Challenges associated with bariatric surgery - a multi-center report

Influence of preoperative weight loss on gastric wall thickness-analysis of laparoscopic sleeve gastrectomy histological material

PURPOSE

The variables possibly enabling the prediction of gastric wall thickness during laparoscopic sleeve gastrectomy remain undetermined. The aim of the study was to identify preoperative factors affecting gastric wall thickness in patients undergoing laparoscopic sleeve gastrectomy.

METHODS

The measurements of the double-wall thickness of gastric specimen excised during sleeve gastrectomy were taken at three locations after 15 s of compression with an applied pressure of 8 g/mm². Statistical calculations were used to determine the influence of preoperative weight loss and other perioperative parameters on gastric wall thickness.

RESULTS

The study involved one hundred patients (78 female; 22 male). The thickest tissue was observed at the antrum with the mean value 2.55 mm (range 1.77-4.0 mm), followed by the midbody, mean 2.13 mm (range 1.34-3.20 mm), and the fundus, mean 1.69 mm (range 0.99-2.69 mm). Positive relationships were found between gastric wall thickness and both preoperative weight loss and age in all three measured locations; p < 0.05. In a linear regression model, age and preoperative weight loss were found to be statistically significant and positive predictors of higher gastric wall thickness only at the antrum. Male patients were observed to have thicker gastric wall at all three locations as compared to female patients.

CONCLUSION

Preoperative weight loss should be considered an important factor influencing gastric wall thickness. Age and gender can also be helpful in predicting the varying tissue thickness. Anatomical region is a key factor determining thickness of the stomach walls.

Current Knowledge and Perceptions of Bariatric Surgery among Diabetologists and Internists in Poland

Perioperative care and follow-up after bariatric surgery (BS) engage various medical professionals. It is key for them to be well informed about these procedures. However, knowledge and attitudes may be not satisfactory enough to provide proper care. We aimed to assess knowledge and perceptions of BS among diabetologists and internists. A total of 34 diabetologists and 30 internists completed the electronic questionnaire. There were no differences in self-estimated knowledge between them, except regarding items related to the treatment of diabetes and metabolic control. Several misconceptions were identified in the questions testing the understanding of key issues in BS. Most participants considered BS effective in weight loss and metabolic control. A total of 75% highlighted the lack of appropriate equipment for dealing with morbidly obese patients. Interestingly, in a multivariable linear regression model, self-estimated knowledge was the only variable associated with frequency of referrals to bariatric surgeons. A total of 92% of respondents were interested in broadening their knowledge. Guidelines for long-term follow-up and funding were the most frequently chosen topics to explore. The study showed a positive attitude of diabetologists and internists towards surgical treatment of obesity and identified some significant gaps in knowledge. The results may be helpful in planning trainings to provide the best care for patients suffering from morbid obesity.

Impact of smoking on weight loss outcomes after bariatric surgery: a literature review

BACKGROUND

The association between smoking and surgical complications after bariatric surgery has been well-established. However, given that this patient population is inherently weight-concerned, understanding the effects of tobacco use on postoperative weight loss is essential to guiding clinicians in counseling patients. We aimed to summarize the current literature examining the effects of preoperative and postoperative smoking, as well as changes in smoking status, on bariatric surgery weight loss outcomes.

METHODS

Ovid MEDLINE, PubMed, and SCOPUS databases were queried to identify relevant published studies.

RESULTS

Overall, 20 studies were included. Preoperative and postoperative smoking rates varied widely across studies, as did requirements for smoking cessation prior to bariatric surgery. Reported preoperative smoking prevalence ranged from 1 to 62%, and postoperative smoking prevalence ranged from 6 to 43%. The majority of studies which examined preoperative and/or postoperative smoking habits found no association between smoking habits and postoperative weight loss outcomes. A minority of studies found relatively small differences in postoperative weight loss between smokers and nonsmokers; these often became nonsignificant with longer follow-up. No studies found significant associations between changes in smoking status and weight loss outcomes.

CONCLUSION

While smoking has been associated with weight loss in the general population, most current evidence demonstrates that smoking habits are not associated with weight loss outcomes after bariatric surgery. However, due to the heterogeneity in study design and analysis, no definitive conclusions can be made, and more robust studies are needed to investigate any relationship between smoking and long-term weight loss outcomes. Given the established increased risk of surgical complications and mortality in smokers, smoking cessation should be encouraged.

The Application of Enhanced Recovery After Surgery (ERAS) for Patients Undergoing Bariatric Surgery: a Systematic Review and Meta-analysis

To systematically evaluate the effectiveness and safety of the enhanced recovery after surgery (ERAS) pathway in bariatric surgery. A literature search was conducted using PubMed, Medline, EMBASE, OVID, World Health Organization International Trial Register, and Cochrane Library identifying all eligible studies comparing ERAS protocols with standard care (SC) in bariatric surgery through May 2020. Relevant perioperative parameters were extracted from the resulting studies for meta-analysis. The primary outcome was the length of hospital stay, and secondary outcomes included operation time, postoperative nausea, and vomiting (PONV), postoperative complications, readmission, reoperation, and subsequent emergency room visits. Postoperative complications were categorized according to the Clavien-Dindo classification. Final analysis included five randomized controlled trials (RCTs) and twelve observational studies which included 4964 patients in the ERAS group and 3218 patients in the SC group. The length of the hospital stay was significantly decreased (p < 0.01) after ERAS protocol management, as did the incidence of POVN (p < 0.01). No significant differences were observed between the ERAS group and SC group in terms of operation time (p = 0.37), postoperative complications (p = 0.18), readmission (p = 0.17), reoperation (p = 0.34), or emergency room visits (p = 0.65). The application of ERAS protocols in bariatric surgery is safe and feasible, effectively shortening the length of a hospital stay without compromising morbidity, and accelerating patient recovery.

Endoscopic management of early GI tract bleeding in a group of bariatric patients undergoing a fast track protocol

Introduction

Enhanced recovery after bariatric surgery (ERABS) and other fast track protocols are currently being implemented in bariatric surgery. This approach has several benefits. However, early complications may occur and require urgent re-hospitalization and management. Gastrointestinal (GI) bleeding following bariatric surgery remains one of the most serious complications requiring endoscopic treatment.

Aim

To evaluate the potential influence of early endoscopic intervention on bariatric patients’ management.

Material and methods

A clinical database was searched for patients undergoing endoscopic treatment because of GI tract bleeding following bariatric surgery under the ERABS protocol. 14 out of 1431 patients operated on were identified and their data were extracted for the purposes of this study. Patients readmitted to the hospital due to developing GI tract bleeding (group 2) were compared with patients undergoing endoscopic intervention during the initial stay (group 1), for the same purpose.

Results

We found no statistically significant differences in hemoglobin level or length of hospital stay before endoscopy between groups. Based on the analyzed data, the percentage of GI bleeding in patients operated on under the ERABS protocol in our center is 0.97% (n = 14). The rate of early (up to 30 days) readmissions due to GI tract bleeding is 0.4% (n = 5) with an overall early readmission rate of 0.91% (n = 13) in the study period since the ERABS protocol was implemented.

Conclusions

Long-term effects (% total weight loss, %TWL) of bariatric surgery do not depend on the need of early endoscopic intervention and rehospitalization. Endoscopic intervention is a safe treatment modality, not associated with risk of reoperation or complications.

The effect of surgical gastric plication on obesity and diabetes mellitus type 2: a systematic review and meta-analysis

Introduction

All the bariatric procedures have evolved greatly over the past decades and laparoscopic greater curvature plication (LGCP) is one of the quite recently introduced techniques lacking systematic evaluation.

Aim

To compare and summarize the current data in the literature in regard to the effect of gastric plication on obesity and diabetes mellitus type 2.

Material and methods

The systematic review and meta-analysis was performed according to the PRISMA guidelines and registered at PROSPERO under the registration number CRD42018114314. The literature in English and German was searched using the MEDLINE (PubMed) and BJS databases for studies published in the last 10 years. A meta-analysis was performed focusing on the effects of this operation on weight loss, glycemia control and improvement of comorbidities.

Results

Mean preoperative body mass index (BMI) ranged from 34.42 to 46.3 kg/m². Most of the patients were female. The operation time was in the range from 50 to 192.23 min. Mean follow-up was from one month to 12 years, with most studies having a follow-up of less than 2 years. The postoperative BMI ranged from 28.59 to 38, with reported excess weight loss (EWL%) in the range 20-70%. Glycated hemoglobin (HbA_1c) values decreased by up to 5.1% after surgery, ranging from 5.1% to 7.5%.

Conclusions

Despite the quality of most of the included studies being low, the present meta-analysis revealed that, in the short term, gastric plication is an effective measure for weight loss, while the effect on diabetes mellitus type 2 is not statistically significant.

Assessment of education effects on patient involvement and bariatric treatment outcome: an observational study

Introduction

As a result of the growing number of people with obesity, the popularity of bariatric surgery has been systematically increasing. It has not yet been explored whether individual education of the patient can contribute to long-term success in weight reduction after bariatric treatment.

Aim

To implement and compare the effects of different education methods, versus receiving one-time written information in the form of a guidebook, on patient involvement in abiding by lifestyle recommendations after laparoscopic sleeve gastrectomy (LSG) bariatric treatment.

Material and methods

The study included 160 patients with morbid obesity. The education session study participants were 100 patients after sleeve gastrectomy, with whom three education sessions were planned, and who were enrolled in the study. The control group consisted of 60 patients who underwent sleeve gastrectomy, and before discharge from the department, they received one-time written recommendations in the form of a guidebook.

Results

We confirmed that the three education sessions we conducted with the study group after LSG had a significant impact on weight loss. The control group, which received only written information, achieved weight loss and abided by the written recommendations, although to a lesser extent than the study group. The differences were evident particularly in motivation to adhere to recommendations and check-ups, which was significantly lower (p < 0.001) after a year of observation in the control group.

Conclusions

This study results should encourage the establishment of education as a permanent element of the LSG procedure.

Laparoscopic sleeve gastrectomy: a study of efficiency in treatment of metabolic syndrome components, comorbidities and influence on certain biochemical markers

Introduction

The worldwide outbreak of morbid obesity forced contemporary medicine to adopt a multidisciplinary approach, which led to the description of metabolic syndrome (MS): a disease with self-aggravating components and one of the most important causes of morbidity and mortality. The need for therapeutic methods provoked development of metabolic surgery, which nowadays give possibilities for safe and effective treatment of all MS aspects simultaneously and improves many obesity-related comorbidities.

Aim

To assess the laparoscopic sleeve gastrectomy (LSG) procedure's efficiency in resolving MS components, treating comorbidities and to analyze the influence on certain biochemical markers in 1-year follow-up.

Material and methods

The retrospective cohort study of 211 patients after an LSG operation relied on statistical analysis of clinical data collected prospectively in follow-up visits. All applicable guidelines and bioethical recommendations were respected in this study.

Results

Assessment of bariatric efficiency proved the LSG operation to be effective in inducing significant weight loss and treating obesity. Analysis on the influence on MS components, such as non-insulin dependent diabetes (NIDDM), arterial hypertension (AH) and dyslipidemia, showed substantial improvement in all observed cases of these diseases. In the present study, follow-up also proved a partial remission inducing effect of this bariatric operation in many comorbidities, especially in chronic obstructive pulmonary disease, obstructive sleep apnea, peptic ulcer disease and depression. A desirable reduction in creatinine, C-reactive protein, uric acid, alanine aminotransferase, asparagine aminotransferase, γ-glutamyltransferase serum levels has also been observed during the follow-up.

Conclusions

The LSG is an effective method of treatment in all areas of metabolic syndrome, provides a significant positive clinical outcome in obesity-related comorbidities and induces desirable changes in inflammatory, kidney and liver related biomarkers.