertility were included in this study. We found a significant increase, after bariatric surgery, in semen volume, total sperm concentration, progressively motile sperm count, and sperm morphology. Considering IVF outcomes, mean number of top-quality oocytes, mean number of fertilized oocytes, mean number of embryos obtained, and top-quality embryos were significantly increased after bariatric procedure.

CONCLUSION

Bariatric surgery is confirmed to be safe and effective in increasing the outcomes of assisted reproductive technology treatment also in case of infertile men with obesity, both in terms of pregnancy and live birth rate.

IFSO Update Position Statement on One Anastomosis Gastric Bypass (OAGB)

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued a position statement on the role of one anastomosis gastric bypass (OAGB) in the field of bariatric/metabolic surgery in 2018 De Luca et al. (Obes Surg. 28(5):1188-206, 2018). This position statement was issued by the IFSO OAGB task force and approved by the IFSO Scientific Committee and IFSO Executive Board. In 2018, the OAGB task force recognized the necessity to update the position statement in the following 2 years since additional high-quality data could emerge. The updated IFSO position statement on OAGB was issued also in response to inquiries to the IFSO by society members, universities, hospitals, physicians, insurances, patients, policy makers, and media. The IFSO position statement on OAGB has been reviewed within 2 years according to the availability of additional scientific evidence. The recommendation of the statement is derived from peer-reviewed scientific literature and available knowledge. The IFSO update position statement on OAGB will again be reviewed in 2 years provided additional high-quality studies emerge.

Roux-en-Y gastric bypass versus one anastomosis-mini gastric bypass as a rescue procedure following failed restrictive bariatric surgery. A systematic review of literature with metanalysis

BACKGROUND

Although different procedures have been proposed as revisional surgery for patients who had previously undergone a failed primary restrictive procedure, the ideal revisional procedure is still a matter of debate.

METHODS

A systematic search was performed in all electronic databases to find studies comparing one anastomosis-mini gastric bypass (OAGB-MGB) or Roux-en-Y gastric bypass (RYGB) as revisional bariatric surgery for weight regain or intolerance/complications of a primary restrictive procedure. The data regarding sample size, patients' gender, age, primary surgery type, number of perioperative complications, operative time, pre- and post-revisional body mass index (BMI), and excess weight loss % (EWL%) at 1-year follow-up were extracted. Five studies were included in the analysis.

RESULTS

The primary bariatric procedures were represented by vertical banded gastroplasty (VBG), laparoscopic adjustable gastric band (LAGB) and laparoscopic sleeve gastrectomy (LSG). About perioperative complications, both RYGB and OAGB-MGB showed a similar rate of leaks but OAGB-MGB had a lower rate of bleedings; considering the progression from pre- to post-revisional BMI, OAGB-MGB reveals a better outcome as well as a shorter operative time.

CONCLUSIONS

Our meta-analysis has shown OAGB-MGB, used as revisional intervention after failed restrictive surgery, achieves outcomes comparable to RYGB in terms of perioperative complications providing a simpler and more effective technique.

Simultaneous Small/Medium Umbilical Hernia Repair With Laparoscopic Sleeve Gastrectomy (LSG): Results of a Retrospective Case-matched Study

PURPOSE

Periumbilical hernias are a common finding in morbidly obese patients undergoing bariatric surgery; however, the timing of repair is still debated. The aim of this paper is to compare the outcomes of simultaneous versus delayed mesh repair of umbilical hernia in patients undergoing laparoscopic sleeve gastrectomy (LSG).

METHODS

We retrospectively compared 2 groups of morbidly obese patients with small/medium periumbilical hernia (up to 4 cm) in a case-matched study: the first group underwent LSG with simultaneous periumbilical hernia repair; in the second, hernioplasty was performed after weight loss induced by LSG. Patients were matched at a 1:1 ratio according to age, comorbidities, defect size (<2 or ≥2 cm), and obesity grade (<40 or ≥40 kg/m). Demographic, clinical information, hernia size, data from the surgery, and its complications were retrieved and analyzed.

RESULTS

In total, 40 patients were retrieved from our prospectively maintained database and divided into 2 matched groups of 20 subjects each. Baseline characteristics were comparable. After a median time of 19.8±5.6 months, the recurrence rate was not significantly different in the 2 groups. There was no difference in the rate of single complications, but overall morbidity was significantly higher in patients undergoing a 2-step approach. LSG operation time and hospital stay resulted in comparable, but total hospital stay was longer for those readmitted for delayed hernioplasty.

CONCLUSIONS

In the case of morbidly obese patients with small/medium periumbilical hernia undergoing LSG, a simultaneous approach should be offered. Our proposed technique did not prolong operative time and showed a lower rate of overall morbidity.

Evaluation of reflux following sleeve gastrectomy and one anastomosis gastric bypass: 1-year results from a randomized open-label controlled trial

Background

Recent reports have demonstrated that de novo reflux and worsening of pre-existing symptoms occur after SG; concerns are still expressed about the risk of symptomatic biliary reflux gastritis and oesophagitis. The aim of our study was to investigate and compare the rate of postoperative acid and non-acid reflux following Mini-/One anastomosis gastric bypass (MGB/OAGB) and laparoscopic sleeve gastrectomy (LSG).

Study design

A prospective randomized open-label, controlled trial registered on clinicaltrial.gov (NCT number: NCT02987673) has been carried out to evaluate esophagogastric junction exposure to reflux in the first year after MGB/OAGB and LSG using high impedance manometry, endoscopy, and a validated questionnaire.

Results

A total of 58 individuals were eventually enrolled in this trial and represented the per-protocol population (n = 28 MGB/OAGB, n = 30 LSG). No difference was found between the two groups in terms of demographic characteristics, PAGI-SYM score, acid exposure time percent of the esophagus (AET%), esophagitis, and other HRiM and MII-pH data at baseline. Comparing MII-pH outcomes of the two groups, AET% resulted significantly higher after LSG at 12 months. Endoscopic findings showed a significant increase of esophagitis ≥ B in the LSG group after 1 year; postoperative esophagitis ≥ B resulted also significantly worsened after LSG when compared to MGB/OAGB.

Conclusion

Since AET% and rate of esophagitis are significantly higher after LSG when compared to MGB/OAGB, this procedure should be preferred in case of preoperative subclinical reflux or low grade (A) esophagitis.

Conversions related to adhesions in abdominal surgery. Robotic versus laparoscopic approach: A multicentre experience

BACKGROUND

An advantage of robotic surgery over laparoscopy is the lower rate of unplanned conversion. One of the implicated reasons for conversion is adhesions from previous abdominal surgeries (PASs).

METHODS

A comparative analysis of 98 patients with history of open PAS treated by laparoscopic or robotic surgery was performed. Primary endpoint was the rate of conversion to open surgery related to adhesiolysis. Secondary endpoints were short-term outcomes and complications.

RESULTS

Conversion rate specifically related to adhesiolysis was significantly lower in robotic group (13 for laparoscopic group vs. 2 for robotic group; p = 0.046). Conversions occurred during adhesiolysis were significantly related to severity of adhesions expressed by peritoneal adhesion index (PAI) score (p < 0.001), number of abdominal areas involved by adhesions (p < 0.001) and severity of PAI into the target area of surgical intervention (p = 0.021).

CONCLUSIONS

Benefits of robotic surgery are more noticeable in performing procedures with increasing technical difficulties.

Robotic repair of iatrogenic left diaphragmatic hernia. A case report

INTRODUCTION

Iatrogenic diaphragmatic hernia after laparoscopic left adrenalectomy has been rarely reported in adults. Surgery is the preferred treatment because of the risks of incarceration, strangulation and pulmonary complications.

PRESENTATION OF CASE

An elderly woman with parasternal diaphragmatic hernia has been successfully treated by robotic repair with mesh placement. The short-term follow-up showed that there was no recurrence or any symptoms after the intervention.

DISCUSSION

Iatrogenic diaphragmatic hernia is a rare complication occurring after abdominal or thoracic surgery. The diagnosis could be challenging because of the presence of chronic symptoms. Computed tomography can be considered the gold standard technique to assess the correct diagnosis of diaphragmatic hernias in the majority of cases. Patients with chronic symptomatic hernia should undergo surgical repair of defect. Robotic technology because of its enhanced precision and the endowrist movement of the robotic arms, facilitates the dissection near the esophago-gastric junction and the other important adjacent structures.

CONCLUSION

Robotic technology seems to be a valid approach for the repair of diaphragmatic defects, even if this remains a high cost-related procedure.

Is there an indication left for gastric band? A single center experience on 178 patients with a follow-up of 10 years

Background

Laparoscopic Adjustable Gastric Banding (LAGB) has been widely performed in the past at our university bariatric center. Aim of this study was to retrospectively assess long term outcomes of LAGB at our university hospital, with special regard to non-response (EWL < 25%) and rate of band removal.

Methods

Retrospective search of prospectively maintained database of our university bariatric center was carried out to find all consecutive patients that had undergone LAGB at our department with a minimum follow-up of 10 years. Collected data were sex, age, body mass index (BMI), obesity related diseases remission, complications and weight loss.

Results

After 10 years, patients with the band (n = 144) in place had a BMI of 35.2 ± 7.5 kg/m2, while %EWL and % TWL were 40.8 ± 52.4 and 18.9 ± 20.7. Seventy-four (41.6%) achieved a success (%EWL > 50), while 38 (21.3%) were non-responders (%EWL < 25), 32 (18%) had an insufficient weight loss (25 < %EWL < 50) and 34 (19.1%) underwent band removal. Among these, 6 (3.4%) were removed for complications and 28 (15.7%) for insufficient weight loss. Weight regain occurred in 38 out of 144 (26.4%) subjects with the band in place at 10 years. Only one case of early vomiting with readmission for medical treatment was recorded. Slippage, erosion/migration and port/tube complications occurred in 4 (2.2%), 2(1.1%) and 9(5%) cases respectively.

Conclusion

LAGB is a safe and moderately effective bariatric procedure but it showed disappointing rates of removal, non-response and remission from comorbidities. However, LAGB could still be proposed for selected/motivated patients.

The rise of one anastomosis gastric bypass: insights from surgeons and dietitians

One anastomosis gastric bypass/Mini Gastric Bypass (OAGB/MGB) is an emerging bariatric surgery (BS) technique. We evaluated and compared attitudes of bariatric surgeons and dietitians towards the considerations for choosing BS-type ("Decision-making"), the contributing factors to the rise of OAGB/MGB in Israel ("OAGB/MGB-rise") and notions regarding the occurrence of gastrointestinal (GI) symptoms and nutritional deficiencies following OAGB/MGB. Anonymous online surveys were distributed. The participants were asked to rate by a 10-point Likert scale (0 = not at all; 100 = very much/often) their attitudes towards "Decision-making", "OAGB/MGB-rise" and occurrence of GI symptoms and nutritional deficiencies following OAGB/MGB. For "Decision-making" and "OAGB/MGB-rise", items were considered prioritized where ≥ 50% of the group considered them as 'very-important' (rating ≥ 80). Data on age, sex, years-in-practice and main workplace were also collected. A total of 106 professionals participated in the survey (42 surgeons; 64 dietitians). The respective mean age, years-in-practice and sex were 52.3 ± 8.7 vs. 42.3 ± 9.0 years, 21.0 ± 10.8 vs. 15.5 ± 9.2 years and 85.7% vs. 3.1% males. The inter-observer agreement for prioritized items related to "Decision-making" was fair (Kappa = 0.250; P = 0.257) and both groups prioritized patient's BMI, comorbidities and compliance. The inter-observer agreement for prioritized items related to "OAGB/MGB-rise" was moderate (Kappa = 0.550; P = 0.099) and both groups prioritized ease of performance, shorter operation duration and failure of former restrictive BS. Surgeons reported lower occurrence of nutritional deficiencies and GI symptoms as adverse effects of OAGB/MGB (P ≤ 0.033). The study highlights the views of bariatric surgeons and dietitians concerning factors that underpin the rise of OABG/MGB in Israel and possible rates of GI symptoms and nutritional deficiencies associated with this modality.

Clinical Outcomes of One Anastomosis Gastric Bypass Versus Sleeve Gastrectomy for Morbid Obesity

BACKGROUND

One anastomosis gastric bypass (OAGB) and sleeve gastrectomy (SG) are popular bariatric surgeries for morbid obesity. Reports on the safety and effectiveness of SG and OAGB are inconsistent. This meta-analysis investigated the clinical outcomes of SG versus those of OAGB for morbid obesity.

METHODS

Based on PRISMA guidelines, we searched the published articles in English from Scopus, PubMed (Medline), Central (Cochrane), and Embase databases. Articles were retrieved from the start date of each database to February 13, 2019. Statistical analysis of this meta-analysis was conducted in Stata 14.0, and the most appropriate effect model was chosen based on heterogeneity.

RESULTS

A total of 20 articles examining 4064 OAGB patients and 3733 SG patients were included in this meta-analysis. Compared with SG, OAGB showed a higher percentage excess weight loss (%EWL) at 6 months (weighted mean difference (WMD) = 11.32; 95% CI 6.00-16.64), 12 months (WMD = 8.22; 95% CI 3.78-12.66), 24 months (WMD = 10.19; 95% CI 0.88-21.25), 36 months (WMD = 7.93; 95% CI 3.37-12.48), 48 months (WMD = 17.22; 95% CI 7.37-27.06), and 60 months (WMD = 16.43; 95% CI 8.96-23.90). In addition, OAGB was associated with a lower rate of postoperative leak, gastroesophageal reflux disease, revisions, mortality, and dyslipidemia remission rates. However, OAGB increased the incidence of ulcers, malnutrition, and bile reflux.

CONCLUSION

OAGB is more effective for %EWL and dyslipidemia remission than SG. In addition, OAGB may lower the risk of postoperative leak, gastroesophageal reflux disease, revision, and mortality. Further comparisons of the clinical outcomes of OAGB versus SG for morbid obesity would benefit from more high-quality controlled studies.

Mini Gastric Bypass-One Anastomosis Gastric Bypass (MGB-OAGB)-IFSO Position Statement

PREAMBLE

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has played an integral role in educating both the metabolic surgical and the medical community at large about the role of innovative and new surgical and/or endoscopic interventions in treating adiposity-based chronic diseases.The mini gastric bypass is also known as the one anastomosis gastric bypass. The IFSO has agreed that the standard nomenclature should be the mini gastric bypass-one anastomosis gastric bypass (MGB-OAGB). The IFSO commissioned a task force (Appendix 1) to determine if MGB-OAGB is an effective and safe procedure and if it should be considered a surgical option for the treatment of obesity and metabolic diseases.The following position statement is issued by the IFSO MGB-OAGB task force and approved by the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence. It will be reviewed in 2 years.

Conversion from laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) to one anastomosis gastric bypass (OAGB): preliminary data from a multicenter retrospective study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric procedure, while laparoscopic adjustable gastric banding (LAGB) has been for a decade one of the most popular interventions for weight loss. After LSG and LAGB, some patients may require a second surgery due to weight regain or late complications. One anastomosis gastric bypass (OAGB) is a promising bariatric procedure, which provides effective long-term weight loss and has a favorable effect on type 2 diabetes.

OBJECTIVES

To retrospectively analyze data from 10 Italian centers on conversion from LAGB and LSG to OAGB.

SETTING

High-volume centers for bariatric surgery.

METHODS

Prospectively collected data from 10 high-volume centers were retrospectively reviewed. Body mass index (BMI), percentage of excess BMI loss, reasons for redo, remission from co-morbidities (hypertension, diabetes, gastroesophageal reflux, and dyslipidemia), and major complications were recorded.

RESULTS

Three hundred patients were included in the study; 196 patients underwent conversion from LAGB to OAGB and 104 were converted from LSG. BMI was 45.1 ± 7 kg/m² at the time of first intervention, 41.8 ± 6.3 kg/m² at redo time, and 30.5 ± 5.5 kg/m² at last follow-up appointment. Mean percentage of excess BMI loss was 13.2 ± 28.2 at conversion and 73.4 ± 27.5 after OAGB. Remission rates from hypertension, diabetes, gastroesophageal reflux, and dyslipidemia were 40%, 62.5%, 58.7% and 52%, respectively. Mean follow-up was 20.8 (range, 6-156) months and overall complications rate was 8.6%.

CONCLUSION

Our data show that OAGB is a safe and effective revisional procedure after failed restrictive bariatric surgery.

Meta-analysis of the effectiveness of laparoscopic adjustable gastric banding versus laparoscopic sleeve gastrectomy for obesity

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) are common weight loss procedures. Our meta-analysis compared these procedures for the treatment of morbid obesity and related diseases.

METHODS

We systematically searched the PubMed, Embase, and the Cochrane Library through January 2018. The percentage of excess weight loss (%EWL), improvement or remission of type 2 diabetes mellitus (T2DM) and hypertension were analyzed and compared.

RESULTS

Thirty-three studies with 4109 patients were included. Greater decreases in excess weight were found in patients who received LSG at 6 months (weighted mean difference (WMD) -9.29, 95% confidence interval (CI): -15.19 to -3.40, P = .002), 12 months (WMD -16.67 95% CI: -24.30 to -9.05, P < .0001), 24 months (WMD -19.63, 95% CI: -29.00 to -10.26, P < .0001), and 36 months (WMD -19.28, 95% CI: -27.09 to -11.47, P < .0001) than in patients who received LAGB. However, there were no significant differences in the 3-month outcomes between the 2 groups (WMD -1.61, 95% CI: -9.96 to 6.73, P = .70). T2DM patients after LSG experience more significant improvement or remission of diabetes (odds ratio (OR): 0.22, 95% CI: 0.06-0.87, P = .03). The 2 groups did not significantly differ regarding improvement or remission of hypertension (OR 0.80, 95% CI: 0.46-1.38, P = .42).

CONCLUSION

LSG is a more effective procedure than LAGB for morbidly obese patients, contributing to a higher %EWL and greater improvement in T2DM.

Comparison between LigaSure™ and Harmonic® in Laparoscopic Sleeve Gastrectomy: A Single-Center Experience on 422 Patients

BACKGROUND

New laparoscopic devices, such as electrothermal bipolar-activated devices (LigaSure™ (LS)) or ultrasonic systems (Harmonic® scalpel (HS)), have been applied recently to bariatric surgery allowing to reduce blood loss and surgical risks. The aim of this study was to retrospectively compare intraoperative performance of HS and LS, postoperative results, and clinical outcomes in a large cohort of patients undergoing LSG.

METHODS

Data from 422 morbidly obese patients undergoing LSG in our Bariatric Unit at the Advanced Biomedical Sciences Department of the "Federico II" University of Naples (Italy) between January 2009 and December 2017 were retrospectively analyzed. Subjects were divided into two groups (HS and LS), and operative time, intraoperative complications, and postoperative (within 30 days from surgery) complications were compared. Bleeding from the omentum or from the staple line, use of hemostatic clips, and absorbable hemostat were recorded as intraoperative complications; hemorrhages, abscess formation, gastric leaks, fever, and mortality were considered as postoperative complications.

RESULTS

Statistical analysis showed no difference in terms of baseline demographics between the two cohorts. Operative time (48 ± 9 vs 49 ± 6 min, p=0.646) and the rates of intraoperative and postoperative complications did not significantly differ between groups.

CONCLUSION

Harmonic® and LigaSure™ are both useful tools in bariatric surgery, and these two advanced power devices are user-friendly and can facilitate surgeon work; from this point of view, the choice of the energy device should be based on the preference of the surgeon and on the hospital costs policy and availability.

Results following laparoscopic sleeve gastrectomy in elderly obese patients: a single center experience with follow-up at three years

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) represents the most performed bariatric surgical procedure worldwide. Morbid Overweight in elderly patients is becoming a significant health problem even in Italy. As well as in younger age groups, bariatric surgery could be indicated even in this subset of patients. However the advantages and results of LSG in patients over 60 years old have received minimal attention.

METHODS

The records of 375 patients underwent LSG between 2008 and 2016 were reviewed. In the entire series 18 patients were aged 60 years or older at the time of surgery. Since a 3 years follow-up was available for 12 patients out of the 18 aged over 60 we included in the study only these. General epidemiologic data, clinical findings, BMI and comorbidities surgical treatment and follow-up data were collected; postoperative measurements such as operative time, intraoperative complications, mortality rate, length of stay, incidence of early and late complications, Body mass Index (BMI), excess weight loss rate (EWL%) and comorbidities resolution were also recorded.

RESULTS

LSG was successfully performed for all geriatric patients. Global complications rate was 16.6% At 3 years mean BMI was 34.4±3.8 with a mean EWL% 66.1±31.9. Postoperative resolution of obesity comorbidities was observed; Hypertension (71.4%), type 2 Diabetes Mellitus (T2DM) (50.0%), obstructive sleep apnea syndrome (OSAS) (66.6%) respectively. No intraoperative complications or mortality were recorded.

CONCLUSIONS

LSG offered cure in geriatric patients affected by morbid obesity for weight loss and comorbidities resolution. Larger studies are necessary to analyze and minimize the incidence of postoperative complications associated to this surgical procedure in elderly patients.

Acute complications following endoscopic intragastric balloon insertion for treatment of morbid obesity in elderly patients. A single center experience

BACKGROUND

Obesity is a serious disease, with an increasing incidence also among subjects over 60 years old; surgical management has proven to be the most effective in the production of significant and durable weight loss. Intragastric balloon (IGB) treatment promotes a reduction of five to nine Body Mass Index (BMI) units in 6 months with an impressive improvement of obesity-associated comorbidities.

METHODS

Two hundred and twenty-five patients, 106 men (47.1%) and 119 women (52.9%), were evaluated at our institution to be submitted to a IGB positioning. Of these, 12 patients (8 women and 4 men) were more than 60 years old. For all patients BMI, comorbidities, weight loss and complications were recorded. χ2 test was used to evaluate differences in complications rate between elderly and other patients.

RESULTS

For the 12 elderly patients, we recorded a mean excess weight loss rate (EWL%) of 31.4. About complications, we recorded 2 severe esophagitis requiring IGB removal and 1 late gastric perforation. A higher complications rate was found in elderly population and the comparison with other patients revealed a significant difference (P<0.001).

CONCLUSIONS

Our results underline that IGB treatment in elderly patients is safe and effective in terms of weight loss and improvement in comorbidities. IGB can cause complications which, sometimes, can be severe such as esophageal damage and gastric perforation. For the management of complications, we highly recommend a close follow-up in all patients and a deepened instrumental study in every suspect case.

Comparison of safety and effectiveness between laparoscopic mini-gastric bypass and laparoscopic sleeve gastrectomy: A meta-analysis and systematic review

BACKGROUND

The laparoscopic mini-gastric bypass is a newly emerged surgical procedure in recent years. Owe to safe and simple process and effective outcomes, laparoscopic mini-gastric bypass has quickly become one of the most popular procedures in some countries. The safety and effectiveness of laparoscopic mini-gastric bypass versus laparoscopic sleeve gastrectomy remain unclear.

METHODS

A systematic literature search was performed in PubMed, Embase, Cochrane library from inception to May 20, 2017. The methodological quality of Randomized Controlled Trials and non-Randomized Controlled Trials were, respectively, assessed by Cochrane Collaboration's tool for assessing risk of bias and Newcastle-Ottawa scale. The meta-analysis was performed by RevMan 5.3 software.

RESULTS

Patients receiving mini-gastric bypass had a lot of advantageous indexes than patients receiving sleeve gastrectomy, such as higher 1-year EWL% (excess weight loss), higher 5-year EWL%, higher T2DM remission rate, higher hypertension remission rate, higher obstructive sleep apnea (OSA) remission rate, lower osteoarthritis remission rate, lower leakage rate, lower overall late complications rate, higher ulcer rate, lower gastroesophageal reflux disease (GERD) rate, shorter hospital stay and lower revision rate. No significant statistical difference was observed on overall early complications rate, bleed rate, vomiting rate, anemia rate, and operation time between mini-gastric bypass and sleeve gastrectomy.

CONCLUSION

Mini-gastric bypass is a simpler, safer, and more effective bariatric procedure than laparoscopic sleeve gastrectomy. Due to the biased data, small sample size and short follow-up time, our results may be unreliable. Large sample and multicenter RCT is needed to compare the effectiveness and safety between mini-gastric bypass and sleeve gastrectomy. Future study should also focus on bile reflux, remnant gastric cancer, and long term effectiveness of mini-gastric bypass.

Frequency of periodontal pathogens and Helicobacter pylori in the mouths and stomachs of obese individuals submitted to bariatric surgery: a cross-sectional study

OBJECTIVES

This cross-sectional study compared the frequency of oral periodontopathogens and H. pylori in the mouths and stomachs of obese individuals with or without periodontitis submitted to bariatric surgery.

MATERIAL AND METHODS

One hundred and fifty-four men and women aged 18-65 were conveniently distributed into four groups. Two groups were composed of individuals who underwent bariatric surgery with (BP) (n=40) and without (BNP) (n=39) periodontitis and two obese control groups with (CP) (n=35) and without (CNP) (n=40) periodontitis. The oral pathogens Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Parvimonas micra, Treponema denticola, Tannerella forsythia, Campylobacter rectus, and Helicobacter pylori were detected by a polymerase chain reaction technique using saliva, tongue and stomach biopsy samples.

RESULTS

Statistical analysis demonstrated that periodontopathogens were highly frequent in the mouth (up to 91.4%). In the bariatric surgically treated group, orally, P. gingivalis, T. denticola and T. forsythia were more frequent in periodontitis, while C. rectus was more frequent in non-periodontitis subjects. Stomach biopsies also revealed the high frequency of five oral species in both candidates for bariatric surgery (91.6%) and the bariatric (83.3%) groups. H. pylori was frequently detected in the mouth (50.0%) and stomach (83.3%). In the stomach, oral species and H. pylori appeared in lower frequency in the bariatric group.

CONCLUSIONS

Obese individuals showed high frequencies of periodontopathogens and H. pylori in their mouths and stomachs. Bariatric surgery showed an inverse microbial effect on oral and stomach environments by revealing higher oral and lower stomach bacterial frequencies.

Efficacy of Bariatric Surgery in Type 2 Diabetes Mellitus Remission: the Role of Mini Gastric Bypass/One Anastomosis Gastric Bypass and Sleeve Gastrectomy at 1 Year of Follow-up. A European survey

BACKGROUND

A retrospective study was undertaken to define the efficacy of both mini gastric bypass or one anastomosis gastric bypass (MGB/OAGB) and sleeve gastrectomy (SG) in type 2 diabetes mellitus (T2DM) remission in morbidly obese patients (pts).

METHODS

Eight European centers were involved in this survey. T2DM was preoperatively diagnosed in 313/3252 pts (9.62%). In 175/313 patients, 55.9% underwent MGB/OAGB, while in 138/313 patients, 44.1% received SG between January 2006 and December 2014.

RESULTS

Two hundred six out of 313 (63.7 %) pts reached 1 year of follow-up. The mean body mass index (BMI) for MGB/OAGB pts was 33.1 ± 6.6, and the mean BMI for SG pts was 35.9 ± 5.9 (p < 0.001). Eighty-two out of 96 (85.4%) MGB/OAGB pts vs. 67/110 (60.9%) SG pts are in remission (p < 0.001). No correlation was found in the % change vs. baseline values for hemoglobin A1c (HbA1c) and fasting plasma glucose (FPG) in relation to BMI reduction, for both MGB/OAGB or SG (ΔFPG 0.7 and ΔHbA1c 0.4 for MGB/OAGB; ΔFPG 0.7 and ΔHbA1c 0.1 for SG). At multivariate analysis, high baseline HbA1c [odds ratio (OR) = 0.623, 95% confidence interval (CI) 0.419-0.925, p = 0.01], preoperative consumption of insulin or oral antidiabetic agents (OR = 0.256, 95% CI 0.137-0.478, p = <0.001), and T2DM duration >10 years (OR = 0.752, 95% CI 0.512-0.976, p = 0.01) were negative predictors whereas MGB/OAGB resulted as a positive predictor (OR = 3.888, 95% CI 1.654-9.143, p = 0.002) of diabetes remission.

CONCLUSIONS

A significant BMI decrease and T2DM remission unrelated from weight loss were recorded for both procedures if compared to baseline values. At univariate and multivariate analyses, MGB/OAGB seems to outperform significantly SG. Four independent variables able to influence T2DM remission at 12 months have been identified.

Long-term results after sleeve gastrectomy: A systematic review

Sleeve gastrectomy (SG) has become one of the most commonly used bariatric procedures worldwide. However, data regarding long-term results remain insufficient. The aim of this study was to review the long-term results after SG. We conducted a comprehensive literature search of Medline and the Cochrane Library for articles published until May 2016 on the long-term results (>5 yr) after SG. Studies representing outcomes of SG were included if they reported≥5-year results that contained at least one outcome of interest-weight loss, co-morbidities, long-term complications, or quality of life-and SG was performed as a primary procedure. Of the 297 initially identified articles, 277 studies met the exclusion criteria, and 20 met the inclusion criteria. SG was performed on 2713 patients and 1626 patients reached the≥5-year follow-up point. Among the patients, 71.3% were women and 28.7% were men. The mean preoperative body mass index was 46.9 kg/m². The duration of follow-up ranged 5 to 11 years. The mean 5-year follow-up rate was 66% (range, 57%-100%). The mean percentage excess weight loss was 58.4%, 59.5%, 56.6%, 56.4%, and 62.5% at 5, 6, 7, 8, and 11 years, respectively. Five years after SG, the resolution or improvement of type 2 diabetes was observed in 77.8% of patients, and arterial hypertension, dyslipidemia, obstructive sleep apnea, gastroesophageal reflux disease, and degenerative joint diseases had improved or resolved in 68.0%, 65.9%, 75.8%, 30.6%, and 55.7% of patients, respectively. This systematic review suggests that SG can lead to substantial and lasting excess weight loss and significant improvement in obesity-related co-morbidities. However, the lack of randomized clinical trials, low follow-up rates, and poorly reported data regarding co-morbidities and quality of life in many of the studies indicate that these findings should be interpreted with caution.

Retrieval of the gastric specimen following laparoscopic sleeve gastrectomy. Experience on 275 cases

Severe obesity leads to a high incidence of complications and a decrease in life expectancy, especially among younger adults. Laparoscopic sleeve gastrectomy (LSG) first intended as the first step of biliopancreatic diversion with duodenal switch is gaining a per-se procedure role because of its effectiveness on weight loss and comorbidity resolution. Different techniques have been described for specimen extraction in LSG. In this article we report the technique adopted in 275 LSGs performed in our department. In the first 120 LSGs performed from 2007, the specimen was extracted through a mini laparotomy. In the following 155 cases the technique has been simplified: the grasped specimen has been withdrawn through the 15 mm trocar site. We registered in the fist group six cases of wound infection (5%), ten cases of hematoma (8.3%) and four cases of port site hernia (3.3%). In the second group only one case of hematoma (0.6%, p = 0.01) but no cases of wound infection (p = 0.01) or port site hernia, (p = 0.03) although we registered a specimen perforation during retrieval in 16 patients, were reported. The technique described in the 155 cases of the control group has shown to be more effective than the technique we used in the case group, allowing significantly lower operative time (112.9 ± 1.0 vs 74.9 ± 9.1 p < 0.001) and complications, and providing unchanged costs.

Efficacy of Laparoscopic Mini Gastric Bypass for Obesity and Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis

Background. Controversies on the utility of laparoscopic mini gastric bypass (LMGB) in weight loss and type 2 diabetes mellitus (T2DM) control still exist. Methods. We conducted a comprehensive literature search of PubMed, EMBASE, and Cochrane Library. Review Manager was used to perform the meta-analysis and the weighted mean difference (WMD) and/or odds ratio with 95% confidence interval (95% CI) were used to evaluate the overall size effect. Results. The literature search identified 16 studies for systematic review and 15 articles for meta-analysis. Compared with LAGB, LSG, and LRYGB, LMGB showed significant weight loss [WMD, −6.58 (95% CI, −9.37, −3.79), P < 0.01 (LAGB); 2.86 (95% CI, 1.40, 5.83), P = 0.004 (LSG); 10.33 (95% CI, 4.30, 16.36), P < 0.01 (LRYGB)] and comparable/higher T2DM remission results [86.2% versus 55.6%, P = 0.06 (LAGB); 89.1% versus 76.3%, P = 0.004 (LAGB); 93.4% versus 77.6%, P = 0.006 (LAGB)]; LMGB also had shorter learning curve and less operation time than LRYGB [WMD, −35.2 (95% CI, −46.94, −23.46)]. Conclusions. LMGB appeared to be effective in weight loss and T2DM remission and noninferior to other bariatric surgeries. However, clinical utility of LMGB needs to be further validated by future prospective randomized controlled trials.

The impact of bariatric surgery on nutritional status of patients

Introduction

Currently, surgical treatment is considered to be the most efficient method of dealing with morbid obesity.

Aim

To evaluate changes in nutritional status after surgical treatment of obesity in the early postoperative period.

Material and methods

The study included 50 patients (30 women and 20 men) treated surgically due to morbid obesity. During the preliminary visit and during control visits measurements of body mass, height, and waist and hip circumference were conducted. Also, analysis of body content was performed and blood was taken for biochemical analysis. Statistical analysis was conducted using the program Statistica 10.

Results

Six months after the surgery, in the group of women, significant reduction of average body mass, average waist circumference, average hip circumference and average body mass index (BMI) was observed. Also, significant reduction of the percentage of body fat and an increase in the percentage of fat-free body mass were observed. A significant decrease in muscle mass was also noted. Both in women and in men, 6 months after the surgery, a significant decrease in fasting glucose concentration, fasting insulin and triglycerides in blood serum was observed.

Conclusions

Bariatric procedures lead to significant body mass, BMI, waist and hip circumference reduction. Loss of body mass is caused mainly by the reduction of fat tissue. Application of surgical procedures in morbid obesity treatment also allowed us to achieve improvement in insulin, glucose and lipid metabolism.