Risk Factors and Management Approaches for Staple Line Leaks Following Sleeve Gastrectomy: A Single-Center Retrospective Study of 402 Patients

Weight loss dynamics after laparoscopic sleeve gastrectomy: a retrospective single center analysis with age and preoperative weight stratification

Laparoscopic Sleeve Gastrectomy (LSG) is the most common bariatric procedure worldwide. However, the influence of preoperative factors on weight loss outcomes remains incompletely understood. We investigated the effects of preoperative weight, height, and age on total weight loss percentage (%TWL) following LSG using advanced statistical modeling. 2014 LSG patients were analyzed and stratified by preoperative weight (7 categories: <90 kg to > 160 kg) and age (5 groups: 14-25 to ≥ 56 years). %TWL was calculated at 1 week, 1, 3, 6, and 12 months post-surgery. A Generalized Additive Model (GAM) was used to calculate Adjusted Total Weight Loss percentage (%ATWL), accounting for height and preoperative weight confounding effects. The population (mean age: 38.0 ± 11.4 years, BMI: 42.9 ± 8.2 kg/m²) showed weight-dependent %TWL at 12 months, from 32.2%±10.0% (< 90 kg) to 39.8%±7.5% (> 160 kg) (p < 0.001). GAM-adjusted %ATWL revealed superior outcomes in younger cohorts. The 14-25 and 26-35 year groups had comparable 12-month %ATWL (38.2% vs. 37.0%, p = 0.222), significantly exceeding older groups (p < 0.001). Early postoperative %ATWL (1-week) was similar across ages (4.6-5.7%), with progressive differentiation at 3, 6, and 12 months. Preoperative weight and age significantly influence LSG weight loss outcomes. Younger patients and those with higher pre-op weights achieved greater 12-month %TWL.

A New Drug for Obesity: Tirzepatide

Obesity is now recognised as an emerging public health problem across the globe. Its incidence has been growing in the last two decades. Furthermore, as per the obesity treatment guidelines, a comprehensive approach that incorporates behavioural treatment, medications, lifestyle modifications, and/or bariatric surgery is the best way to manage weight. A novel dual agonist of Glucose-dependent insulinotropic peptide (GIP) and Glucagon-like peptide -1 (GLP- 1) receptors, Tirzepatide, was recently approved for the management of obesity. Tirzepatide manages blood sugar levels and enhances weight loss more than GLP-1 receptor agonists.

Endoscopic therapies for bariatric surgery complications

PURPOSE OF REVIEW

The aim of this review is to present the current state of the field, highlight recent developments, and describe the clinical outcomes of endoscopic therapies for bariatric surgery complications.

RECENT FINDINGS

The field of interventional endoscopy now presents a range of minimally invasive procedures for addressing postbariatric complications. Lumen-opposing metal stents have emerged as a reliable solution for managing gastrojejunal strictures following Roux-en-Y gastric bypass, whether with or without associated leaks. Additionally, they serve as a conduit for performing endoscopic retrograde cholangiopancreatography (ERCP) post-RYGB via EUS-directed ERCP (EDGE). Gastric peroral endoscopic myotomy, originally designed for gastroparesis, has demonstrated effectiveness in treating postgastric sleeve stenosis, particularly the challenging helical stenosis cases. Furthermore, innovative endoscopic antireflux techniques are showing encouraging outcomes in addressing gastroesophageal reflux disease (GERD) following sleeve gastrectomy. Additionally, several modifications have been proposed to enhance the efficacy of transoral outlet reduction (TORe), originally developed to treat weight regain due to gastrojejunal anastomotic issues post-RYGB.

SUMMARY

Endoscopic management of bariatric surgery complications is continuously evolving. The development of new techniques and devices allows endoscopists to provide novel, minimally invasive alternatives that were not possible in the near past. Many techniques, however, are limited to expert centers because they are technically demanding, and specialized training in bariatric endoscopy is still required.

The Effects of Laparoscopic Sleeve Gastrectomy on Body Mass Index (BMI) and Glycated Hemoglobin (HbA1c) Levels

Background and significance Bariatric surgery is an effective surgical intervention for weight loss and metabolic improvement. Articles tackling obesity and bariatric surgery with its preoperative preferences and postoperative findings are needed. From that stance, we aim to accurately document the impact of bariatric surgery, particularly laparoscopic sleeve gastrectomy (LSG), on body mass index (BMI) and glycated hemoglobin (HbA1c) levels. Patients and methods We present a retrospective cohort study conducted on 111 LSG patients from a total of 1633 patients who underwent bariatric surgery from January 23, 2018, to December 31, 2019, at King Saud University Medical City in Riyadh, Saudi Arabia. Patients were divided into three groups: nondiabetics, prediabetics, and diabetics. For each group, demographic characteristics as well as preoperative and postoperative BMI and HbA1c values were collected. Results The mean patient age was 41.35±11.8 years, with 56.8% being female. Our analysis showed that BMI values for all three groups had a significant and nearly similar overall decrease in value postoperatively (mean difference: 14.43, p<0.001). HbA1c levels also significantly improved, with the largest reduction seen in the diabetic group (from 8.7±1.5 to 6.6±1.4, p<0.001), followed by the prediabetic group (from 5.9±0.2 to 5.4±0.3, p<0.001) and the nondiabetic group (from 5.4±0.1 to 5.2±0.3, p=0.003). Conclusion LSG leads to significant improvements in BMI and HbA1c levels. Postoperatively, diabetic patients showed the greatest reduction in HbA1c percentage, supporting LSG's role in enhancing metabolic health.

Comparative Safety and Efficacy of Roux-en-Y Gastric Bypass Versus One-Anastomosis Gastric Bypass: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Obesity has become a global epidemic, affecting both developed and developing nations. Despite extensive efforts, historical outcomes of medical interventions for obesity have been unsatisfactory. Bariatric surgeries, including sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB), are now recognized as the primary treatment for severe obesity. However, laparoscopic one-anastomosis gastric bypass (OAGB) has emerged as a promising alternative, offering simplified procedures compared to RYGB. While OAGB's initial outcomes are optimistic, concerns about biliary reflux persist. Our systematic review aims to compare the safety and efficacy outcomes of RYGB and OAGB to inform clinical decision-making in managing obesity. We searched five databases up to February 2024. We included randomized controlled trials (RCTs) comparing RYGB and OAGB in obese patients, focusing on safety and efficacy outcomes. Data extraction covered study details, participant demographics, interventions, and outcomes related to operative details, complications, follow-up results, and weight changes. The risk of bias was assessed using the Cochrane tool. The analysis involved risk ratios for dichotomous data and mean differences for continuous data, using fixed or random effects models based on heterogeneity. Analyses were performed with Review Manager software v5.4. A total of 1057 patients were included in the analysis, sourced from 12 distinct RCTs. The analysis indicated OAGB outperformed RYGB in BMI reduction (MD = -0.69, p = 0.005), whereas RYGB was more effective in excess weight loss (MD = 6.51, p < 0.0001) and excess BMI loss (MD = 3.91, p < 0.0001). OAGB led to shorter operation times (MD = -34.89 minutes, p < 0.0001) and shorter periods of hospital stays (MD = -0.27 days, p = 0.01), along with fewer overall complications (RR = 0.58, p = 0.02) and lower incidence of upper gastrointestinal endoscopy complications (RR = 2.98, p = 0.0001). On the other hand, RYGB showed higher remission rates for dyslipidemia (RR = 0.60, p = 0.0003) and higher remissions of hypertension (RR = 0.83, p = 0.04). The majority of results were homogenous. Both OAGB and RYGB have their respective advantages and limitations. OAGB appears to offer benefits in terms of operation efficiency and early postoperative recovery, making it a potentially preferable option for patients and surgeons focused on these aspects. On the other hand, RYGB might be more suitable for patients prioritizing long-term weight loss and remission of certain comorbidities like hypertension. Ultimately, the choice between OAGB and RYGB should be made on an individual basis, considering the specific needs, conditions, and goals of each patient.

Six-year analysis of 30-day post-operative leaks for primary sleeve gastrectomy: a MBSAQIP database study

BACKGROUND

Sleeve gastrectomy is the most performed bariatric surgery. Post-operative gastric sleeve leaks, although rare, are dreaded complications. This study aims to perform an updated investigation of the factors associated with sleeve leaks.

METHODS

This retrospective cohort study analyzed 692,554 cases from the MBSAQIP database (2016-2021) with CPT code 43,775 for primary sleeve gastrectomy. We excluded emergency operations, conversions/revisions, endoscopic interventions, patient with prior foregut surgery, and open operations. Multivariate logistic regression analysis (STATA version 15) was performed to identify factors associated with sleeve gastrectomy leaks.

RESULTS

Out of 692,554 patients, 600,910 (86.77%) patients underwent laparoscopic sleeve gastrectomy, and 91,644 (13.23%) patients underwent robotic sleeve gastrectomy. 1179 (0.17%) developed leaks within 30 days; 177(0.19%) were in the robotic group and 1002 (0.17%) in the laparoscopic group with no significant difference in leak rates between two groups on multivariate analysis. Black patients had lower odds of having leaks as compared to white patients (Odds Ratio (OR): 0.68 (0.56-0.82); p < 0.01). Hispanic patients had lower odds of having leak as compared to non-Hispanics. Factors associated with higher leak odds (p < 0.05) included hypertension, GERD, smoking, immunosuppression, increased operating time, and albumin < 3.5 g/dl. Higher odds of leaks were observed in years 2016-2019 vs 2020-2021 (OR: 1.44 (1.25-1.65), p < 0.01). Higher odds of leak in operations with general surgeons compared to bariatric surgeons was found (OR: 1.46 (1.04-2.02), p = 0.02); observed only on robotic group on subgroup analysis (OR: 2.2 (1.2-4.2), p = 0.02). Staple line reinforcement, oversewing, and performance of leak test showed no differences in leak rate. Bougie size and distance from pylorus were not associated with changes in leak rate.

CONCLUSION

This study provides updated insights into the factors associated with sleeve leaks, reinforcing information gained from prior studies. A higher association of leak among general surgeons could represent a learning curve for new robotic general surgeons. The overall decreasing trend for gastric sleeve leak is encouraging and may be a sign of improved techniques.

Endoscopic Management of Post-Sleeve Gastrectomy Complications

Obesity is associated with several chronic conditions including diabetes, cardiovascular disease, and metabolic dysfunction-associated steatotic liver disease and malignancy. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, is an effective treatment modality for obesity and can improve associated comorbidities. Over the last 20 years, there has been an increase in the rate of bariatric surgeries associated with the growing obesity epidemic. Sleeve gastrectomy is the most widely performed bariatric surgery currently, and while it serves as a durable option for some patients, it is important to note that several complications, including sleeve leak, stenosis, chronic fistula, gastrointestinal hemorrhage, and gastroesophageal reflux disease, may occur. Endoscopic methods to manage post-sleeve gastrectomy complications are often considered due to the risks associated with a reoperation, and endoscopy plays a significant role in the diagnosis and management of post-sleeve gastrectomy complications. We perform a detailed review of the current endoscopic management of post-sleeve gastrectomy complications.

How Does an Eating Disorder Affect Your Physical and Mental Health and How It Is Related to Sleeve Gastrectomy?

Background Obesity is the pandemic of this era. At the same time, the commercialisation of thinness has also increased its adversity. Dissatisfaction with body shape is leading to many eating disorders. These disorders further cause several health problems. It has been found that individuals with eating disorders experience insomnia, depression, and anxiety. It also affects the endocrine system and digestive systems of the body. The surgical approach provides a more efficient treatment of obesity with sustainable results. Sleeve gastrectomy is the most popular surgical treatment. Sleeve gastrectomy is one of the prominent bariatric surgeries. Patients going through sleeve gastrectomy not only lose weight but also improve their mental health. Objective This study assesses the relationship between obesity, eating disorders, and physical health. It also focuses on the prevalence of sleeve gastrectomy procedures in such individuals and their outcomes. Methods This study used a cross-sectional design and a convenient sampling technique. The obese individuals who had eating disorders residing in Medina Al-Munawara and Riyadh city were taken as the samples. Online questionnaires were shared with participants to collect their perspectives on their weight, eating disorders, and their impact on physical health. The study collected both retrospective and present data. Results A total sample of 335 participants was taken, of which 181 (54%) were females and 154 (46%) were males, with a mean BMI of 28.85±2.57. The fear of weight gain was found among 265 (79%) of participants, 151 (45%) were feeling guilt while eating, 275 (82%) were weighing themselves daily, 325 (97%) were unable to stop eating even when complete, and 117 (35%) were unable to control themselves when they have food. As per the methods of avoiding weight gain, 166 (49.6%) were skipping a meal, 157 (47%) were following a diet, 17 (5%) were inducing vomiting, and 16 (4.8%) reused laxatives and diuretics. A total of 158 (47.2%) were involved in sports, but it was reduced to 61 (18.25%) upon sickness. Only 24 (7%) participants had undergone sleeve gastrostomy, and 181 (54%) believed that their cravings had increased, 238 (71%) complained of dizziness, and 151 (45%) believed that fast food caused gut unrest. Conclusion Obese individuals who are going through eating disorders are psychologically and physically compromised. They consider skipping meals to be the most efficient means of weight loss, and only a small percentage prefer to go for sleeve gastrectomy.