Risk factors for complications of laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass

Effectiveness of Tranexamic Acid in Reducing Hidden Blood Loss During Laparoscopic Sleeve Gastrectomy: A Randomized Clinical Trial

Background: Tranexamic acid (TXA), an antifibrinolytic agent, has demonstrated efficacy in reducing bleeding across various surgical procedures. However, its role in bariatric surgery remains underexplored. This study aimed to evaluate the effectiveness of TXA in mitigating hidden blood loss following laparoscopic sleeve gastrectomy (SG). Methods: A single-center, single-blind, randomized, controlled trial was conducted at the University Clinical Center, Medical University of Gdańsk, Poland, between July 2022 and June 2023. A total of 238 patients undergoing SG were randomized to receive either TXA or no pharmacological intervention. The primary outcome was hemoglobin concentration in abdominal drainage post-surgery. Secondary outcomes included total blood loss, drainage volume, the need for blood transfusion, and postoperative complications. Statistical analyses were conducted using intention-to-treat and per-protocol strategies. Results: A statistically significant reduction in hemoglobin concentration in abdominal drainage samples was observed in the TXA group (p = 0.011). No significant differences were found in total blood loss, drainage volume, necessity for blood transfusions, or extended hospital stay between groups. Conclusions: While TXA administration may reduce the hidden blood loss effect, its general clinical significance appears questionable. Nonetheless, intraoperative TXA may be beneficial for a selected patient group with multiple preoperative disorders and risk factors. Further research is necessary to comprehensively assess the risks and benefits of TXA administration in bariatric surgery.

Demographic Factors Associated with Postoperative Complications in Primary Bariatric Surgery: A Rapid Review

BACKGROUND

Bariatric surgery is highly effective for the management of severe obesity, but its safety profile is not completely understood. This review aimed to synthesise evidence linking demographic factors to postoperative complications and mortality following primary bariatric surgery.

METHODS

We searched Medline for observational studies of adult patients linking demographic factors to postoperative complications of primary bariatric surgery published from 2017 to 2022. Risk ratios (RR) with 95% confidence intervals (95% CI) were calculated and pooled using random effect meta-analysis. Heterogeneity was quantified using the I2 statistic and tested for statistical significance using the Q-statistic. Sensitivity analyses were used to explore potential sources of heterogeneity.

RESULTS

A total of 71 observational studies (69 cohort, 2 case-control) were reviewed and appraised. Older age was consistently associated with increased risks of postoperative mortality (RR = 2.62, 95% CI 1.63-4.23, I2 = 42.04%), serious complications (RR = 1.76, 95% CI 1.09-2.82, I2 = 93.24%), anastomotic leak (RR = 1.64, 95% CI 1.04-2.58, I2 = 61.09%), and haemorrhage (RR = 1.44, 95% CI 1.07-1.94, I2 = 45.25%). Male sex was associated with increased anastomotic leak (RR = 1.39, 95% CI 1.04-1.87, I2 = 72.36%). Sensitivity analyses did not identify sources of bias. Socioeconomic factors, including Black/African American race, low financial status, and marital status (mixed results), were linked to higher complication risks in some studies.

CONCLUSIONS

Older age and certain demographic factors (male sex, Black/African American race, low financial status, marital status) were associated with increased risks of postoperative complications following primary bariatric surgery.

Is It Possible to Predict Difficulties During Laparoscopic Sleeve Gastrectomy? A Single Centre Experience

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) is a widely performed bariatric surgery across the globe. Understanding preoperative risk factors for possible intraoperative complications can aid in predicting surgical outcomes and shaping the approach to the procedure. This study aimed to identify and analyze potential risk factors associated with intraoperative difficulties during LSG.

PATIENTS AND METHODS

The analysis encompassed consecutive patients who underwent LSG from 2017 to 2020. Patients who encountered intraoperative difficulties during the procedure were categorized into Group 1, whereas those who did not experience such complications were placed in Group 2. To identify potential risk factors for intraoperative challenges, a thorough evaluation of demographic characteristics was conducted, including variables such as age, body mass index (BMI), comorbidities, and previous surgical history.

RESULTS

Group 1 included 37 patients (11.71%), while Group 2 comprised 279 patients (88.29%). Apart from higher rates of diabetes, pulmonary disease, and sleep apnea in Group 1, no significant differences were observed between the groups regarding demographic parameters. A univariate logistic regression analysis identified several risk factors associated with intraoperative difficulties, including a body mass index (BMI) greater than 50 kg/m2 (OR 2.15, 95%, CI 1.05-4.39, p = 0.0362), the experience of the operating surgeon (OR 9.22, 95% CI 4.31-19.72, p = 0.0058), the presence of diabetes (OR 2.44, 95% CI 1.19-4.98, p = 0.0146), and pulmonary disease (OR 12.22, 95% CI 1.97-75.75, p < 0.0001). In multivariate logistic regression analysis, only the surgeon's experience (OR 8.61, 95% CI 3.75-19.72, p < 0.0001) remained a significant factor influencing intraoperative difficulties.

CONCLUSIONS

The sole significant factor influencing the occurrence of intraoperative difficulties was the level of the surgeon's experience.

Preoperative risk factors for early postoperative bleeding after Roux-en-Y gastric bypass surgery: a systematic review and meta-analysis

PURPOSE

Although bariatric surgery is an effective intervention for obesity, it comes with risks such as early postoperative bleeding (EPB). Identifying preoperative risk factors for this complication can help patients' risk stratification and optimization. We performed a systematic review and meta-analysis to find predictors for early postoperative bleeding after Roux-en-Y gastric bypass (RYGB).

METHODS

We conducted a systematic review, searching PubMed, Cochrane Library, and Web of Science until November 2023. We performed a random-effects meta-analysis to explore preoperative risk factors associated with early postoperative bleeding after RYGB. Sources of heterogeneity were explored by leave-one-out analyses.

RESULTS

23 studies were included, comprising 232,488 patients. Male gender (meta-analytical RR = 1.42, 95%CI = 1.21-1.66, I2 = 18%, Q Cochran test p-value = 0.29) and revisional surgery (meta-analytical RR = 1.35, 95%CI = 1.12-1.62, I2 = 22%, Q Cochran test p = 0.21) were associated with higher risk of EPB. On average, patients with EPB were older than the remainder (MD for the mean age = 2.82 years, 95%CI = 0.97-4.67, I2 = 0.00%, Q Cochran test p = 0.46). Except for hypertension (meta-analytical RR = 1.33, 95%CI = 1.02-1.73, I2 = 66%, Q Cochran test p < 0.0001), comorbidities were not associated with a higher risk of EPB.

CONCLUSION

Preoperative risk factors, including age, gender, hypertension, and revisional bariatric surgery, are associated with early postoperative bleeding after RYGB. Further primary studies, with higher methodological quality, are required to detail more risk factors.

Mesenteric Vein Thrombosis following Sleeve Gastrectomy: A Case Report and Review of the Literature

INTRODUCTION

Acute mesenteric ischemia (AMI) is a rare but lethal disease. Mesenteric vein thrombosis (VAMI) is a subtype of AMI. Morbid obesity is usually accompanied by hypertension, hyperlipidemia, or diabetes mellitus, which are risk factors associated with AMI.

CASE PRESENTATION

We present a 28-year-old man with VAMI post-laparoscopic sleeve gastrectomy. He was first misdiagnosed with intestinal obstruction. Superior VAMI was confirmed after computed tomography angiography. Laparotomy, resection of the necrotic small bowel, and ostomy were performed immediately.

CONCLUSION

Patients with morbid obesity accompanied by hypertension, hyperlipidemia, or diabetes mellitus have a high risk of AMI. Abdominal pain with sudden onset should be considered AMI. Anticoagulation therapy post-sleeve gastrectomy might help reduce the incidence of AMI.

Early versus delay oral feeding for patients after upper gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

To evaluate the efficacy and safety of early oral feeding (EOF) in patients after upper gastrointestinal surgery through meta-analysis of randomized controlled trials (RCTs).

METHODS

We analyzed the endpoints of patients including the length of stay (LOS), time of first exhaust, anastomotic leakage and pneumonia from included studies. And we retrieved RCTs from medical literature databases. Weighted mean difference (WMD), risk ratios (RR) and 95% confidence intervals (CI) were calculated to compare the endpoints.

RESULTS

In total, we retrieved 12 articles (13 trial comparisons) which contained 1771 patients. 887 patients (50.1%) were randomized to EOF group whereas 884 patients (49.9%) were randomized to delay oral feeding group. The result showed that compared with the delay oral feeding group, EOF after upper gastrointestinal surgery significantly shorten the LOS [WMD = - 1.30, 95% CI - 1.79 to - 0.80, I² = 0.0%] and time of first exhaust [WMD = - 0.39, 95% CI - 0.58 to - 0.20, I² = 62.1%]. EOF also reduced the risk of pneumonia (RR: 0.74, 95% CI 0.55 to 0.99, I² = 0.0%). There is no significant difference in the risk of anastomotic leak, anastomotic bleeding, abdominal abscess, reoperation, readmission and mortality.

CONCLUSIONS

Overall, compared with the traditional oral feeding, EOF could shorten the LOS and time of first exhaust without increasing complications after upper gastrointestinal surgery.

A Hub and Spoke Learning Program in Bariatric Surgery in a Small Region of Italy

Background

Metabolic and bariatric surgery (BS) are considered life-changing and life-saving treatments for obese patients. The Italian Society of Obesity Surgery (SICOB) requires at least 25 operations per year to achieve the standard of care in the field. Despite the increasing need to treat obese patients, some small southern regions of Italy, such as Molise, do not have enough experience in bariatric procedures to be allowed to perform them. Therefore, our aim was to run a Hub and Spoke Program with a referral center in BS to treat obese patients and provide a proper learning curve in BS in Molise.

Methods

In 2020, the “A. Cardarelli Hospital” in Campobasso, Molise, started a formal “Learning Model of Hub and Spoke Collaboration” with the Hub center “Ospedale Del Mare”, Naples. A multidisciplinary approach was achieved. Patients were supervised and operated under the supervision and tutoring of the referral center. We retrospectively reviewed our prospectively collected database from February 2020 to August 2021 in order to analyze the safety and effectiveness of our learning program.

Results

In total, 13 (3 men and 10 women) patients underwent BS with the mean age of 47.08 years and a presurgery BMI of 41.79. Seven (53.84%) patients were the American Society of Anesthesiologist (ASA) II, and 6 (46.16%) patients were ASA III. Twelve (92.31%) procedures were laparoscopic sleeve gastrectomies, 1 (7.69%) patient underwent endoscopic BioEnterics Intragastric Balloon (BIB) placement. One (8.33%) sleeve gastrectomy was associated to gastric band removal. Mean surgical time was 110.14 ± 23.54 min. The mean length of stay was 4.07 ± 2.40 days. No Clavien-Dindo ≥ III and mortality were reported. The follow-up program showed a mean decrease of 11.82 in terms of body mass index (BMI) value. The last 5 procedures were performed by the whole equips from “A. Cardarelli” under external tutoring without any impact on complication rate.

Conclusion

The setup of a proper Hub and Spoke Program may allow to perform BS to provide the standard of care. This approach may reduce health costs and related patient migration.

Risk Factors for Early and Late Complications after Laparoscopic Sleeve Gastrectomy in One-Year Observation

BACKGROUND

Although laparoscopic sleeve gastrectomy (LSG) is considered a safe bariatric procedure in the treatment of obesity, it still involves a risk of developing postoperative complications. Knowledge of risk factors for possible complications would allow appropriate preoperative planning, optimization of postoperative care, as well as early diagnosis and treatment. The aim of this study was to evaluate risk factors for complications after laparoscopic sleeve gastrectomy.

METHODS

A retrospective study of 610 patients who underwent LSG at a tertiary institution were included in the study through retrospective analysis of the medical data. Complications were categorized as early (<30 days) and late (≥30 days) and evaluated according to the Clavien-Dindo Classification.

RESULTS

Early complications were observed in 35 patients (5.74%) and late complications occurred in 10 patients (1.64%). Independent risk factors of early complications after laparoscopic sleeve gastrectomy included hypercholesterolemia (OR 3.73; p-value = 0.023) and smoking (OR = 274.66, p-value < 0.001). Other factors that may influence the postoperative course are length of hospital stay and operation time. Smoking, peptic ulcer diseases and co-existence of hiatal hernia were found to be an independent predictors of late complications.

CONCLUSIONS

Smoking is associated with the higher risk of both, early and late complications, while hypercholesterolemia with only <30 days complications after laparoscopic sleeve gastrectomy.

The impact of severe postoperative complications on outcomes of bariatric surgery-multicenter case-matched study

BACKGROUND

Bariatric surgery has relatively low complication rates, especially severe postoperative complications (defined by Clavien-Dindo classification as types 3 and 4), but these rates cannot be ignored. In other than bariatric surgical disciplines, complications affect not only short-term but also long-term results. In the field of bariatric surgery, this topic has not been extensively studied.

OBJECTIVES

The aim of the study was to assess the outcomes of bariatric treatment in patients with obesity and severe postoperative complications in comparison to patients with a noneventful perioperative course.

SETTING

Six surgical units at Polish public hospitals.

METHODS

We performed a multicenter propensity score matched analysis of 206 patients from 6 Polish surgical units and assessed the outcomes of bariatric procedures. A total of 103 patients with severe postoperative complications (70 laparoscopic sleeve gastrectomy [SG] and 33 with laparoscopic Roux en Y gastric bypass [RYGB]) were compared to 103 patients with no severe complications in terms of peri- and postoperative outcomes.

RESULTS

The outcomes of bariatric treatment did not differ between compared groups. Median percentage of total weight loss 12 months after the surgery was 28.8% in the group with complications and 27.9% in patients with no severe complications (P = 0.993). Remission rates of both type 2 diabetes mellitus and arterial hypertension showed no significant difference between SG and RYGB (36% versus 42%, P = 0.927, and 41% versus 46%, P = 0.575. respectively).

CONCLUSIONS

The study suggests that severe postoperative complications had no significant influence either on weight loss effects or obesity-related diseases remission.

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

BACKGROUND

Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus.

OBJECTIVE

To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed.

DESIGN

A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes.

RESULTS

Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise.

CONCLUSION

Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.

Postoperative Olfaction Alteration Following Laparoscopic Bariatric Surgery

INTRODUCTION

Bariatric surgery is an effective method of treatment for morbid obesity that is known to change nutritional habits. Proper nutrition has an impact on postoperative recovery and outcomes. Diet preferences depend on flavour and olfaction stimuli. Some studies show long-term changes in the sense of smell after bariatric surgery, but little research has addressed olfactory function shortly after surgery. Observations of olfactory changes that occur immediately after bariatric surgery may lead to improvements in postoperative care.

AIM

The aim of this study is to investigate the impact of bariatric surgery on olfactory changes in the short postoperative period.

MATERIAL AND METHODS

This is a prospective study of patients undergoing laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) between April 2018 and December 2018. The control group consists of patients who underwent various non-oncological elective surgical procedures. Patients' olfaction was tested qualitatively and quantitatively the day before and 24 h after surgery. Sniffin Sticks test consists of three subtests: odor threshold, discrimination, and identification.

RESULTS

The study enrolled 83 patients (LSG = 39; LRYGB = 14; control = 30). Mean scores in the threshold subtest differed significantly in the bariatric group, 9.3 ± 3.9 before the surgery and 8.2 ± 3.0 a day after the surgery (p = 0.032). There were no significant differences between scores from the discrimination subtest, identification subtest and the mean total scores in the bariatric group. There was no observed change in the intensity of the smell in the control group. Analyzing the results of patients undergoing LSG and LRYGB separately, we only showed significant differences in the case of LSG. Mean score from the 1st test (9.12 ± 3.97 vs. 7.75 ± 2.98; p = 0.0339) and mean total score (32.83 ± 5.45 vs. 30.67 ± 4.88; p = 0.0173) differ between repetitive measurements in LSG patients.

CONCLUSIONS

Our study shows deterioration of odor threshold in the bariatric surgery group compared to the control group 24 h after surgery. However, this change occurred only in patients undergoing LSG.

Laparoscopic Sleeve Gastrectomy with Omentopexy: Is It Really a Promising Method?-A Systematic Review with Meta-analysis

Purpose

Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed bariatric procedure worldwide. Omentopexy during LSG is a novel variation of this well-established technique. There are no clear conclusions on indications for this procedure, safeness, and effects of such a method. We aimed to compare the outcomes of laparoscopic sleeve gastrectomy (LSG) with omentopexy (OP) and without omentopexy.

Materials and Methods

We searched the Medline, EMBASE, and Scopus databases up-to June 2020. Full-text articles and conference abstracts were included for further analysis. This review follows the PRISMA guidelines.

Results

Of initial 66 records, only 4 studies (N = 1396 patients) were included in the meta-analysis. Our findings showed that LSG with omentopexy had significantly lowered overall morbidity compared to LSG without omentopexy (RR = 0.38; 95% CI [0.15, 0.94]; p=0.04). Gastric leakage rate (RR = 0.17; 95% CI [0.04, 0.76]; p = 0.02) was also significantly lower in LSG with omentopexy. There were no significant differences between groups in length of hospital stay.

Conclusions

Our meta-analysis showed that LSG with omentopexy may be a feasible procedure for decreasing morbidity and gastric leak rate. However, despite promising results, the procedure needs to be researched more in randomized controlled studies to draw solid conclusions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-021-05327-8.

Type 2 Diabetes Remission 5 Years After Laparoscopic Sleeve Gastrectomy: Multicenter Cohort Study

PURPOSE

Bariatric surgery is no longer considered only as a weight loss surgery but also a way of treating obesity-related comorbidities such as type 2 diabetes mellitus (T2DM). Short-term T2DM remissions in patients undergoing laparoscopic sleeve gastrectomy (LSG) have been shown, but there are very few reports on the mid-term results. We aimed to assess the remission rate of T2DM in obese patients after LSG throughout 5-year follow-up.

MATERIALS AND METHODOLOGY

We performed a retrospective multicenter cohort analysis of 240 patients who underwent LSG. We assessed the remission rate of T2DM 1 year and 5 years after surgery.

RESULTS

Forty-six percent of patients achieved T2DM remission 5 years after LSG. The remission group had better weight loss results (median% of total weight loss 5 years after: 30.1% (22.9-37.0) vs 23.0% (13.7-30.2), p < 0.001) and were significantly younger than the no remission group (43 (38-52) vs 52 (44-58) years, p < 0.001). Duration of T2DM was significantly shorter (2 (1-5) vs 5 (3-10) years, p < 0.001) with less insulin requirement and less diabetes-related complications (7.2% vs 19.8%, p < 0.001) and significantly lower median DiaRem score (4.0 (IQR 2.0-6.0) vs 12.0 (IQR 5.0-16.0), p < 0.001). Preoperative body mass index (BMI) had no effect on remission.

CONCLUSIONS

Our study suggests that diabetes remission after laparoscopic sleeve gastrectomy occurs frequently, and in the 5-year follow-up, it may remain at the level of 46%. We identified the age of patients, duration, and severity of T2DM as factors affecting mid-term diabetes remission. Nevertheless, further well-designed trials are needed to support our findings.

Does the Length of the Common Channel as Part of the Total Alimentary Tract Matter? One Year Results from the Multicenter Dutch Common Channel Trial (DUCATI) Comparing Standard Versus Distal Roux-en-Y Gastric Bypass with Similar Biliopancreatic Bowel Limb Lengths

PURPOSE

Although the laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is the gold-standard bariatric procedure, it remains uncertain what the optimal bowel limb lengths are to accomplish maximal weight loss while minimizing nutritional deficiencies and related gastro-intestinal complaints. The aim of this randomized controlled multicenter trial is to investigate the effect of significant lengthening of the length of the Roux limb (RL) at the cost of the length of the common channel (CC) while keeping the biliopancreatic limb (BPL) lengths the same on both study arms.

METHODS

Four hundred forty-four patients were randomized to receive either a Very Long Roux Limb LRYGB (VLRL-LRYGB) (variable RL length, BPL 60 cm, and CC 100 cm) or a Standard LRYGB (S-LRYGB) (RL 150 cm, BPL 60 cm, and a variable CC length). Results at 1-year follow-up for weight loss, effect on obesity-related comorbid conditions, complications, re-operation rate, malnutrition rate, and re-admission rate were investigated.

RESULTS

Weight loss at 1-year showed no significant differences for %EWL (84.3% versus 85.3%, p = 0.72) and %TWL (34.2% versus 33.6%, p = 0.359) comparing VLRL-LRYGB versus S-LRYGB. Malabsorption requiring surgical bowel length adjustment was observed in 1.4% in VLRL-LRYGB group versus 0.9% in S-LRYGB group (p = 0.316).

CONCLUSION

Significant lengthening of the RL at the cost of the common channel seems to have no effect on the weight loss at 1-year follow-up, which supports the theory that absorption of nutrients also occurs in the RL. Nevertheless, long-term results of the VLRL-LRYGB have to be awaited to draw final conclusions as part of the discussion towards optimal limb length in LRYGB surgery.

Integrative genomics reveal a role for MCPIP1 in adipogenesis and adipocyte metabolism

Obesity is considered a serious chronic disease, associated with an increased risk of developing cardiovascular diseases, non-alcoholic fatty liver disease and type 2 diabetes. Monocyte chemoattractant protein-1-induced protein-1 (MCPIP1) is an RNase decreasing stability of transcripts coding for inflammation-related proteins. In addition, MCPIP1 plays an important role in the regulation of adipogenesis in vitro by reducing the expression of key transcription factors, including C/EBPβ. To elucidate the role of MCPIP1 in adipocyte biology, we performed RNA-Seq and proteome analysis in 3T3-L1 adipocytes overexpressing wild-type (WTMCPIP1) and the mutant form of MCPIP1 protein (D141NMCPIP1). Our RNA-Seq analysis followed by confirmatory Q-RT-PCR revealed that elevated MCPIP1 levels in 3T3-L1 adipocytes upregulated transcripts encoding proteins involved in signal transmission and cellular remodeling and downregulated transcripts of factors involved in metabolism. These data are consistent with our proteomic analysis, which showed that MCPIP1 expressing adipocytes exhibit upregulation of proteins involved in cellular organization and movement and decreased levels of proteins involved in lipid and carbohydrate metabolism. Moreover, MCPIP1 adipocytes are characterized by decreased level of insulin receptor, reduced insulin-induced Akt phosphorylation, as well as depleted Glut4 level and impaired glucose uptake. Overexpression of Glut4 in 3T3-L1 cells expressed WTMCPIP1 rescued adipogenesis. Interestingly, we found decreased level of MCPIP1 along with an increase in body mass index in subcutaneous adipose tissue. The presented data show a novel role of MCPIP1 in modulating insulin sensitivity in adipocytes. Overall, our findings demonstrate that MCPIP1 is an important regulator of adipogenesis and adipocyte metabolism.

Metabolic syndrome and liver disease in the era of bariatric surgery: What you need to know!

Metabolic syndrome (MS) is defined as the constellation of obesity, insulin resistance, high serum triglycerides, low high-density lipoprotein cholesterol, and high blood pressure. It increasingly affects more and more people and progressively evolves into a serious issue with widespread healthcare, cost, and quality of life associated consequences. MS is associated with increased morbidity and mortality due to cardiovascular or chronic liver disease. Conservative treatment, which includes diet, exercise, and antidiabetic agents, is the mainstay of treatment, but depends on patient compliance to medical treatment and adherence to lifestyle modification recommendations. Bariatric surgery has recently emerged as an appropriate alternative treatment with promising long-term results. Sleeve gastrectomy and Roux-en-Y gastric bypass constitute the most commonly performed procedures and have been proven both cost-effective and safe with low complication rates. Liver transplantation is the only definitive treatment for end-stage liver disease and its utilization in patients with non-alcoholic steatohepatitis has increased more than fivefold over the past 15 years. In this review, we summarize current state of evidence on the surgical treatment of MS.

Influence of Preoperative Weight Loss on Outcomes of Bariatric Surgery for Patients Under the Enhanced Recovery After Surgery Protocol

INTRODUCTION

The enhanced recovery after surgery (ERAS) protocol, which emphasizes preoperative interventions, is safely implemented in patients undergoing bariatric surgery. Patients are additionally encouraged to achieve weight loss preoperatively. We aimed to identify factors contributing to preoperative weight loss and assess their influence on outcomes of bariatric surgery among patients under the ERAS protocol.

MATERIALS AND METHODS

We reviewed a prospectively created database in two bariatric centers with 909 bariatric patients treated in accordance with ERAS principles. The database included demographic characteristics, factors related to the surgery or perioperative period, and short-term outcomes. Our endpoints included analyses of (1) factors potentially contributing to preoperative weight loss and (2) the influence of preoperative weight loss on short-term outcomes of bariatric treatment.

RESULTS

Diabetes mellitus (p = 0.007), obstructive sleep apnea (p < 0.001), and previous surgery (p = 0.012) were identified as predictors of preoperative weight loss. Steatohepatitis (p < 0.001) and respiratory disorder (p = 0.004) decreased the chance of achieving satisfactory preoperative body mass reduction. Except for operative time, early outcomes of bariatric surgery were not influenced by preoperative weight loss. Patients who achieved preoperative weight loss were less likely to be lost to follow-up (p = 0.023). Postoperative weight loss was better in patients who could lose ≥ 5% total weight preoperatively (p = 0.009).

CONCLUSION

Unsatisfactory preoperative weight loss among patients treated under ERAS principles is not associated with increased risk of complications. Satisfactory preoperative weight loss predicts superior postoperative weight loss and follow-up participation.

The Influence of Surgical Experience on Postoperative Recovery in Fast-Track Bariatric Surgery

INTRODUCTION

Short duration of surgery is an important aspect in fast-track protocols. Peroperative training of surgical residents could influence the duration of surgery, possibly affecting patient outcome. This study evaluates the influence of the operator's level of experience on patient outcome in fast-track bariatric surgery.

METHODS

Data was analyzed of all patients who underwent a primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) between January 2004 and July 2018. Residents were trained according to a stepwise training program. For each operator, learning curves of both procedures were created by dividing the procedures in time-subsequent groups (TSGs). Data was also analyzed by comparing "beginners" with "experienced operators," with a cut-off point at 100 procedures. Primary outcome measure was duration of surgery. Secondary outcome measures were length of hospital stay (LOS), complications, and readmission rate within 30 days postoperatively.

RESULTS

There were 4901 primary procedures (53.1% LSG) performed by seven surgeons or surgical residents. We found no difference between beginning and experienced operators in complications or readmissions rates. The experience of the operator did not influence LOS (p = 0.201). Comparing each new operator with previous operator(s), the starting point in terms of duration of surgery was shorter, and the learning curve was steeper. The duration of surgery was significantly longer for supervised beginning operators as compared with experienced operators.

CONCLUSION

Within the stepwise training program for residents, there is a slight increase in duration of surgery in the beginning of the learning curve, without affecting the patient outcome.

The influence of bariatric surgery on serum levels of irisin and nesfatin-1

Introduction: Bariatric surgery is associated with multiple endocrine and metabolic changes. Irisin and nesfatin-1 have recently been described as regulatory peptides involved in obesity-related insulin resistance. Our aim was to analyze the changes of those two molecules observed in patients after bariatric procedures. Materials and methods: This prospective study involved 40 patients treated for morbid obesity. Irisin and nesfatin-1 were measured before, 6 months and 1 year after surgical intervention. We also gathered demographic data, information concerning comorbidities, factors related to the surgery and outcomes of bariatric treatment. Results: Twenty-seven patients completed the study (15 females). The mean age of the group was 43.5 ± 10.4 years. Six (22.2%) patients were submitted to Laparoscopic Sleeve Gastrectomy and 21 (77.8%) patients were submitted to Laparoscopic Roux-en-Y Gastric Bypass. The participants in our study achieved significant weight loss. The irisin level remained stable in the whole study group during all three measurements included in our study protocol (p = .71). Our study group presented a reduction of the nesfatin-1 level 6 months after bariatric surgery and a slight further decrease after one-year observation, although these changes were also not significant (p = .17). Conclusions: We did not find any significant correlation between changes of irisin or nesfatin-1 level and bariatric surgery, as an aid in the regulation of glucose metabolism.

Analysis of Laparoscopic Sleeve Gastrectomy Learning Curve and Its Influence on Procedure Safety and Perioperative Complications

PURPOSE

Laparoscopic sleeve gastrectomy (LSG) has become an attractive bariatric procedure with promising treatment effects yet amount of data regarding institutional learning process is limited.

MATERIALS AND METHODS

Retrospective study included patients submitted to LSG at academic teaching hospital. Patients were divided into groups every 100 consecutive patients. LSG introduction was structured along with Enhanced Recovery after Surgery (ERAS) treatment protocol. Primary endpoint was determining the LSG learning curve's stabilization point, using operative time, intraoperative difficulties, intraoperative adverse events (IAE), and number of stapler firings. Secondary endpoints: influence on perioperative complications and reoperations. Five hundred patients were included (330 females, median age of 40 (33-49) years).

RESULTS

Operative time in G1-G2 differed significantly from G3-G5. Stabilization point was the 200th procedure using operative time. Intraoperative difficulties of G1 differed significantly from G2-G5, with stabilization after the 100th procedure. IAE and number of stapler firings could not be used as predictor. Based on perioperative morbidity, the learning curve was stabilized at the 100th procedure. The morbidity rates in the groups were G1, 13%; G2, 4%; G3, 5%; G4, 5%; and G5, 2%. The reoperation rate in G1 was 3%; G2, 2%; G3, 2%; G4, 1%; and G5, 0%.

CONCLUSION

The institutional learning process stabilization point for LSG in a newly established bariatric center is between the 100th and 200th operation. Initially, the morbidity rate is high, which should concern surgeons who are willing to perform bariatric surgery.

Postoperative Care and Functional Recovery After Laparoscopic Sleeve Gastrectomy vs. Laparoscopic Roux-en-Y Gastric Bypass Among Patients Under ERAS Protocol

Background

The most commonly performed bariatric procedures are laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). There are major differences between LSG and LRYGB during postoperative period. Optimization of the postoperative care may be achieved by using enhanced recovery after surgery (ERAS) protocol, which allows earlier functional recovery.

Purpose

The aim was to assess differences in the course of postoperative care conducted in accordance with ERAS protocol among patients after LSG and LRYGB.

Material and Methods

Data concerning patients treated for morbid obesity were prospectively gathered in one academic center. Patients were divided into two groups: LSG (n = 364, 63.41%) and LRYGB (n = 210, 36.59%). Multiple factors were used as endpoints to determine the influence of the type of bariatric procedure on postoperative course.

Results

The rate of postoperative nausea and vomiting and incidence of intravenous fluid administration during the operation was higher in LSG group. LRYGB patients were able to tolerate higher oral fluid intake volumes during the first and the second postoperative day. Mean diuresis during the second and the third postoperative day was significantly higher in LRYGB group. Administration of diuretics and painkillers was comparable between groups, while the risk of fever after the operation was higher in LRYGB group. Mean length of stay was higher in LSG group (LRYGB vs. LSG, 3.46 days ± 1.58 vs. 3.64 days ± 4.41, p = 0.039).

Conclusions

In our opinion, postoperative treatment after LSG requires more supervision and longer time until functional recovery is achieved.

Impact of age on postoperative outcomes in bariatric surgery

BACKGROUND

Age is often related to the increase of perioperative complications and reoperation rates. The authors aimed to determine the influence of age on outcomes of most commonly performed bariatric procedures.

METHODS

The retrospective study included patients qualified for primary Laparoscopic Sleeve Gastrectomy (LSG) or Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) in two academic hospitals. Patients were divided into two groups: ≥50 (21.2-26.9%) and <50 (57.6-73.1%) years old. Endpoints assessed the influence of patients' age on the perioperative and the one-year postoperative period.

RESULTS

Operative time was longer in the ≥50-year-old group, but only for LRYGB. There were no differences in the intraoperative adverse events, postoperative morbidity, reoperation and readmission rates between the groups. The risk of port site hernia was increased (OR: 4.23, CI: 1.49-12.06) in the ≥50-year-old group. The mean % of total weight loss 12 months after the bariatric procedure was comparable, but % of excess weight loss and % of excess body mass index loss were lower in the ≥50-year-old group (p = .033 and .032).

CONCLUSIONS

Bariatric surgery is safe and feasible in patients over 50 years old. The weight loss effect can be worse among patients over 50 years old; nevertheless, the treatment should be considered as effective.

Bariatric patients' nutritional status as a risk factor for postoperative complications, prolonged length of hospital stay and hospital readmission: A retrospective cohort study

BACKGROUND

The prevalence of obesity is growing worldwide. Malnutrition has been identified as a risk factor, leading to higher morbidity rate and prolonged length of hospital. So far there are no high quality data on the impact of malnutrition on length of hospital stay and morbidity regarding bariatric surgery. The aim of the study was to assess association between nutritional status and outcomes bariatric surgeries.

MATERIAL AND METHODS

The study was a prospective observational study.

INCLUSION CRITERIA

informed consent to participate in the study, age 18-65 years, meeting the eligibility criteria for bariatric treatment, qualification for laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y Gastric By-pass (LRYGB).

EXCLUSION CRITERIA

revision surgery, lack of necessary data. The primary endpoint was the evaluation of protein malnutrition risk prevalence. Secondary: influence of malnutrition risk patients' on treatment course and postoperative complications.

RESULTS

533 patients met inclusion criteria and were analyzed. 169 patients (32%) had qualitative risk of malnutrition. The body mass index (BMI) was significantly higher in malnutritioned group, p = 0.001. Albumins in malnutritioned group was 38 g/l (IQR 35-42), whereas in control group it was 41 g/l (IQR 39-43), p = 0.027. Lymphocyte count in malnutrition risk group and control group were 1.24 10'3/μl (IQR 1.1-1.37) and 1.94 10'3/μl (IQR1.7-2.3) respectively, p < 0.001. In linear regression model, a correlation between BMI and total number of lymphocytes was present, p < 0.001. Malnutrition risk did not affect the total morbidity rate. There was a difference in occurrence of postoperative nausea and vomiting, p = 0.033.

CONCLUSIONS

Higher BMI is associated with greater risk of malnutrition. Proper perioperative care may diminish the impact of malnutrition on adverse effects and length of stay (LOS).

Does previous abdominal surgery affect the course and outcomes of laparoscopic bariatric surgery?

BACKGROUND

Global experiences in general surgery suggest that previous abdominal surgery may negatively influence different aspects of perioperative care. As the incidence of bariatric procedures has recently increased, it is essential to assess such correlations in bariatric surgery.

OBJECTIVES

To assess whether previous abdominal surgery influences the course and outcomes of laparoscopic bariatric surgery.

SETTING

Seven referral bariatric centers in Poland.

METHODS

We conducted a retrospective analysis of 2413 patients; 1706 patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) matched the inclusion criteria. Patients with no history of abdominal surgery were included as group 1, while those who had undergone at least 1 abdominal surgery were included as group 2.

RESULTS

Group 2 had a significantly prolonged median operation time for RYGB (P = .012), and the longest operation time was observed in patients who had previously undergone surgeries in both the upper and lower abdomen (P = .002). Such a correlation was not found in SG cases (P = .396). Groups 1 and 2 had similar rates of intraoperative adverse events and postoperative complications (P = .562 and P = .466, respectively). Group 2 had a longer median duration of hospitalization than group 1 (P = .034), while the readmission rate was similar between groups (P = .079). There was no significant difference between groups regarding the influence of the long-term effects of bariatric treatment on weight loss (percentage of follow-up was 55%).

CONCLUSIONS

Previous abdominal surgery prolongs the operative time of RYGB and the duration of postoperative hospitalization, but does not affect the long-term outcomes of bariatric treatment.

Management of Slipped Gastric Bands via Creation of a De Novo Tunnel and Band Replacement: a Single-Centre Experience

BACKGROUND

A lack of clarity remains over the optimal strategy for the management of laparoscopic adjustable gastric band (LAGB) slippage, which, although rare (around 3% in our experience), can when acute result in obstruction, gastric erosion or ischaemia. Typically, slipped bands are removed acutely. The aim of this study was to explore outcomes following immediate or delayed resiting of slipped LAGBs in a single centre, comparing simple repositioning with retunnelling and replacement.

METHODS

A retrospective analysis of computerised records, notes and prospectively maintained bariatric databases was undertaken to identify all patients with a slipped LAGB in a single centre.

RESULTS

Thirty-two patients required operative intervention following a diagnosis of slipped LAGB (median time from initial LAGB insertion to slippage 2.9 years). Two (6%) patients underwent band removal and 30 (94%), band revision surgery (25 immediately and five at a planned but expedited procedure).Twenty-four (77%) patients underwent insertion of a new LAGB via a de novo retrogastric tunnel, five (21%) of which required further future operative intervention; whereas, six (23%) patients underwent repositioning of the existing LAGB within the same tunnel, five (83%) of which underwent further operative intervention (log-rank test p = 0.0001). Following LAGB revision, there was no significant further change in BMI (median + 1 kg/m²; range - 13 to + 10 kg/m²).

CONCLUSION

Resiting of slipped LAGBs is safe and maintains weight loss. Although a significant risk of future operative intervention remains, this can be reduced via the creation of a de novo retrogastric tunnel for band resiting.