Short-term outcomes for super-super obese (BMI > or =60 kg/m2) patients undergoing weight loss surgery at a high-volume bariatric surgery center: laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and open tubular gastric bypass

Obesity And Cash Rewards

In a multi-phase randomized controlled trial, we examine the impacts of cash rewards of EUR 150 and EUR 300 for reducing body weight on the likelihood of weight loss and weight-related behavioral change among 700 obese individuals. We find effects during all experimental phases, including 18 months after exposure to the incentives. Additional monetary rewards of EUR 250 and EUR 500 provided to participants who had lost a substantial amount of body weight exerted only short-term effects.

Scientific Evidence for the Updated Guidelines on Indications for Metabolic and Bariatric Surgery (IFSO/ASMBS)

The 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) updated the indications for Metabolic and Bariatric Surgery (MBS), replacing the previous guidelines established by the NIH over 30 years ago. The evidence supporting these updated guidelines has been strengthened to assist metabolic and bariatric surgeons, nutritionists, and other members of multidisciplinary teams, as well as patients. This study aims to assess the level of evidence and the strength of recommendations compared to the previously published criteria.

Scientific evidence for the updated guidelines on indications for metabolic and bariatric surgery (IFSO/ASMBS)

The 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) updated the indications for metabolic and bariatric surgery (MBS), replacing the previous guidelines established by the National Institutes of Health (NIH) over 30 years ago. The evidence supporting these updated guidelines has been strengthened to assist metabolic and bariatric surgeons, nutritionists, and other members of multidisciplinary teams (MDTs), as well as patients. This study aims to assess the level of evidence and the strength of recommendations compared to the previously published criteria.

BMI ≥ 70: A Multi-Center Institutional Experience of the Safety and Efficacy of Metabolic and Bariatric Surgery Intervention

PURPOSE

With the escalating prevalence of obesity, healthcare providers are increasingly managing patients with a body mass index (BMI) exceeding 70. The aim of this study was to describe the perioperative experiences of this demographic group at two institutions.

METHODS

An analysis encompassing 84 patients presenting with BMI ≥ 70 kg/m2 from two institutions was conducted. Data included patient demographics, 30-day postoperative outcomes, and weight-loss at different intervals (30 days, 6 months, 1 year). Additionally, rates of emergency department (ED) utilization, readmission, and reoperation in the first postoperative year were examined.

RESULTS

Most patients were black (66.7%) and female (86.9%) with a mean age of 41.7 years. The majority underwent laparoscopic sleeve gastrectomy (SG, 88.1%). Patients exhibited a marked decrease in BMI (7.84% at 30 days, 20.13% at 6 months, and 26.83% at 1 year). Average length of stay was comparable across procedure (F(3,80) = 0.016, p = .997). While 30-day complications were minimal (0.7%), 14.4% of patients experienced ED visits within 30 days, escalating to 19.6% by six months and 25% at 1 year. Readmission and reoperation rates at 1 year were 6.45% and 4.83%, respectively.

CONCLUSION

With global obesity rates rising, clinicians are being challenged to care for patients with BMI ≥ 70 kg/m2. Analysis of two institutions demonstrated low rates of 30-days complications but increased readmission rates and ED utilization in this patient population. Despite increased resource utilization, the study suggests that BMI ≥ 70 kg/m2 alone should not be a deterrent for surgery, emphasizing the need for nuanced care in this expanding demographic.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60 kg/m2): a Modified Delphi Study

BACKGROUND

Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60 kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology.

METHODS

A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70% of experts' votes was achieved.

RESULTS

A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations.

CONCLUSION

This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population.

Bariatric Surgery in Obesity: Metabolic Quality Analysis and Comparison of Surgical Options

Obesity is a constantly growing health problem which reduces quality of life and life expectancy. Bariatric surgery (BS) for obesity is considered when all other conservative treatment modalities have failed. Comparison of the multidisciplinary programs with BS regarding to the weight loss showed that substantial and durable weight reduction have been achieved only with bariatric surgical treatments. Although laparoscopic sleeve gastrectomy is the most popular BS, it has high long-term failure rates, and it is claimed that one of every three patients will undergo another bariatric procedure within a 10-year period. Although BS provides weight loss and improvement of metabolic comorbidities, in long-term follow-up, weight gain is observed in half of the patients, while decrease in bone mass and nutritional deficiencies occur in up to 90%. Moreover, despite significant weight loss, several psychological aspects of patients are worsened in comparison to preoperative levels. Nearly one-fifth of postoperative patients with "Loss-of-eating control" meet food addiction criteria. Therefore, the benefits of weight loss following bariatric procedures alone are still debated in terms of the proinflammatory and metabolic profile of obesity.

Nutrition, Physical Activity, and Prescription of Supplements in Pre- and Post-bariatric Surgery Patients: An Updated Comprehensive Practical Guideline

Only in the USA, 315 billion dollars are spent annually on the medical cost of obesity in adult patients. Till now, bariatric surgery is the most effective method for treating obesity and can play an essential role in reducing the direct and indirect costs of obesity treatment. Nonetheless, there are few comprehensive guidelines which include nutrition, physical activity, and supplements, before and after surgery. The purpose of the present narrative review is to provide an updated and comprehensive practical guideline to help multidisciplinary teams. The core keywords include nutrition, diet, physical activity, exercise, supplements, macronutrients, micronutrients, weight reduction, bariatric surgery, Roux-en-Y Gastric Bypass, Sleeve Gastrostomy, Laparoscopic Adjustable Gastric Banding, and Biliopancreatic diversion with duodenal switch which were searched in databases including PubMed/Medline, Cochrane, and some other sources such as Google Scholar. We answered questions in five important areas: (a) nutritional strategies before bariatric surgery, (b) nutrition after bariatric surgery, (c) physical activity before and after bariatric surgery, (d) weight regain after bariatric surgery, and (e) micronutrient assessments and recommendations before and after bariatric surgery. Some new items were added in this updated guideline including "weight regain" and "pregnancy after bariatric surgery." Other fields were updated based on new evidence and guidelines.

Very Low-Calorie Ketogenic Diet (VLCKD) as Pre-Operative First-Line Dietary Therapy in Patients with Obesity Who Are Candidates for Bariatric Surgery

Bariatric surgery is currently the most effective method for achieving long-term weight loss and reducing the risk of comorbidities and mortality in individuals with severe obesity. The pre-operative diet is an important factor in determining patients' suitability for surgery, as well as their post-operative outcomes and success in achieving weight loss. Therefore, the nutritional management of bariatric patients requires specialized expertise. Very low-calorie diets and intragastric balloon placement have already been studied and shown to be effective in promoting pre-operative weight loss. In addition, the very low-calorie ketogenic diet has a well-established role in the treatment of obesity and type 2 diabetes mellitus, but its potential role as a pre-operative dietary treatment prior to bariatric surgery has received less attention. Thus, this article will provide a brief overview of the current evidence on the very low-calorie ketogenic diet as a pre-operative dietary treatment in patients with obesity who are candidates for bariatric surgery.

2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) Indications for Metabolic and Bariatric Surgery

MAJOR UPDATES TO 1991 NATIONAL INSTITUTES OF HEALTH GUIDELINES FOR BARIATRIC SURGERY: Metabolic and bariatric surgery (MBS) is recommended for individuals with a body mass index (BMI) >35 kg/m2, regardless of presence, absence, or severity of co-morbidities.MBS should be considered for individuals with metabolic disease and BMI of 30-34.9 kg/m2.BMI thresholds should be adjusted in the Asian population such that a BMI >25 kg/m2 suggests clinical obesity, and individuals with BMI >27.5 kg/m2 should be offered MBS.Long-term results of MBS consistently demonstrate safety and efficacy.Appropriately selected children and adolescents should be considered for MBS.(Surg Obes Relat Dis 2022; https://doi.org/10.1016/j.soard.2022.08.013 ) © 2022 American Society for Metabolic and Bariatric Surgery. All rights reserved.

2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery

Major updates to 1991 National Institutes of Health guidelines for bariatric surgery.

A Single-Center Experience: What is the Effect of Sleeve Gastrectomy in Patients With a BMI ≥ 50 kg/m²?

BACKGROUND

Our research aimed to see how sleeve gastrectomy (SG) affects weight loss and comorbidities in patients with a body mass index (BMI) ≥ 50 kg/m².

MATERIALS AND METHODS

Prospectively kept data of patients with a BMI ≥50 kg/m² who underwent SG between February 2016 and February 2020 were evaluated.

RESULTS

A total of 138 patients with a BMI ≥ 50 kg/m² were operated on. The average BMI was 56.36±7.661, the average age was 37.41±12.33. Forty-eight patients underwent concomitant cholecystectomy and/or hiatal hernia repair (HHR). The percentage of excess weight loss (EWL%) of patients at the 3rd, 6th, 12th, 18th, and 24th months were 36%, 54%, 67%, 72%, and 74%, respectively. Mean BMI values of the 0th, 3rd, 6th, 12th, 18th, and 24th months were 56, 45, 39, 35, 33, and 33, respectively. 0th, 3rd, 6th, 12th, 18th, and 24th months were significantly different for EWL%, total weight loss (TWL%), and BMI variables (p<0.001), but EWL% (p=0.527), TWL% (p=0.396) and BMI (p=0,657) were not found significantly different between the 18th and 24th months. When EWL% ≥ 50 was accepted, the success rate was 93% (n=93) and 92% (n=50) at the 18th and 24th months, respectively. While there was 82% remission in type 2 diabetes mellitus (DM) and 90% in hypertension (HT), the remission rate in patients with obstructive sleep apnea syndrome (OSAS) and gastroesophageal reflux disease (GERD) undergoing HHR was 100%.

CONCLUSIONS

In patients with a BMI ≥ 50 kg/m², SG seems to be an effective and safe therapy option as the first line for weight loss and treatment of comorbid diseases. Further long-term studies are needed to confirm these results.

Outcome of Sleeve Gastrectomy Versus Roux-en-Y Gastric Bypass for Patients with Super Obesity (Body Mass Index > 50 kg/m2)

PURPOSE

With increasing BMI, the complexity of treating patients with obesity rises. The focus of this study is to investigate the effects of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on perioperative morbidity and remission of comorbidities at 3 years in patients with a BMI > 50 kg/m².

MATERIALS AND METHODS

A retrospective multicenter analysis of a prospectively maintained database was performed to enroll patients with a 3-year follow-up after SG or RYGB between 2005 and 2019 and a BMI of > 50 kg/m² preoperatively. Patients' BMI and comorbidity status were recorded preoperatively.

RESULTS

We analyzed data from 2939 patients who had at least a preoperative BMI > 50 kg/m². A total of 1278 patients underwent RYGB surgery, and 1661 underwent SG. The distribution of sex, BMI, hypertension, reflux, and sleep apnea was significant between the two groups. Three years after surgery, the percent excess weight loss (%EWL) was 62.21% in RYGB and 55.87% in SG (p < 0.001). The change in hypertension (p < 0.001) and reflux (p < 0.001) was significantly in favor of RYGB. The change in diabetes mellitus was not significant between the two groups (p > 5%). There was a minimal difference in sleep apnea in favor of SG (p < 0.001). Mortality and overall complication rates were not significant in either group.

CONCLUSION

Both procedures positively affected comorbidities, BMI, and %EWL in patients with super obesity 3 years after surgery. In some categories, RYGB was better than SG. Nevertheless, the decision between the two methods remains a matter of the surgeon's experience and the patient's general condition.

Clinical outcomes after one anastomosis gastric bypass versus sleeve gastrectomy in super-super-obese patients

BACKGROUND

Bariatric surgery in super-super-obese (SSO) patients remains a continuous challenge due to intraabdominal fat masses, higher liver volume and existing comorbidities. A convenient procedure in SSO patients is one anastomosis gastric bypass (OAGB). The aim of this study was to compare the outcome of SSO patients undergoing OAGB in comparison to laparoscopic sleeve gastrectomy (LSG).

METHODS

We retrospectively reviewed data from SSO patients who underwent OAGB and LSG in our institution between 2008 and 2020. Primary endpoints included percentage total body weight loss and percentage BMI loss at 12, 24, and 36 months after the operation. Secondary endpoints were perioperative complications, procedure length, length of hospital stay and outcome of comorbidities.

RESULTS

243 patients were included in this study. 93 patients underwent LSG and 150 underwent OAGB. At any of the time points evaluated, weight loss in patients after OAGB was greater than in LSG patients, while procedure length was significantly shorter for OAGB than LSG (81.4 vs. 92.1 min, p-value < 0.001). Additionally, mean length of hospital stay was shorter in the OAGB group (3.4 vs. 4.5 days, p-value < 0.001). There were more severe complications (Clavien-Dindo ≥ 3a) in the LSG group (11.8% vs 2.7%, p-value = 0.005).

CONCLUSION

In this retrospective analysis, OAGB was superior to LSG in terms of weight loss in SSO patients. Procedure length and hospital stay were shorter after OAGB in comparison to LSG and there were fewer severe complications. OAGB can therefore be regarded a safe and effective treatment modality for SSO patients.

Metabolic surgery in treatment of obese Japanese patients with type 2 diabetes: a joint consensus statement from the Japanese Society for Treatment of Obesity, the Japan Diabetes Society, and the Japan Society for the Study of Obesity

Bariatric surgery has been shown to have a variety of metabolically beneficial effects for patients with type 2 diabetes (T2D), and is now also called metabolic surgery. At the 2nd Diabetes Surgery Summit held in 2015 in London, the indication for bariatric and metabolic surgery was included in the “algorithm for patients with type T2D”. With this background, the Japanese Society for Treatment of Obesity (JSTO), the Japan Diabetes Society (JDS) and the Japan Society for the Study of Obesity (JASSO) have formed a joint committee to develop a consensus statement regarding bariatric and metabolic surgery for the treatment of Japanese patients with T2D. Eventually, the consensus statement was announced at the joint meeting of the 38th Annual Meeting of JSTO and the 41st Annual Meeting of JASSO convened in Toyama on March 21, 2021. In preparing the consensus statement, we used Japanese data as much as possible as scientific evidence to consider the indication criteria, and set two types of recommendation grades, “recommendation” and “consideration”, for items for which recommendations are possible. We hope that this statement will be helpful in providing evidence-based high-quality care through bariatric and metabolic surgery for the treatment of obese Japanese patients with T2D.

Ten year comparative analysis of sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch in patients with BMI ≥ 50 kg/m2

INTRODUCTION

Bariatric surgery is the most effective modality to stably reduce weight and related comorbidities in patients suffering from class II and III obesity. Data comparing long-term safety and efficacy of the three most effective bariatric operations are limited in patients with BMI ≥ 50 kg/m², which complicate shared surgeon-patient decision making regarding optimal procedure selection.

METHODS

A retrospective analysis was performed on all patients with BMI ≥ 50 kg/m² who underwent biliopancreatic diversion with duodenal switch (BPD/DS), Roux-en-Y gastric bypass (RYGB), or sleeve gastrectomy (SG) at our institution between 2009 and 2019. Data collected from patients' electronic medical records included operative details as well as BMI and presence and resolution of obesity-related comorbidities at 0, 6, 12, 24, 48, and 60 months post-operatively.

RESULTS

Among 537 patients with BMI ≥ 50 kg/m² who had a primary bariatric procedure, 93 patients underwent BPD/DS (17.3%), 341 patients underwent RYGB (63.5%), and 103 patients underwent SG (19.2%). BMI decreased by 23.7 kg/m² in BPD/DS, 14.7 kg/m² in RYGB, and 13.6 kg/m² in SG cohorts at 60 months post-operatively (p < 0.0001). The greatest %TWL occurred in BPD/DS cohort (38.4%) followed by the RYGB (26.3%) and SG (23.6%) cohorts (p < 0.0001). The thirty-day complication rate was 12.9% for BPD/DS, 4.7% for RYGB, and 8.7% for SG (p = 0.015).

CONCLUSIONS

Our study demonstrated that the BPD/DS is the most effective operation at long-term reduction of BMI and achieved highest %TWL while SG and RYGB had similar results at 60 months post-op. BPD/DS is associated with increased early and late surgical complications compared to RYGB and SG.

Outcomes of bariatric surgery in extreme obesity: results from the United Kingdom National Bariatric Surgery Registry for patients with a body mass index >70 kg/m2

BACKGROUND

Bariatric and metabolic surgery (BMS) is an established safe, effective, and durable treatment for obesity and its complications. However, there is still a paucity of evidence on surgery outcomes in patients suffering from extreme obesity.

OBJECTIVES

This study aimed to evaluate outcomes of BMS in weight loss and the resolution of co-morbidities in patients with a body mass index (BMI) ≥70kg/m2.

SETTING

National Health Service and private hospitals in the United Kingdom.

METHODS

This cohort study analyzed prospectively collected records from the UK National Bariatric Surgery Registry of patients with a BMI ≥70 kg/m2 undergoing Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), or adjustable gastric band (AGB) between January 2009 and June 2014.

RESULTS

There were 230 patients (64% female) eligible for inclusion in the study: 22 underwent AGB; 102 underwent SG, and 106 underwent RYGB. Preoperative weight and BMI values were comparable (76 ± 7 kg/m2 for AGB; 75 ± 5 kg/m2 for SG; 74 ± 5 kg/m2 for RYGB). The median postoperative follow-up was 13 months for AGB (10-22 mo), 18 for SG (6-28 mo), and 15 for RYGB (6-24 mo). Patients undergoing RYGB and SG exhibited the greatest postoperative total body weight loss (35 ± 13% and 31 ± 15%, respectively; P = .14), which led to postoperative BMIs of 48 ± 10 kg/m2 and 51 ± 11 kg/m2, respectively (P = .14). All procedures conferred a reduction in the incidence of co-morbidities, including type 2 diabetes, and led to improved functional statuses. The overall complication rate was 7%, with 3 deaths (1%) within 30 days of surgery.

CONCLUSION

This study found that primary BMS in patients with a BMI >70kg/m2 has an acceptable safety profile and is associated with good medium-term clinical outcomes. RYGB and SG are associated with better weight loss and great improvements in co-morbidities than AGB. Given the noninferiority of SG outcomes and SG's potential for further conversion to other BMS procedures if required, SG may be the best choice for primary BMS in patients with extreme obesity.

Outcomes of Bariatric Surgery: Patients with Body Mass Index 60 or Greater

Introduction:

Perioperative outcomes of bariatric surgery in patients with super super obesity (SSO) (BMI ≥ 60 kg/m²) merit further investigation.

Methods:

A retrospective review was conducted of patients with SSO who underwent surgery from Jun 2005 through Jun 2018 at a Metabolic and Bariatric Surgery Center of Excellence. Quantitative demographic data was summarized using descriptive statistics; categorical variables were compared using Fisher’s exact test.

Results:

Two hundred fourteen procedures were performed, of which 208 were eligible for inclusion. Majority were female (65.4%). The mean age and BMI was 43 (17–68 years) and 65.9 kg/m² (60 95 kg/m²), respectively. Comorbidities included: obstructive sleep apnea (74%), hypertension (59%), gastro-esophageal reflux disease (43%), osteoarthritis (41%), and diabetes mellitus (30%). Surgical approach: 97 Roux-en-Y gastric bypasses (46%), 88 laparoscopic sleeve gastrectomies (42%), and 23 adjustable gastric bands (11%). Additional subset included: primary (87%), conversion (7.7%), and revision (5.3%); majority being laparoscopic (75%) and robotic (24%). Complications via Clavien-Dindo classification: one Grade I, one Grade II, three Grade IIIa, three Grade IIIb, and three Grade IVa. Thirty-day events: 11 complications (5.3%; one leak [0.5%], one deep vein thrombosis [0.5%]), six re-admissions (3%), four re-operations (2%): repair of staple-line leak, repair of incisional hernia, uterine dilation and curettage, and cholecystectomy. No mortalities occurred. Complications occurred in 14.8% of conversion/revision cases, 3.9% in primary cases (p = 0.0395) with no difference observed between laparoscopic (4.5%) and robotic (6.1%) modalities (p = 0.7051).

Conclusion:

Bariatric surgery is feasible in patients with SSO. Revision procedures may increase risk of operative complications.

Endoscopic Sleeve Gastroplasty (ESG) for High-Risk Patients, High Body Mass Index (> 50 kg/m2) Patients, and Contraindication to Abdominal Surgery

BACKGROUND

For high-risk classified patients, patients with superobesity and in cases of contraindication to abdominal surgery, traditional bariatric surgery might lead to potential morbidity and mortality. Endoscopic sleeve gastroplasty (ESG) is a novel and effective bariatric therapy for morbidly obese patients. Our research group initially evaluated the safety, feasibility, and efficacy of ESG for high-risk, high body mass index (BMI) patients, and patients contraindicated to abdominal surgeries.

METHODS

Eligible patients characterized as high-risk for bariatric surgery due to high-BMI, severe comorbidities, or impenetrable abdomen were prospectively documented. ESG was performed by using Overstich® (Apollo Endosurgery, Austin, TX, USA). Primary outcomes included technical success, post-procedure adverse events and mortality, and the change of weight and BMI.

RESULTS

ESG was successfully performed for all patients (N = 24, mean age was 55.6 (± 9.2) years old, 75% male). Baseline weight and BMI were 157.9 (± 49.1) kg and 49.9 (± 14.4) kg/m². According to Edmonton Obesity Staging System (EOSS), 8 (33.3%), 14 (58.3%), and 2 (8.3%) patients were respectively classified as EOSS 2, 3, and 4. Mean operation time was 114.7 (± 26.0) min, without intraoperative complication. Weight loss, BMI reduction, %total weight loss (%TWL), and %excess weight loss (%EWL) were 17.5 (± 14.6) kg, 5.6 (± 4.6) kg/m², 12.2% (± 8.9%), and 29.1% (± 17.9%) at post-ESG 12-month, respectively. One (4.2%) moderate post-procedure adverse event (gastric mucosal bleeding) was observed.

CONCLUSIONS

ESG can be used as a safe, feasible, and effective option for the therapy of patients with superobesity, high-risk patients, and patients contraindicated to abdominal surgery. Graphical Abstract.

Should Sleeve Gastrectomy Be Considered Only as a First Step in Super Obese Patients? 5-Year Results From a Single Center

PURPOSE

Sleeve gastrectomy (SG) has been originally conceived as a first step procedure for super obese (SO) patients, but it is currently considered a stand-alone intervention. Medium-term to long-term studies have shown weight regain and risk of de novo gastroesophageal reflux (GERD). The aim of this study was to evaluate outcomes of SG in SO subjects.

MATERIALS AND METHODS

A retrospective analysis of a prospectively maintained database was carried out to find all SO patients who had undergone SG with a minimum follow-up of 5 years. Inclusion criteria were preoperative endoscopy negative for esophagitis and/or hiatal hernia, and no GERD or acid reduction medication before SG. Reflux symptoms were evaluated using a validated questionnaire and endoscopy. Remission rates from comorbidities and percentage of excess body mass index (BMI) loss were recorded.

RESULTS

A total of 66 (45 male/21 female) patients were included in our study. Mean preoperative BMI and age were 57.4±5.8 kg/m2 and 32.7±11.2 years, respectively. After 5 years, mean percentage of excess BMI loss was 56.42±27.8, and remission rates from hypertension, diabetes, and dyslipidemia were 33.3%, 5.3%, and 20%, respectively. After 5 years, new-onset GERD occurred in 66.7% of patients and 33.3% were taking acid reduction medication. Endoscopy revealed 12 (18.2%) cases of esophagitis ≥grade A.

CONCLUSIONS

After 5 years, weight loss in SO patients is satisfactory, but the vast majority of patients is still in class II obesity, and resolution of comorbidities is disappointing. High rates of de novo GERD and esophagitis may occur.

Influence of weight gain on risk for cesarean delivery in obese pregnant women by class of obesity: pregnancy risk assessment monitoring system (PRAMS)

BACKGROUND

Currently, all obese women in the United States (US) are recommend to gain the same amount of weight during pregnancy, regardless of class of obesity. Limited literature has looked at the risk of cesarean, and possible mitigation of this risk, by specific class of obesity.

OBJECTIVE

To determine the influence of weight gain on the odds of cesarean delivery for obese women (as determined by pre-pregnancy body mass index [BMI]), by class of obesity.

STUDY DESIGN

Retrospective cohort, from the Pregnancy Risk Assessment Monitoring System (PRAMS) in the US. Specifically, the unadjusted odds of cesarean delivery were determined for each class of BMI (underweight, normal weight, overweight, class I obesity, class II obesity, and class III obesity). These odds were then adjusted by demographic and prenatal care factors influencing either weight gain during pregnancy or risk of cesarean delivery. Finally, the association of weight gain (insufficient <11 lbs, adequate 11-20 lbs, and excessive >20 lbs) on the odds of cesarean delivery in obese women was noted via multivariate logistic regression analysis.

RESULTS

60,431 women (including 21,208 with a cesarean delivery) were included in this study, with an adjusted odds ratios (OR) of cesarean delivery by BMI: underweight 0.92 (95% CI 0.83, 1.01), normal weight (referent group), overweight 1.38 (95% CI 1.32, 1.45), class I obesity 1.77 (95% CI 1.68, 1.88), class II obesity 2.17 (95% CI 2.02, 2.34), and class III obesity 3.07 (95% CI 2.82, 3.34). Class I and II obese women are more likely to have a cesarean with excessive weight gain, with class I OR 1.20 (95% CI 1.06, 1.36) and class II OR 1.24 (1.04, 1.48) when compared to women in their same class of obesity with adequate weight gain. There was no difference in risk for cesarean for class III obese women by weight gain.

CONCLUSION

Although obesity is a known risk factor for cesarean delivery, this risk is thought to be mitigatable by appropriate weight gain during the pregnancy. Weight gain of 11-20 pounds was associated with the least risk of cesarean delivery among obese (specifically class I and II) individuals.

Nutrition, Physical Activity, and Prescription of Supplements in Pre- and Post-bariatric Surgery Patients: a Practical Guideline

According to ASMBS, the rate of bariatric surgery increased from 158,000 in 2011 to 196,000 in 2015. Nevertheless, this growth in invasive techniques does not eliminate unhealthy habits, so lifestyle modification such as healthy nutrition and correct physical activity programs may improve surgical results. The objective of the present narrative review was to categorize the guidelines related to nutrition, physical activity, and supplement prescription before and after bariatric surgery. The main key words including nutrition, diet, physical activity, exercise, supplements, macronutrients, micronutrients, weight reduction, bariatric surgery, Roux-en-Y gastric bypass, sleeve gastrostomy, laparoscopic adjustable gastric banding, and biliopancreatic diversion with duodenal switch were searched in databases including PubMed/Medline, Cochrane, and some other sources such as Google scholar. The recommendations are classified based on the type of surgery. The indications for surgery and the type of bariatric surgery are not included in this review. This review helps medical teams, including bariatric surgeons, nutritionists, and sports medicine specialists, with proper management before and after bariatric surgery.

Bariatric surgery in the super-super morbidly obese: outcome analysis of patients with BMI >70 using the ACS-NSQIP database

BACKGROUND

Bariatric surgery offers patients short- and long-term benefits to their health and quality of life. Currently, we see more patients with superior body mass index (BMI) looking for these benefits. Evidence-based medicine is integral in the evaluation of risks versus benefit; however, data are lacking in this high-risk population.

OBJECTIVES

To assess the morbidity and mortality of patients with BMI ≥70 undergoing bariatric surgery.

SETTING

University Hospital, Bronx, New York, United States using national database.

METHODS

Using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database for years 2005 to 2016, we identified patients who underwent primary laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass. Patients with BMI ≥70 were assigned to the BMI >70 (BMI70+) cohort and less obese patients were assigned to the BMI <70 (U70) cohort. Length of stay and 30-day morbidity and mortality were compared.

RESULTS

A total of 163,413 patients underwent non-revisional bariatric surgery. Of those, 2322 had a BMI ≥70. BMI70+ was associated with increased mortality (.4% versus .1%, P = .0001), deep vein thrombosis (.6% versus .3%, P = .007), pulmonary (1.9% versus .5%, P = .0001), renal (.9% versus .2%, P = .0001), and infectious complications (1.1% versus .4%, P = .0001). BMI70+ patients had longer mean length of stay (2.6 versus 2.1 d, P = .0001) and operative time (126.1 versus 114.5 min, P = .0001). There was no statistically significant difference in the number of myocardial infarctions (.1% versus .1%, P = .319), pulmonary embolisms (.3% versus .2%, P = .596), and transfusion requirements (.1% versus .1%, P = .105) between groups.

CONCLUSIONS

Evaluation of risk and benefit is performed on a case-by-case basis, but evidence-based medicine is critical in empowering surgeons and patients to make informed decisions. The overall rate of morbidity and mortality for BMI70+ patients undergoing bariatric surgery was increased over U70 patients but was still relatively low. Our study will allow surgeons to incorporate objective data into their assessment of risk for super-obese patients pursuing bariatric surgery.

Surgery in Patients with Super Obesity: Medium-Term Follow-Up Outcomes at a High-Volume Center

OBJECTIVE

There is a need to determine which bariatric operations are the most effective for patients with super obesity and super-super obesity.

METHODS

A retrospective cohort study was performed on patients with super obesity and super-super obesity at Mohak Bariatrics and Robotics Surgery Center in Indore, India.

RESULTS

Five hundred fourteen patients with super obesity and super-super obesity had surgery at our center from January 2010 through December 2013. The baseline characteristics were different in different operations. The initial average age, weight, and BMI were 44.4 (SD 11.9) years, 145.4 (SD 24.2) kg, and 55.48 (SD 5.32) kg/m² , respectively. Sleeve gastrectomy (SG) (227 [44.2%]) was the most common procedure, followed by one-anastomosis gastric bypass (OAGB) (124 [24.1%]), Roux-en-Y gastric bypass (RYGB) (102 [19.8%]), banded sleeve gastrectomy (BSG) (33 [6.4%]), and banded Roux-en-Y gastric bypass (BRYGB) (28 [5.4%]). After 3 years, the percentages of excess body weight loss (%EBWL) for SG, OAGB, RYGB, BSG, and BRYGB were 62.38%, 78.59%, 69.55%, 85.11%, and 75.77% (P < 0.0001), respectively. Failure to achieve BMI < 35 kg/m² was more frequent in the group who underwent SG (67.9%), followed by RYGB (29.16%), BRYGB (22.2%), OAGB (9.87%), and none in the BSG group.

CONCLUSIONS

BSG, OAGB, and BRYGB have very good to excellent midterm outcomes for patients with super obesity and super-super obesity, whereas RYGB and SG have average outcomes at 3 years. There is a need for multicenter, long-term, and prospective studies to be performed to confirm these findings.

Perioperative outcomes of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in super-obese and super-super-obese patients: a national database analysis

BACKGROUND

Evidence remains contradictory for perioperative outcomes of super-obese (SO) and super-super-obese (SSO) patients undergoing bariatric surgery.

OBJECTIVE

To identify national 30-day morbidity and mortality of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in SO and SSO patients.

SETTING

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.

METHODS

All LSG and LRYGB patients from 2015 through 2017 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database were grouped based on body mass index (BMI) as follows: morbidly obese (MO; BMI 35.0-49.9 kg/m²), SO (BMI 50.0-59.9 kg/m²), and SSO (BMI ≥60.0 kg/m²). Complications and mortality within 30 days were compared between BMI groups using Pearson X² or Fischer's exact tests. Multivariate logistic regression was used to adjust for demographic characteristics and co-morbidities, and adjusted odds ratio (AOR) was reported for each outcome.

RESULTS

Of 356,621 patients, 71.6% had LSG and 28.4% LRYGB. A total of 272,195 patients were in the MO group, 65,565 in the SO group, and 18,861 in the SSO group. Higher BMI was associated with increased overall morbidity and mortality. The overall complication rate was significantly higher for SO (AOR = 1.20, 95% confidence interval [CI] 1.13-1.28 for LSG; AOR = 1.08, 95% CI 1.01-1.15 for LRYGB) and SSO (AOR = 1.44, 95% CI 1.31-1.58 for LSG; AOR = 1.31, 95% CI 1.19-1.45 for LRYGB) compared with the MO group. Mortality was also significantly higher for SO (AOR = 1.65, 95% CI 1.10-2.48 for LSG; AOR = 1.85, 95% CI 1.23-2.80 for LRYGB) and SSO (AOR = 3.30, 95% CI 1.98-5.48 for LSG; AOR = 3.32, 95% CI 1.93-5.73 for LRYGB) compared with the MO group.

CONCLUSIONS

SO and SSO patients are at increased risk of 30-day morbidity and mortality compared with MO patients. Despite this elevated perioperative risk, the overall risk of these procedures remains low and acceptable especially as bariatric surgery is the durable treatment option for obesity.

Outcomes of Roux-en-Y gastric bypass versus sleeve gastrectomy in super-super-obese patients (BMI ≥60 kg/m2): 6-year follow-up at a single university

BACKGROUND

Among the population of morbidly obese people, super-super-obese (SSO) individuals (body mass index >60 kg/m²) present a treatment challenge for bariatric surgeons.

OBJECTIVES

To compare the long-term outcomes between laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB) and to evaluate the efficacy of SG as a stand-alone bariatric procedure for SSO patients.

SETTING

University hospital, Paris, France.

METHODS

We retrospectively reviewed the data outcomes of 210 SSO patients who underwent SG or RYGB between January 2000 and December 2011. The 6-year follow-up data were analyzed and compared.

RESULTS

Follow-up data at 6 years were collected for 57.1% and 52.1% of patients in the SG group and RYGB groups, respectively. Both procedures were effective at promoting weight loss. Most weight loss was achieved at 24 months with both procedures. The average percent excess weight loss and change in body mass index of SG versus RYGB showed no significant differences at the 4-year follow-up. Except for sleep apnea, RYGB showed slightly better resolution of the evaluated co-morbidities. The composite endpoint of major short-term adverse events (<30 d) occurred in 11.7% of patients with RYGB and 6.4% of those with SG (P = .02). Postoperative complications were seen in 26% of RYGB patients and 16.1% of SG patients.

CONCLUSIONS

SG as a primary procedure for SSO patients remains effective even though RYGB achieves better midterm outcomes. SG can be proposed as the primary-option p+rocedure. Further investigations are needed to identify the ideal procedure for patients with symptoms of gastroesophageal reflux disease.

Intragastric balloon outcomes in super-obesity: a 16-year city center hospital series

BACKGROUND

Intragastric balloons represent an endoscopic therapy aimed at achieving weight loss by mechanical induction of satiety. Their exact role within the bariatric armamentarium remains uncertain.

OBJECTIVE

Our study aimed to evaluate the use of intragastric balloon therapy alone and before definitive bariatric surgery over a 16-year period.

SETTING

A large city academic bariatric center for super-obese patients.

METHODS

Between January 2000 and February 2016, 207 patients underwent ORBERA intragastric balloon placement at esophagogastroduodenoscopy. Four surgeons performed the procedures, and data were entered prospectively into a dedicated bariatric database. Patients' weight loss data were measured through body mass index (BMI) and excess weight loss and recorded at each clinic review for up to 5 years (60 mo). Treatment arms included intragastric balloon alone with lifestyle therapy or intragastric balloon and definitive bariatric surgery: gastric banding, sleeve gastrectomy, or Roux-en-Y gastric bypass. An additional treatment arm of analysis included the overall results from intragastric balloon followed by stapled procedure.

RESULTS

One hundred twenty-nine female and 78 male patients had a mean age of 44.5 (±11.3) years and a mean BMI of 57.3 (±9.7) kg/m². Fifty-eight percent of patients suffered from type 2 diabetes. Time from initial or first balloon insertion to definitive surgical therapy ranged between 9 and 13 months. Seventy-six patients had intragastric balloon alone, and 131 had intragastric balloon followed by definitive procedure. At 60 months postoperatively the intragastric balloon alone with lifestyle changes demonstrated an excess weight loss of 9.04% and BMI drop of 3.8; intragastric balloon with gastric banding demonstrated an excess weight loss of 32.9% and BMI drop of 8.9. Intragastric balloon and definitive stapled procedure demonstrated a BMI drop of 17.6 and an excess weight loss of 52.8%. Overall, there were 3 deaths (1.4%), 2 within 10 days due to acute gastric perforation secondary to vomiting and 1 cardiac arrest at 4 weeks postoperatively.

CONCLUSION

Intragastric balloons can offer effective weight loss in selected super-obese patients within a dedicated bariatric center offering multidisciplinary support. Balloon insertion alone offers only short-term weight loss; however, when combined with definitive bariatric surgical approaches, durable weight loss outcomes can be achieved. A strategy of early and continual vigilance for side effects and a low threshold for removal should be implemented. Surgeon and unit experience with intragastric balloons can contribute to "kick starting" successful weight loss as a bridge to definitive therapy in an established bariatric surgical pathway.

Is bariatric surgery effective for co-morbidity resolution in the super-obese patients?

BACKGROUND

Type 2 diabetes (T2D), obstructive sleep apnea (OSA), hypertension (HTN), and hyperlipidemia (HLD) are common co-morbidities that are strongly associated with obesity.

OBJECTIVE

The purpose of this study was to compare the rate of obesity-related co-morbidity remission and percent total body weight loss of super-obese patients with a body mass index (BMI) ≥50 kg/m² with bariatric patients who have a BMI of 30 to 49.9 kg/m².

SETTING

Academic hospital, United States.

METHODS

A retrospective analysis of outcomes of a prospectively maintained database was done on obese patients with a diagnosis of ≥1 co-morbidity (T2D, OSA, HTN, or HLD) who at the time of initial visit had undergone either a sleeve gastrectomy or a Roux-en-Y gastric bypass at our hospital between 2011 and 2015. The patients were stratified based on their preoperative BMI class, BMI of 30 to 49.9 kg/m² versus BMI ≥50 kg/m².

RESULTS

Of the 930 patients, 732 underwent sleeve gastrectomy and 198 underwent Roux-en-Y gastric bypass. The 6-month follow-up co-morbidity remission rates for patients with a BMI of 30 to 49.9 kg/m² (n = 759) versus super-obese patients (n = 171) were 46.0% and 36.7% (P = .348) for T2D; 75.0% and 73.2% (P = .772) for OSA; 35.0% and 22.0% (P = .142) for HTN; and 37.0% and 21.0% (P = .081) for HLD, respectively. The 1-year follow-up co-morbidity remission rates for patients with a BMI of 30 to 49.9 kg/m² versus super-obese patients were 54.2% and 45.5% (P = .460) for T2D; 87.0% and 89.7% (P = .649) for OSA; 37.4% and 23.9% (P = .081) for HTN; and 43.2% and 34.6% (P = .422) for HLD, respectively. Furthermore, there was no difference in the mean percent total weight loss for patients with a preoperative BMI of 30 to 49.9 kg/m² versus the super-obese at the 6-month (21.4%, 20.9%, P = .612) and 1-year (28.0%, 30.7%, P = .107) follow-ups.

CONCLUSION

In our study, preoperative BMI did not have an impact on postoperative co-morbidity remission rates or percent total body weight loss. Future studies should investigate the effect of other factors, such as disease severity and duration.

Perioperative outcomes and anesthetic considerations of robotic bariatric surgery in a propensity-matched cohort of super obese and super-super obese patients

BACKGROUND

The use of the robotic platform has not been well established in patients with super obesity (SO; body mass index, BMI ≥ 50) and super-super obesity (SSO, BMI ≥ 60). We aimed to determine safety and feasibility of robotic bariatric surgery in this cohort.

METHODS

Review of a prospectively maintained database was performed of consecutive patients undergoing robotic bariatric surgery between 2015 and 2017. Propensity score analysis with 1:2 nearest neighbor matching was performed to control for baseline characteristics and procedure type.

RESULTS

A propensity-matched cohort of 47 SO patients (median BMI 55.3, range 50.1-92.5) and 94 morbidly obese (MO; median BMI 41.8, range 35.1-48.8) patients were analyzed. After matching, there were no difference in baseline characteristics including age, American Society of Anesthesiologists (ASA) score, or preoperative comorbidities. Most patients in each group underwent sleeve gastrectomy (81% of SO patients versus 76% of MO patients) or Roux-en-Y gastric bypass (13% vs. 18%, respectively), p = 0.66. There were no differences in operative time, intraoperative complications, postoperative complications, or re-admissions between groups. Length of stay was slightly longer in the MO group (2.2 days, IQR 1.8-3.2 vs. 1.8 days, IQR 1.2-2.7; p = 0.01). A subset of SSO patients (n = 11, median BMI 67, range 60-92) was analyzed; there was no increase in operation time, and zero intraoperative complications, conversions to open, or postoperative complications in this subset.

CONCLUSIONS

Robotic bariatric surgery can safely be performed on patients with SO or SSO with low perioperative morbidity and no increase in operating time.

Does Bariatric Surgery Improve Obesity Associated Comorbid Conditions

Obesity is a constantly growing health problem which reduces quality of life and life expectancy. Bariatric surgery for obesity is taken into account when all other conservative treatment modalities have failed. Comparison of the multidisciplinary programs with bariatric surgery regarding to weight loss showed that substantial and durable weight reduction have been achieved only with bariatric surgical treatments. However, the benefits of weight loss following bariatric procedures are still debated regarding the pro-inflammatory and metabolic profile of obesity.

Rapid Evidence Review of Bariatric Surgery in Super Obesity (BMI ≥ 50 kg/m2)

BACKGROUND

Despite accumulating evidence of the important health benefits of bariatric surgery in morbidly obese patients in general, bariatric surgery outcomes are less clear in higher-risk, high-priority populations of patients with BMI ≥ 50 kg/m². To help the Department of Veterans Affairs (VA) Health Services Research & Development Service (HSR&D) develop a research agenda, we conducted a rapid evidence review to better understand bariatric surgery outcomes in adults with BMI ≥ 50 kg/m².

METHODS

We searched MEDLINE^®, the Cochrane Database of Systematic Reviews, the Cochrane Central Registry of Controlled Trials, and ClinicalTrials.gov through June 2016. We included trials and observational studies. We used pre-specified criteria to select studies, abstract data, and rate internal validity and strength of the evidence (PROSPERO registration number CRD42015025348). All decisions were completed by one reviewer and checked by another.

RESULTS

Among 1892 citations, we included 23 studies in this rapid review. Compared with usual care, one large retrospective VA study provided limited evidence that bariatric surgery can lead to increased mortality in the first year, but decreased mortality long-term among super obese veterans. Studies that compared different bariatric surgical approaches suggested some differences in weight loss and complications. Laparoscopic gastric bypass generally resulted in greater short-term proportion of excess weight loss than did other procedures. Duodenal switch led to greater long-term weight loss than did gastric bypass, but with more complications.

CONCLUSIONS

The published literature that separates the super obese is insufficient for determining the precise balance of benefits and harms of bariatric surgery in this high-risk subgroup. Future studies should evaluate a more complete set of key outcomes with longer follow-up in larger samples of more broadly representative adults.

Bariatric surgery operating room time--size matters

BACKGROUND

The goal of this study was to document the relationship between BMI and the components of bariatric surgical operating room (OR) time.

METHODS

The Stanford Translational Research Integrated Database Environment identified all patients who underwent laparoscopic Roux-en-Y gastric bypass procedures at Stanford University Medical Center between May 2008 and November 2013. The 434 patients were divided into 3 groups: group 1 (n = 213) BMI ≥35 to <45 kg/m(2), group 2 (n = 188) BMI ≥45.0 to <60 kg/m(2), and group 3 (n = 33) BMI ≥60 kg/m(2). The primary variable measured was total operating room time, defined as beginning when the patient entered the OR until the moment the patient physically left the OR. Secondary variables were anesthetic induction time, nursing preparation time, operation time, time for emergence from anesthesia, and total length of hospital stay.

RESULTS

Increasing BMI was associated with increased total OR time (group 1 = 202 min, group 2 = 215 min, group 3 = 235 min), mainly due to longer operation time (group 1 = 147 min, group 2 = 154 min, group 3 = 163 min). Anesthetic induction (group 1 = 17 min, group 2 = 18 min, group 3 = 23 min) and emergence times (group 1 = 12 min, group 2 = 12 min, group 3 = 22 min) were also significantly longer in the largest patients.

CONCLUSIONS

Operating room schedules and plans for resource utilization should recognize that the same bariatric procedure will require more time for patients with BMI >60 kg/m(2) than for smaller bariatric patients.

Outcomes of Roux-en-Y gastric bypass in the super obese: comparison of body mass index 50-60 kg/m(2) and≥60 kg/m(2) with the morbidly obese

BACKGROUND

Reports on the outcomes of Roux-en-Y gastric bypass (RYGB) in super-obese patients are limited, especially on patients with body mass index (BMI)≥60 kg/m(2).

OBJECTIVES

The aim of the present study was to evaluate and compare the tolerability and efficacy of RYGB in the super-obese by comparing patients with a BMI of 50-60 kg/m(2) and a BMI of≥60 kg/m(2) with patients with a BMI of 40-50 kg/m(2).

SETTING

Academic practice.

METHODS

Between January 2004 and November 2013, a total of 2717 patients underwent RYGB at our institution. Of these, 661 (24.3%) had a preoperative BMI of 50-60 kg/m(2) and 230 (8.5%) had a BMI≥60 kg/m(2). A retrospective review of outcomes and complications was performed, comparing these patients with 1555 patients with a BMI between 40-50 kg/m(2).

RESULTS

Fifty-two (3.3%) patients in the BMI 40-50 kg/m(2) group, 15 (2.3%) patients in the BMI 50-60 kg/m(2) group, and 3 (1.3%) patients in the BMI≥60 kg/m(2) had<30 days of follow-up. Readmission rates were 10.7%, 9.2%, and 11.7%, and reoperation rates were 7.3%, 5.0%, and 6.1%, in the BMI 40-50, 50-60, and≥60 kg/m(2) groups, respectively. No significant difference was found in readmission rate among the 3 groups, and reoperation rate was significantly lower in the BMI 50-60 kg/m(2) group. Mean percentage of excess BMI loss was 58.3%, 80.6%, 85.8%, 83.3%, and 80.9% in the BMI 40-50 kg/m(2) group; 44.9%, 65.0%, 70.1%, 72.1%, and 65.9% in the BMI 50-60 kg/m(2) group; and 38.5%, 57.4%, 62.2%, 62.8%, and 59.1% in the≥60 kg/m(2) group at 6, 12, 18, 24, and 36 months, respectively. The differences in excess BMI loss were statistically significant among all 3 groups at all follow-up time points. All groups experienced a significant decrease in their mean number of co-morbidities after the procedure.

CONCLUSION

Readmission and reoperation rates were similar in the BMI 40-50, 50-60, and≥60 kg/m(2) groups. Super-obese and super-super-obese patients are not at greater risk for surgical complications compared with those with lower BMIs.

Weight loss outcomes and complications from bariatric surgery in the super super obese

BACKGROUND

Bariatric surgery has been established as the most effective long-term treatment for morbid obesity.

METHODS

We performed a retrospective review of SSO patients treated at our institute between 2008 and 2013 who underwent a laparoscopic gastric bypass (LGBP) or sleeve gastrectomy (LSG). The primary end point for this study was excess weight loss (EWL) at 1, 3, 6, and 12 months. Secondary end points included procedure length (PL), length of stay (LOS), diabetes management and postoperative complications.

RESULTS

We identified 135 SSO patients who underwent bariatric surgery (93 LGBP, 42 LSG) at our institute from 2008 to 2013 with a median follow-up of 49 months. The incidence of EWL > 30 % for patients in the LGBP group was 3.9, 29.0, 72.2 and 94.6 % at 1, 3, 6 and 12 months, respectively, while the incidence of EWL > 30 % in patients in the LSG group was 4.2, 25.0, 59.1 and 100 % at 1, 3, 6 and 12 months, respectively. PL was 124 ± 49 min for the LGBP group and 98 + 51 min for the LSG group (p < 0.005). LOS was on average 3.0 days (range 1-21) for the LGBP group and 3.4 days (range 1-13) for the LSG group (p = 0.41). Patients experienced a decrease in their hemoglobin A1C level by 10 % for the LGBP group and 9 % for the LSG group at 1 year (p = 0.89). Postoperative complications were seen in 15.1 % of LGBP patients and 4.8 % of LSG patients.

CONCLUSIONS

Bariatric surgery is feasible in the SSO patients with comparable EWL outcomes and postoperative complications to historical non-SSO patients.

Twenty-first century weight loss: banding versus bypass

BACKGROUND

The two most commonly performed procedures for bariatric surgery include Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (AGB). While many studies have commented on short-term, postoperative outcomes of these procedures, few have reported long-term data. The purpose of this study was to compare long-term, postoperative outcomes between RYGB and AGB.

METHODS

This was a retrospective, cohort comparing all patients undergoing RYGB or AGB at our institution, from 01/1998 to 08/2012. Patients were followed at 1-, 3-, and 5-year intervals. Adjusted, Cox proportional hazard regression and mixed effects repeated measures modeling were performed to generate cure ratios (CR) and 95 % confidence intervals (CI).

RESULTS

Two thousand four hundred twenty bariatric surgery patients (380 AGB, 2,040 RYGB) were identified by CPT code. Median (range) follow-up for patients was 3 (1-5) years. Preoperatively, RYGB patients were significantly younger, more obese, had higher hemoglobin A1c, and less often suffered from hypertension (HTN), dyslipidemia, and asthma as compared to AGB patients. Postoperatively, RYGB patients experienced significantly longer operating room times, higher incidences of intensive care unit admissions, longer hospital lengths of stay, and increased incidence of small bowel obstruction compared to AGB patients. After adjusting for statistically significant and clinically relevant factors [e.g., age, gender, body mass index, degenerative joint disease (DJD), diabetes, HTN, dyslipidemia, heart disease, apnea, and asthma], RYGB was independently associated with a significantly greater percentage of total body weight loss (p = 0.0065) and greater CR (95 % CI) regarding gastroesophageal reflux disease [2.1(1.4-3.0)], DJD [3.4(2.0-5.6)], diabetes [3.4(2.2-5.4)], apnea [3.1(1.9-5.3)], HTN [5.5(3.4-8.8)], and dyslipidemia [6.3(3.5-11)] compared to AGB.

CONCLUSION

Our results support previous studies that have observed a greater weight loss associated with RYGB as compared to AGB and provide further evidence toward the long-term sustainability of this weight loss. Additionally, RYGB appears to result in a greater reduction of medical comorbidity.

Early and long-term clinical outcomes of bilio-intestinal diversion in morbidly obese patients

PURPOSE

To evaluate the early and long-term postoperative results of malabsorptive surgery in morbidly obese patients.

METHODS

Between 2000 and 2007, 102 morbidly obese patients were referred to the Department of Surgery "Pietro Valdoni", "Sapienza" University of Rome, Policlinico "Umberto I°", Rome, Italy for malabsorptive surgery. All patients underwent derivative biliodigestive surgery after they had been reviewed by a team of surgeons, physicians, dieticians, and psychologists.

RESULTS

There were no intra-operative complications, but two patients suffered postoperative pulmonary embolisms, which resolved with medical treatment. The mean postoperative hospital stay was 7 days, with no early or late mortality. Maximum weight loss was reached 12-24 months after surgery, while the mean percentage excess weight loss at 3-5 years ranged from 45 to 64 %. Specific postoperative complications in the first 2 years after surgery were abdominal abscess (n = 2), gastroduodenal reflux (n = 4), and incisional hernia (n = 6). Diabetes resolved in 98 % of the diabetic patients within a few weeks after surgery and blood pressure normalised in 86.4 % of those who had had hypertension preoperatively. Obstructive sleep apnoea and obesity hypoventilation syndrome also improved significantly in 92 % of the patients.

CONCLUSIONS

Morbidly obese patients can undergo biliodigestive surgery safely with good long-term weight loss and quality of life expectancy.

Five-year outcomes of gastric bypass for super-super-obesity (BMI≥60 kg/m²): a case matched study

BACKGROUND

Laparoscopic gastric bypass (LRYGB) is feasible for patients with body mass index (BMI)≥60 kg/m² (super-super-obesity [SSO]) but long-term data are lacking. The objective of this study was to compare the 5-year weight loss and changes in obesity-related co-morbidities after LRYGB for SSO and non-SSO patients.

METHODS

From January 2004 to November 2008, 32 SSO and 320 non-SSO patients underwent LRYGB. We matched 30 SSO patients undergoing LRYGB (case group) with 60 non-SSO patients (control group) for age, sex, and presence of type 2 diabetes.

RESULTS

Baseline data indicate that case and control groups did not differ for age (42±12.4 versus 41.8±11.5 yr; P=.92) or sex ratio (80% female, P=.99). Preoperative BMI were 64.1±4.1 and 46.3±5.6 kg/m² in SSO and non-SSO groups, respectively (P<.0001). The rates of coexisting conditions in the 2 groups were comparable except for hypertension (76.7% versus 53.3%; P=.03). At 5 years after surgery, the percentage of initial weight loss (%IWL) (27.4±11.8 versus 29.7±9.2; P=.35) for the groups were comparable whereas percentage of excess weight loss (%EWL) (44.9±19.9 versus 66.5±21.2; P<.0001) was higher for non-SSO patients. Rates of remission or improvement of coexisting conditions, including diabetes and hypertension, did not differ significantly different between groups.

CONCLUSION

According to %IWL and rate of partial or complete remission of diabetes and hypertension, our study shows similar outcomes for LRYGB in SSO and non-SSO patients 5 years after surgery. The %EWL does not seem to be an adequate indicator for evaluation of LRYGB outcomes in patients with extreme obesity, such as SSO.

Is laparoscopic single-stage biliopancreatic diversion with duodenal switch safe in super morbidly obese patients?

BACKGROUND

It has been hypothesized that the morbidity and mortality of laparoscopic biliopancreatic diversion with duodenal switch (BPD-DS) are likely to increase with increasing body mass index (BMI), especially with BMI>50 kg/m(2). Therefore, a 2-stage approach to this procedure has been advocated in super morbidly obese patients. The authors hypothesized that a BMI ≥ 50 kg/m(2) does not significantly influence the morbidity and mortality perioperatively associated with this procedure.

METHODS

A retrospective analysis of all patients who underwent laparoscopic BPD-DS between January 2009 and September 2011 was performed. The patients were divided into 2 groups: patients with BMI<50 kg/m(2) and those with BMI>50 kg/m(2). Patient characteristics, perioperative variables, 30-day outcomes, and complications were analyzed and compared.

RESULTS

A total of 226 patients underwent laparoscopic BPD-DS. Mean patient age was 44.9 years (range: 20-72 yr). Male to female ratio was 59 to 170 patients (75% versus 25%), respectively. Mean BMI was 50.2 kg/m(2) (range: 37.2-68.8 kg/m(2)). A total of 127 patients had a BMI<50 kg/m(2) (Group 1), and 99 patients had a BMI ≥ 50 kg/m(2) (Group 2). The length of procedure in Groups 1 and 2 was 296 minutes and 287 minutes, respectively (P = .25). The rate of conversion to open BPD-DS was 1.5% in Group 1 and 3% in Group 2 (P = .65). Two leaks occurred in Group 1; no patient in Group 2 developed this complication. One patient in Group 2 developed pulmonary embolism. The rates of all other complications resulting in a longer length of stay were 11% in Group 1 and 8% in Group 2 (P = .50). The 30-day reoperation rate was 3% in Group 1 and 1% in Group 2 (P = .39). The mean length of stay was 3.97 days for Group 1 and 3.67 days for Group 2 (P = .34). No mortality occurred in this series.

CONCLUSION

In the present study, BMI ≥ 50 kg/m(2) did not increase intraoperative or postoperative complications at 30 days after laparoscopic PBD-DS. No significant differences were noted between patients with BMI ≥ 50 kg/m(2) and patients with BMI<50 kg/m(2). A single-stage laparoscopic BPD-DS procedure can be safely offered to the super morbidly obese patients.

The effect of centralization of caseload for primary brain tumor surgeries: trends from 2001-2007

BACKGROUND

Improved patient outcomes have been associated with high-caseload hospitals for a multitude of conditions. This study analyzed adult patients undergoing surgical resection or biopsy of primary brain tumors. The aim of this study is two-fold: (1) to evaluate whether the trend towards centralization of primary brain tumor care in the US has continued during the period of between 2001 and 2007, and (2) to analyze volume-outcome effects.

METHODS

Surgical volume trends of adults undergoing resection/biopsy of primary supratentorial brain tumors were analyzed using the Nationwide Inpatient Sample. High- and low-caseload hospitals were defined as those performing in the highest and lowest quintile of procedures, respectively. Length of stay (LOS), mortality and discharge disposition were the main outcomes of interest.

RESULTS

NIS estimated 124,171 patients underwent resection/biopsy of primary supratentorial brain tumors between 2001 and 2007 in the US. The average number of annual resections in the highest 2 % and lowest 25 % caseload hospitals were 322 and 12 cases, respectively. Surgeries in high-caseload hospitals increased by 137 %, while those in low-caseload centers declined by 16.0 %. Overall, mortality decreased 35 %, with a reduction of 45 % in high- (from 2.2 % to 1.2 %) and 19 % in low- (from 3.2 % to 2.6 %) caseload hospitals. High-caseload centers had lower LOS than hospitals with lower caseload centers (6.4 vs. 8.0 days, p < 0.001). Multivariate analysis showed that patients treated in low-volume hospitals had an increased risk of death (OR 1.8, CI: 1.2-2.7, p = 0.006) and adverse discharge (OR 1.4, CI: 1.1-1.7, p = 0.01).

CONCLUSIONS

Neurosurgical caseload at the nation's high volume craniotomy centers has continued to rise disproportionately, while low-caseload centers have seen a decrease in overall surgical volume. Over the time period between 2001 and 2007 there was a trend towards improved in-hospital mortality, LOS and discharge disposition for all hospitals; however, the trend is convincingly favorable for high-caseload hospitals.

Preoperative weight loss with intragastric balloon decreases the risk of significant adverse outcomes of laparoscopic gastric bypass in super-super obese patients

BACKGROUND

Extreme obesity increases morbi-mortality in bariatric surgery. We previously showed that significant weight loss can be obtained within 3 months in super-super obese patients (BMI > 60 kg/m(2)) with an intragastric balloon (IGB). Here, we explored the potential benefit of preoperative IGB on the outcome of laparoscopic gastric bypass (LGBP) in super-super obese patients.

METHODS

In this case-control study, we compared the records of 60 consecutive super-super obese patients (66.5 ± 3.4 kg/m(2)) submitted to a LGBP between 2004 and 2009, with preoperative IGB (n = 23, cases) or without (n = 37, controls). We analyzed the clinical outcome of surgery and a composite end point of significant adverse events defined as the presence of at least one of the following conditions: conversion to laparotomy, intensive care unit stay for more than 2 days, and overall hospital stay superior to 2 weeks.

RESULTS

All baseline clinical and biological characteristics were homogenous between both groups. IGB was maintained during 155 ± 62 days and induced a loss of 5.5 ± 1.3 kg/m(2) (11.2 ± 3.2% of excess body mass index) at the time of LGBP, associated with a decrease in systolic blood pressure and gamma-glutamyl transpeptidase level (p < 0.05 vs. baseline). Operative time was lower in the IGB group (146 ± 47 vs. 201 ± 81 min in controls; p < 0.01). Significant adverse events occurred less frequently after LGBP in the IGB group (2 vs. 13 in controls; p < 0.05). All patients were alive at 1 year and overall weight loss was similar in both groups (52.4 ± 17.3 vs. 50.3 ± 12.7 percent of excess BMI loss in controls; NS).

CONCLUSIONS

IGB prior to LGBP in super-super obese patients significantly reduced excess BMI. It was associated with a shorter operative time and a lower overall risk of significant adverse outcomes.

Comparison of fat-free mass in super obesity (BMI ≥ 50 kg/m2) and morbid obesity (BMI <50 kg/m2) in response to different weight loss surgeries

BACKGROUND

Differences in excess weight loss, body mass index (BMI) change, and body composition have been related to different types of bariatric procedures. Our objective was to explore these alterations related to body mass in superobese (SO) and morbidly obese (MO) patients in a university hospital setting.

METHODS

Patients provided written informed consent and had their body composition measured before and after surgery using bioimpedance (Tanita 310). The t test was used to compare MO and SO. Pearson's correlations were used to examine the BMI, excessive BMI loss, percentage of body fat (BF) change, and fat-free mass.

RESULTS

A total of 133 MO patients had a BMI of 43.3 kg/m(2) and 88 SO patients had a BMI of 59.4 kg/m(2). The percentage of BF was 46.7% and 51.9% (P < .0001). The differences in the follow-up period after surgery (21.5 and 20.6 months; P = .62) and patient age (43.4 and 42.5 yr) were not significant, but the gender distribution was significant (P = .003). After surgery, the MO patients had a BMI of 30.9 ± 5.7 kg/m(2) and the SO patients had a BMI of 37.3 ± 9.0 kg/m(2). The percentage of BF was not different between the 2 groups (MO, 33.1% ± 9.6% and SO, 35.0% ± 12.4%; P = .21). Gender differences in the percentage of BF were present before surgery; however, after surgery, these were absent for the men in the 2 groups (24.8% and 26.6%; P = .51). The change in the BMI and the change in the BF had a stronger correlation for the MO patients (r = .83 versus r = .53) than for the SO patients. The fat-free mass loss correlated with the change in BMI without regard to procedure. The percentage of excessive BMI loss was 65.1% for the MO and 63.4% for the SO patients (P = .64).

CONCLUSIONS

The SO patients achieved excessive BMI loss similar to that of the MO patients, with more SO men choosing biliopancreatic diversion/duodenal switch. At a BMI of 37.3 kg/m(2), the SO patients had a percentage of BF that was not different from that of the MO patients at 30.9 kg/m(2). The fat-free mass losses correlated with the change in BMI.

Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy for the treatment of morbid obesity. A prospective study of 117 patients

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most widely used bariatric procedures today, and laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure for the treatment of morbid obesity is becoming increasingly popular. In this study, we prospectively compared both techniques in order to establish whether there is any superiority of one over the other based on morbidity and effectiveness. From January 2008 to December 2008, 117 obese patients with indication for bariatric surgery were assigned by patient choice after informed consent to either a LRYGB procedure (n = 75) or a LSG procedure (n = 42). We determined operative time, length of stay, morbidity, co-morbidity outcomes, and excess weight loss at 1 year postoperative. Both groups were comparable in age, sex, body mass index, and co-morbidities. Mean operative time of LSG was 82 min while LRYGB was 98 min (p < 0.05). Differences in length of stay, major complications, improvement in co-morbidities, and excess weight loss were not significant (p > 0.05). One year after surgery, average excess weight loss was 86% in LRYGB and 78.8% in LSG (p > 0.05). In the short term, both techniques are comparable regarding safety and effectiveness, so not one procedure is clearly superior to the other.

Variations in referral patterns for hypophysectomies among pediatric patients with sellar and parasellar tumors

PURPOSE

It has been shown that patients admitted to high-volume hospitals for resection of sellar and parasellar lesions experience reduced mortality and morbidity. It remains unknown what preoperative factors influence admission to high-volume centers. We report a nationwide analysis of patients <18 years of age undergoing neurosurgical intervention for these lesions.

METHODS

A retrospective analysis of the Nationwide Inpatient Sample was performed with additional factors from the Area Resource File. International Classification of Diseases, 9th Revision diagnosis/procedural codes were used to identify patients undergoing resection of tumors from the pituitary gland or related structures. Patients >or=18 years old were excluded. Covariates included age, gender, race, and insurance status. Multivariate analysis was performed using multiple logistic regression models. A p value <0.05 was considered statistically significant.

RESULTS

In total, 1,063 patients were identified. Most (69.8%) were seen at low-volume centers. Mean (median) patient age was 13.7 (15) years. The majority of patients were female (54.8%), white (61.9%), and insured (90.3%). Hispanics were 44% less likely (odds ratio (OR) 0.56, 95% confidence interval (CI) 0.34-0.92, p < 0.05) to be seen at high-volume centers than their Caucasian counterparts. Each increase in 2-year patient age category was associated with greater access to high-volume centers (OR 1.12, 95% CI 1.03-1.23, p < 0.05), relative to 0-2 years old. Female gender, insurance status, county poverty, neurosurgeon density, and calendar year were not significantly associated with admission to high-volume centers.

CONCLUSIONS

Age and racial disparities play a significant role in access neurosurgical care, affecting admission of pediatric patients to high-volume neurosurgical centers across the USA.