Bariatric Surgery Is Highly Effective and Underutilized in Patients with ADHD: A 5-Year Retrospective Cohort Study

INTRODUCTION

Obesity and ADHD have become increasingly common diagnoses. In the last decade, research has found that there is a high prevalence of obesity in patients with ADHD. The mainstays of management in the general population include lifestyle modifications, pharmacotherapies, and/or bariatric surgery. However, there is a lack of understanding of appropriate management of patients with both ADHD and obesity.

METHODS

We identified those with obesity for at least five consecutive years (BMI > 30) in the TriNetX database before separating into two groups based on the presence or absence of ADHD. We assessed both the distribution of treatment modalities and the change in average BMI over time in each of our four groups across 5 years.

RESULTS

Average BMI decreased over time in all groups, with the smallest change seen in the ADHD Pharmacology cohort (- 0.366 kg/m2) and the largest in the ADHD Surgery group (- 8.532 kg/m2). Average BMIs at the 5-year mark were significantly different.

CONCLUSION

Our research found that pharmacological management of individuals with ADHD was only half as effective for individuals with ADHD than our control. Though surgical management of patients with ADHD is roughly 20 times more effective in managing obesity, it was not used as frequently in comparison to medication for management of weight.

Bariatric Nutritional Intervention in Obese Patients with Compensated Liver Cirrhosis: A Four-Year Prospective Study

BACKGROUND

Obesity and liver cirrhosis represent significant health challenges, often leading to various complications.

AIMS

This prospective study aimed to investigate the impact of a four-year bariatric intervention, focusing on adherence to the Mediterranean Diet, on anthropometric, hematologic, and biochemical parameters in obese patients with compensated liver cirrhosis. Additionally, the study evaluated the concurrent contribution of weight loss to these health indicators.

METHODS

The study involved 62 patients with compensated liver cirrhosis (mean age 65.87 ± 6 years) and 44 healthy controls (mean age 59.11 ± 8 years), all with a BMI > 30 kg/m2. Both groups underwent a weight loss intervention based on the Mediterranean diet, with a four-year follow-up. Anthropometric, biochemical and hematologic parameters were evaluated at several time points during the study and their statistical significance was assessed.

RESULTS

Anthropometric parameters, including weight, BMI, waist and hip circumference, percentage of fat mass, and handgrip strength, exhibited significant improvements (p < 0.05), particularly within the first year of the intervention. Liver function tests and lipid profiles of the patients also showed significant enhancements (p < 0.05). Hematological and biochemical indices, such as hematocrit and ferritin, experienced discreet improvements in the patient cohort (p < 0.05).

CONCLUSIONS

This study highlights the potential of a structured bariatric intervention rooted in the Mediterranean diet to positively influence the health of obese patients with compensated liver cirrhosis. The observed improvements in anthropometric, biochemical, and hematologic parameters, particularly within the first year of the intervention, suggest the importance of dietary modifications in managing the health of this patient population.

Bariatric Surgeon Ergonomics: A Comparison of Laparoscopy and Robotics

INTRODUCTION

Bariatric surgery is routinely performed using laparoscopic and robotic approaches. Musculoskeletal injuries are prevalent among both robotic and laparoscopic bariatric surgeons. Studies evaluating ergonomic differences between laparoscopic and robotic bariatric surgery are limited. This study aims to analyze the ergonomic, physical, and mental workload differences among surgeons performing robotic and laparoscopic bariatric surgery.

MATERIALS AND METHODS

All primary laparoscopic and robotic bariatric surgeries, Roux-en-Y gastric bypass, and sleeve gastrectomy between May and August 2022 were included in this study. Objective ergonomic analysis was performed by an observer evaluating each surgeon intraoperatively according to the validated Rapid Entire Body Assessment tool, with a higher score indicating more ergonomic strain. After each operation, surgeons subjectively evaluated their physical workload using the body part discomfort scale, and their mental workload using the surgery task load index.

RESULTS

Five bariatric surgeons participated in this study. In total, 50 operative cases were observed, 37 laparoscopic and 13 robotic. The median total Rapid Entire Body Assessmentscore as a primary surgeon was significantly higher in laparoscopic (6.0) compared to robotic (3.0) cases (P < 0.01). The laparoscopic and robotic approaches had no significant differences in the surgeons' physical (body part discomfort scale) or mental workload (surgery task load index).

CONCLUSIONS

This study identified low-risk ergonomic stress in surgeons performing bariatric surgery robotically compared to medium-risk stress laparoscopically. Since ergonomic stress can exist even without the perception of physical or mental stress, this highlights the importance of external observations to optimize ergonomics for surgeons in the operating room.

Bariatric arterial embolization in patients with body mass index ranging from 25 to 40 kg/m2: A systematic review & meta-analysis

The present review sought to evaluate by meta-analysis the efficacy of bariatric arterial embolization (BAE) in promoting weight loss in patients with body mass index (BMI) ranging from 25-40 kg/m2. This study was performed and reported according to Preferred Reporting Items for Systematic reviews and Meta-analysis guidelines. A systematic literature search of MEDLINE, Embase Google Scholar, and World Health Organization Library database was done for studies evaluating BAE for promoting weight loss in patients with BMI ranging from 25-40 kg/ m2 published up to March 10, 2021. Primary outcome measure included weight loss after the embolisation procedure. Three single-arm studies comprising of a total of 28 patients (BMI: 25- 40 kg/m2) were found eligible for meta-analysis. All patients underwent embolization with either Embosphere microspheres or PVA particles. The predominant artery embolised was left gastric artery (in all patients). Additional arteries embolised included gastroepiploic artery (8 patients), or accessory left gastric artery (1 patient), or short gastric artery (1 patient). Pooled absolute mean weight loss was 7.854 kg (95% CI: 6.103-9.605). No significant statistical heterogeneity was detected (I2=51.75%, P=0.126) among pooled studies. In conclusion, limited single-arm studies report BAE as an effective, and relatively safe procedure for promoting weight loss in patients with BMI ranging from 25-40 kg/m2, although the number of patients included is very small. Initial results of BAE in promoting weight loss are promising with no major/severe complications reported; however, long term follow-up is required to see the sustainability of the effects.

The patient-practitioner interaction in post bariatric surgery consultations: an interpersonal process recall study

PURPOSE

The patient-practitioner relationship is fundamental to rehabilitation practice and patients' health and wellbeing. Dissonance between patients who have had bariatric surgery and health care practitioners about what supportive care and good outcomes are can undermine care. To address the mechanisms of this process, we conducted an Interpersonal Process Recall study.

MATERIALS AND METHODS

We interviewed patients (11), video recorded consultations (10), conducted video-assisted individual interviews with patients (10) and practitioners (11) and a dyadic data analysis.

RESULTS

We identified relational states and shifts in the clinical encounter 2-3 years post-surgery, described in themes: a) Playing by the Book - Making it Easier for Each Other, b) Down the Blind Alley - Giving up on Each Other, and c) Opposite Poles - Towards and Away from Each Other.

CONCLUSIONS

The post-surgery consultations facilitated responsibility for health and self-care but did not invite dialogues about the psychosocial burdens of living with obesity and undergoing bariatric surgery. Patients and practitioners tried to avoid creating conflict, which in turn seemed to foster distance, rather than human connection. This limits the encounter's benefit to both parties, leaving them frustrated and less willing to either meet again or take any gains into their future lives.IMPLICATIONS FOR REHABILITATIONIllness evokes feelings of stress and uncertainty and is experienced very differently from the perspective of patients and health care practitioners (HCPs), who encounter each other in a field fraught with tension.Bodily changes and difficult emotions related to food and eating are to be expected when undergoing bariatric surgery, and to explicitly "notice, name and validate" emotions can promote the patient's capacity to sustain self-care, lifestyle change, weight loss and health gains.Making interpersonal connection and interaction between patient and HCP the centre of bariatric aftercare can enhance engagement in and outcomes of the post-surgery clinical encounter.

Postoperative micronutrient changes in bariatric surgery patients compliant with nutritional supplementation

BACKGROUND

Bariatric surgery is commonly used in patients with body mass indexes over 35 kg/m and obesity-related comorbidities. Despite the significant clinical benefits of bariatric surgery, nutritional deficiencies post-surgery remain a challenge for both patient and healthcare provider [Toninello et al. in Nutrients 13:1565, 2021, Gasmi et al. in Eur J Nutr 61:55-67, 2022]. Nutritional supplementation is a way of reducing the likelihood of postoperative deficiencies; however, prior studies have shown varying degrees of mostly poor to moderate patient adherence [Spetz et al. in Obes Res Clin Pract 16:407-412, 2022, Mahawar et al. in Obes Surg 29:1551-1556, 2019, Santonicola et al. in J Am Nutr Assoc 41:11-19, 2022, Sherf Dagan et al. in Obes Surg 27:2258-2271, 2017]. Our present study aims to provide insights into the micronutrient biochemical profile in patients previously found to be compliant with supplementation following roux-en-y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG).

METHODS

An 11-point outpatient survey was administered to consecutive patients ≥ 18 years who had undergone either RYGB or VSG to determine adherence with nutritional supplementation. Medical records were retrospectively reviewed to determine preoperative and postoperative lab values, including vitamins A, B1, B12, and D, thyroid stimulating hormone (TSH), iron binding capacity, transferrin, ferritin, folate, iron, albumin, hemoglobin A1C, zinc, glomerular filtration rate (GFR, and liver function values. Values were classified as "abnormal" or "normal." Preoperative and postoperative values were compared for differences. Postoperative values were also compared between RYGB and VSG.

RESULTS

There were no significant differences between preoperative and postoperative values for any nutritional marker aside from vitamin B12. A total of 51/60 patients (85.0%) had normal preoperative B12 measurements, compared with 40/65 (61.5%) patients postoperatively (P = 0.03). Notably, of 25 "abnormal" postoperative measurements, 20 (80%) were elevated values. There were no differences in postoperative deficiencies between RYGB and VSG.

CONCLUSIONS

Patients in our sample did not have worsened micronutrient deficiencies following bariatric surgery, and there were no differences in micronutrient deficiencies between surgical technique.

Hypothesis that alpha-amylase evokes regulatory mechanisms originating in the pancreas, gut and circulation, which govern glucose/insulin homeostasis

The anti-incretin theory involving the abolishment of diabetes type (DT) II by some of methods used in bariatric surgery, first appeared during the early years of the XXI century and considers the existence of anti-incretin substances. However, to date no exogenous or endogenous anti-incretins have been found. Our concept of the acini-islet-acinar axis assumes that insulin intra-pancreatically stimulates alpha-amylase synthesis ("halo phenomenon") and in turn, alpha-amylase reciprocally inhibits insulin production, thus making alpha-amylase a candidate for being an anti-incretin. Additionally, gut as well as plasma alpha-amylase, of pancreatic and other origins, inhibits the appearance of dietary glucose in the blood, lowering the glucose peak after iv or oral glucose loading. This effect of alpha-amylase can be interpreted as an insulin down regulatory mechanism, possibly limiting the depletion of pancreatic beta cells and preventing their failure. Clinical observations agree with the above statements, where patients with high blood alpha-amylase concentrations are seldom obese and seldom develop DT2. Obese-DT2, as well as DT1 patients, usually develop exo-crine pancreatic insufficiency (EPI) and vice versa. Ultimately, DT2 patients develop DT1, when the pancreatic beta cells are exhausted and insulin production ceases. Studies on biliopancreatic diversion (BPD) and on BPD with duodenal switch, a type of bariatric surgery, as well as studies on EPI pigs, allow us to observe and investigate the above-mentioned phenomena of intra-pancreatic interactions.

Impact of Medical and Surgical Obesity Treatment on Dental Caries: A 2-Year Prospective Cohort Study

The objective was to study the long-term effects on oral health of bariatric surgery compared with medical treatment of obesity. Swedish females with morbid obesity (n = 66; 18-35 years at baseline) were followed prospectively from before obesity treatment until 2 years after treatment. The main response variable was dental caries registered according to the ICDAS-II system. Possible confounding factors, such as sociodemographic characteristics, general health, oral health habits, and oral hygiene, were controlled for. The statistical methods included χ2 tests, Student's t tests, one-way ANOVA, Wilcoxon's nonparametric tests, and linear regression models. In the surgically treated patients (n = 40), a significant increase over time in enamel caries (mean increase 4.13 tooth surfaces ICDAS1-2), dentine caries (mean increase 2.18 tooth surfaces ICDAS3-6), and total caries (mean increase 6.30 tooth surfaces ICDAS1-6) was registered (all p < 0.001), which was not seen in the medically treated patients (n = 26). However, the difference between the treatment groups (surgical or medical) was only statistically significant for enamel caries (crude β 4.89, p = 0.003) and total caries (crude β 6.53, p < 0.001). The relationships were stable and independent of differences in confounders as socioeconomy, general health, and oral health behaviors. In conclusion, 2 years after obesity treatment, a significant increase in dental caries was registered in the surgically treated but not in the medically treated women. The dental service should intensify its preventive efforts in individuals undergoing obesity treatment.

Anaesthetic nurse specialist role in perioperative anaesthetic management of patients who are morbidly obese

This integrative literature review examined the role of an anaesthetic nurse specialist (ANS) in the perioperative anaesthetic nursing management of morbidly obese patients associated with elective orthopaedic surgery. The responsibility of the ANS is to provide high-quality perioperative anaesthetic care to ensure patient safety. Morbid obesity is increasing globally, with significant implications for healthcare delivery, care and treatment, including perioperative care. The Association of Anaesthetists of Great Britain and Ireland emphasises that the perioperative management of these patients presents significant organisational and practical issues. However, there are limited data or guidelines on whether surgeons, anaesthetists and nurses routinely take special precautions in managing morbidly obesity patients undergoing elective orthopaedic operative procedures. The authors carried out a search of databases, followed by an integrated literature review and synthesis of 11 studies. The main findings revealed significant clinical challenges and resource requirements for perioperative anaesthetic management of this patient group. Recommendations are made to prepare for and manage these surgical patients, from preoperative assessment to postoperative care.

Endoscopic sleeve gastroplasty: early results of a minimally invasive procedure in patients with obesity

OBJECTIVES

We aimed to analyze the efficacy and safety of endoscopic sleeve gastroplasty at 3 months as well as to determine factors influencing post-procedural weight loss.

METHODS

Seventy-three patients with obesity classes I, II and III (BMI 31.1-46.6 kg/m²) underwent ESG between September 2021 and April 2022 at a tertiary care hospital using Overstitch (Apollo Endosurgery, Austin, TX). ESG's efficacy and safety was evaluated at 1 and 3 months post-procedure with regard to excess weight loss (EWL) and total weight loss (TWL). Categorical variables were expressed as percentages and compared with chi-square test while continuous variables were expressed as mean ± standard deviation and compared with paired t test and analysis of variance (ANOVA) as applicable. Pearson's correlation was used to determine association between factors at baseline and weight loss.

RESULTS

Mean age was 49.2 ± 9.7 years with 61 (83.6%) patients being female. Mean initial weight was 105.7 ± 15.7 kg, and mean BMI was 38.6 ± 3.5 kg/m². Median hospitalization was 2.0 ± 1.8 days with 62 (84.9%) patients discharged after 24 h. One patient had accidental suturing of the stomach to the abdominal wall and diaphragm which was managed laparoscopically. Mean %EWL was 25.4 ± 7.1 and 36.3 ± 11.4, and %TBWL was 11.2 ± 2.6 and 15.8 ± 4.2 at 1 and 3 months, respectively. Significant excess weight loss at 3 months was only observed in patients with BMI < 40 kg/m² (p = 0.001).

CONCLUSIONS

ESG is safe and effective to manage obesity. Significant weight loss at 3 months was only observed in patients with obesity class I and class II.

Current Trends in the Utilization of a Robotic Approach in the Field of Bariatric Surgery

PURPOSE

The utilization rate of robotic surgery for bariatric procedures is not well-described. Our study identified the proportion of metabolic and bariatric surgery (MBS) procedures in the United States between 2015 and 2020 performed using a robotic (R-) or laparoscopic (L-) approach.

MATERIALS AND METHODS

A descriptive analysis of the 2015-2020 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant User Data File (PUF) datasets was performed. The primary outcome was (1) surgical cases performed annually and (2) proportion of cases performed using a R- or L- approach. Analysis was done separately for sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS), and revisional bariatric surgery (RBS). Statistical analysis consisted of means and proportions, fold difference, annual slope, and Student's t tests or chi-square tests as appropriate, with statistical significance set to p < .05.

RESULTS

A total of 1,135, 214 procedures were captured between 2015 and 2020. R-RYGB increased from 2554 to 6198 (6.8% to 16.7%), R-SG increased from 5229 to 17,063 (6.0% to 17.2%), R-RBS increased from 993 to 3386 (4.7% to 17.4%), and R-BPD-DS increased from 221 to 393 (22.0% to 28.4%). The greatest annual increase was observed among R-RBS and R-SG (3.70-fold difference; slope 2.4% per year and 2.87-fold difference; slope 2.2% per year, respectively).

CONCLUSION

There is a nationwide increase in the utilization of a R- approach in bariatric surgery. There are concerns related to the potential increase in healthcare expenditures related to robotics. Further studies are needed to establish key performance indicators along with guidelines for training, adoption and utilization of a R- approach.

Four-year outcomes for endoscopic sleeve gastroplasty from a single centre in India

Background

Bariatric endoscopy has emerged for non-surgical treatment of obesity, providing a treatment option for weight loss and associated comorbidities. Outcomes of endoscopic sleeve gastroplasty (ESG) of 12 months have been published by our team and there is a need for longer follow-up period understanding the effects of ESG techniques.

Aim

This report emphasises on weight loss pattern in follow-up time points and monitors the post-procedure improvement in comorbidities with minimum 4-year follow-up of patients undergoing ESG at a single academic centre in India.

Subjects and Methods

This was a prospective cohort study. All procedures were performed by the same surgeon. Patients with a body mass index of >30 kg/m² (or >27 with comorbidities) underwent ESG for treatment of obesity. Patients were systematically followed yearly after their procedure. Data collected on the primary outcome and secondary outcomes were analysed and presented.

Results

612 patients (69.3% female) with a mean age of 40.70 ± 12.66 years and mean body mass index of 34.30 ± 5.05 kg/m² underwent ESG. Out of 612 patients, follow-up rates for a 1-2-3 and 4 years were 93.1%, 90.2%, 81.7% and 81.9%, respectively. The mean percentage total body weight loss was 18.19% (95% confidence interval [CI]: 17.72-18.57) and %EWL was 49.30% (95% CI: 48.91-49.68) with 90% of participants-maintaining a percentage of total weight loss of ≥5% and 70% of patients maintaining an EWL of ≥25% at 4 years, respectively. Resolution/improvement of comorbidities was 51.2% cases of T2DM, 65.8% cases of hypertension, 73.6% cases of dyslipidaemia and 89.9% remission were in obstructive sleep apnoea. No patient required an emergency intervention, and there was no mortality or significant morbidity.

Conclusions

This study shows acceptable results with ESG at 4 years in our unit. Regular monitoring by a multidisciplinary nurtures weight loss, resolution or improvement of comorbidities and improvement of quality of life with low perioperative complications. There is a need for more reports with this approach to determine the amount and duration of weight loss outcome and medical intervention.

Efficacy and safety of intragastric balloon for obesity in Korea

Background/Aims

Intragastric balloon (IGB) is the only available endoscopic bariatric and metabolic therapy in Korea. End-ball (Endalis) has the longest history of clinical use among the IGBs available in Korea. However, little clinical data on this system have been reported. In this study, we aimed to evaluate the efficacy and safety of End-ball in Korea.

Methods

We performed a retrospective cohort study of patients who underwent IGB insertion (End-ball) from 2013 to 2019. Demographic and anthropometric data were collected. The efficacy and safety of IGB treatment were analyzed.

Results

In total, 80 patients were included. Mean age was 33.7 years and 83.8% were female. Initial body mass index was 34.48±4.69 kg/m2. Body mass index reduction was 3.72±2.63 (kg/m2) at the time of IGB removal. Percent of total body weight loss (%TBWL) was 10.76%±6.76%. Percentage excess body weight loss was 43.67%±27.59%. Most adverse events were minor, and 71.4% of participants showed nausea, vomiting, or abdominal pain.

Conclusions

IGB treatment showed good efficacy and safety profile in Korean patients with obesity. In terms of %TBWL and percentage excess body weight loss, the efficacy was similar to that in the Western population.

Challenges of developing and executing a multi-site registry for a novel device with evolving indications for use

BACKGROUND

The introduction of new technologies in endoscopy has been met with uncertainty, skepticism, and lack of standardization or training parameters, particularly when disruptive devices or techniques are involved. The widespread availability of a novel endoscopic suturing device (OverStitch™) for tissue apposition has enabled the development of applications of endoscopic suturing.

METHODS

The American Gastroenterological Association partnered with Apollo Endosurgery to develop a registry to capture in a pragmatic non-randomized study the safety, effectiveness, and durability of endoscopic suturing in approximating tissue in the setting of bariatric revision and fixation of endoprosthetic devices.

RESULTS

We highlight the challenges of the adoption of novel techniques by examining the process of developing and executing this multicenter registry to assess real-world use of this endoscopic suturing device. We also present our preliminary data on the safety and effectiveness of the novel device as it is applied in the treatment of obesity.

CONCLUSIONS

The Prospective Registry for Trans-Orifice Endoscopic Suturing Applications (ES Registry) was an effective Phase 4, postmarketing registry aimed at capturing pragmatic, real-world use of a novel device. These findings serve to solidify the role of endoscopic suturing in clinical practice.

Do bariatric patient's in rural areas achieve comparative weight loss as national average? single center experience in appalachia west virginia

INTRODUCTION

Obesity is one of the leading public health concerns with over half a million Americans being classified as obese and almost two billion classified as overweight. This has an impact on overall health of the individual, with increased comorbidities and premature death, as well as increased economic cost. This study evaluates the weight loss of patients with limited societal support and resources cared for at a single bariatric center of excellence, The Center for Surgical Weight Control, in Cabell County, West Virginia.

METHODS

Retrospective review of patients that have undergone either a Vertical Sleeve Gastrectomy (VSG) or a Roux-en-Y gastric bypass (RNYGB) between the years of 2017 and 2018 At the Center for Surgical Weight Control. Weight loss was evaluated at 6 months, 1 year, and 2 years.

RESULTS

There were 290 patients between 2017 and 2018. On average, the VSG group lost 46% of excess body weight (EBW) at 6 months, 57% of EBW at 1 year, and 61% of EBW at 2 years. In the RNYGB group patients lost on average 54% of EBW at 6 months, 65% of EBW at 1 year, and 88% of EBW at 2 years.

DISCUSSION

A loss of 5-15% of EBW can improve obesity-related comorbidities. These comorbidities include diabetes, hypertension, hyperlipidemia, gastroesophageal reflux disease, and obstructive sleep apnea. Improvement in these comorbidities not only benefits each patient individually, but will also help improve the effects on society as a whole.

CONCLUSION

Obesity is a debilitating and deadly disease, thus makes it very important to address in order to reduce burden on both patients and society as a whole. There is an expected amount of weight loss a patient should have depending on the type of surgery they undergo. Our patients were successful at meeting and exceeding the expected percentage of EBW loss after both VSG and RNYGB.

Distal gastric bypass revision for weight recurrence or nonresponse to primary procedure: initial experience and outcomes in an academic practice

BACKGROUND

Considerable weight recurrence (WR) after Roux-en-Y gastric bypass (RYGB) may occur in nearly 20% of patients. While several nonoperative, endoscopic, and surgical interventions exist for this population, the optimal approach is unknown. This study reports our initial experience with distal bypass revision (DGB) and provides a comparison with patients after primary RYGB.

METHODS

Single-institution, retrospective review was conducted for patients who underwent DGB from 2018 to 2020. A Roux and common channel of 150 cm each were constructed (total alimentary limb 300 cm). A group of primary RYGB patients with similar demographics were selected as controls. Demographics, comorbidity resolution, surgical technique, complications, excess weight loss (EWL), total weight loss (TWL), BMI, and weight change data were compared. Patient postoperative weight loss (WL) was also compared after their primary and DGB operations.

RESULTS

Sixteen DGB patients, all female, were compared with 29 controls. DGB was performed on average 12.3 years after primary RYGB. In the DGB group, mean BMI was 53.7 before primary RYGB, 31.9 at nadir, and 44.1 prior to DGB. Post-DGB, mean BMI was 40.5, 37.4, 34.8, and 34.4, at 3-, 6-, 12-, and 24-months, respectively. Five patients (31.3%) experienced complications and were readmitted within 30 days, with two of them (12.5%) requiring reintervention and one (6.3%) undergoing reoperation. Mean EWL and TWL up to 2 years after DGB were lower than that after the patient's original RYGB (52.3 ± 18.6 vs. 67.2 ± 33.2; p = 0.126 and 19.6 ± 13.3 vs. 29.6 ± 11.8; p = 0.027, respectively).

CONCLUSIONS

DGB resulted in excellent WL up to 2 years after surgery but was associated with considerable postoperative complication rates. The magnitude of TWL was lower compared with the primary operation. Only a few patients experienced nutritional complications. Results of this study can help counsel patients pursuing DGB for WR or nonresponse to primary RYGB. The comparative effectiveness of this approach to other available options remains to be determined.

Early postoperative weight loss predicts nadir weight and weight regain after laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass

BACKGROUND

Weight regain (WR) post bariatric surgery affects almost 20% of patients. It has been theorized that a complex interplay between physiologic adaptations and epigenetic mechanisms promotes WR in obesity, however, reliable predictors have not been identified. Our study examines the relationship between early postoperative weight loss (WL), nadir weight (NW), and WR following laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG).

METHODS

A retrospective review of prospectively collected data was conducted for LRYGB or LSG patients from 2012 to 2016. Demographics, preoperative BMI, procedure type, and postoperative weight at 6, 12, 24, 36, and 48 months were recorded. WR was defined as > 20% increase from NW. Univariate and multivariate linear and logistic regression models were used to determine the association between early postoperative WL with NW and WR at 4 years.

RESULTS

Thousand twenty-six adults were included (76.8% female, mean age 44.9 ± 11.9 years, preoperative BMI 46.1 ± 8); 74.6% had LRYGB and 25.3% had LSG. Multivariable linear regression models showed that greater WL was associated with lower NW at 6 months (Coef - 2.16; 95% CI - 2.51, - 1.81), 1 year (Coef - 2.33; 95% CI - 2.58, - 2.08), 2 years (Coef - 2.04; 95% CI - 2.25, - 1.83), 3 years (Coef - 1.95; 95% CI - 2.14, - 1.76), and 4 years (Coef - 1.89; 95% CI - 2.10, - 1.68), p ≤ 0.001. WR was independently associated with increased WL between 6 months and 1 year (Coef 1.59; 95% CI 1.05,2.14; p ≤ 0.001) and at 1 year (Coef 1.24; 95% CI 0.84,1.63;p ≤ 0.001) postoperatively. The multivariable logistic regression model showed significantly increased risk of WR at 4 years for patients with greater WL at 6 months (OR 1.20, 95% CI 1.08,1.33; p = 0.001) and 1 year (OR 1.14; 95% CI 1.06,1.23; p ≤ 0.001).

CONCLUSION

Our findings demonstrate that higher WL at 6 and 12 months post bariatric surgery may be risk factors for WR at 4 years. Surgeons may need to follow patients with high early weight loss more closely and provide additional treatment options to maximize their long-term success.

Perception of Bariatric Surgery and Endoscopic Bariatric Therapies Among Primary Care Physicians

INTRODUCTION

In the USA, less than 1% of eligible patients who qualify for bariatric surgery ultimately undergo surgery. Perceptions of endoscopic bariatric therapies (EBTs) for weight management remain unknown.

METHODS

A 22-question survey was distributed to primary care physicians (PCPs) across the Mayo Clinic healthcare system. Survey invitations were sent via email, and all surveys were unanimously conducted electronically.

RESULTS

A total of 130 PCPs participated in the survey (40% response rate). Twenty-four PCPs were between 20 and 24 years out of training (18.5%), and 71 (54.6%) were female. Most providers had a body mass index (BMI) between 18.5 and 24.9 kg/m² (n = 62, 47.7%). Among the weight loss options discussed during clinic visits, PCPs discussed lifestyle modification including diet and exercise (n = 129; 99.2%), and 68 PCPs (52.3%) were not aware of EBTs as weight loss interventions. While 46.2% of the PCPs agreed that a bariatric endoscopy is an effective option for weight loss, only 24.6% of PCPs were familiar with the indications for EBTs. Most of the cohort (n = 69, 53.1%) experienced barriers in referring their patients. Moreover, most of the patients referred to bariatric clinics were from PCPs who had a BMI between 18.5 and 24.9 kg/m² (n = 62, 47.7%) as compared to PCPs with a BMI of 40 kg/m² and greater (n = 5, 3.8%).

CONCLUSIONS

Due to the rise of bariatric therapies in recent years, PCPs are increasingly involved in the referral and management of patients with obesity and obesity-related comorbidities. However, knowledge gaps regarding weight loss options, including EBTs, could limit optimal care to patients desiring medically monitored weight loss.

Outcome prediction in bariatric surgery through video-based assessment

INTRODUCTION

The relationship between intraoperative surgical performance scores and patient outcomes has not been demonstrated at a single-case level. The GEARS score is a Likert-based scale that quantifies robotic surgical proficiency in 5 domains. Given that even highly skilled surgeons can have variability in their skill among their cases, we hypothesized that at a patient level, higher surgical skill as determined by the GEARS score will predict individual patient outcomes.

METHODS

Patients undergoing robotic sleeve gastrectomy between July 2018 and January 2021 at a single-health care system were captured in a prospective database. Bivariate Pearson's correlation was used to compare continuous variables, one-way ANOVA for categorical variables compared with a continuous variable, and chi-square for two categorical variables. Significant variables in the univariable screen were included in a multivariable linear regression model. Two-tailed p-value < 0.05 was considered significant.

RESULTS

Of 162 patients included, 9 patients (5.5%) experienced a serious morbidity within 30 days. The average excess weight loss (EWL) was 72 ± 12% at 6 months and 74 ± 15% at 12 months. GEARS score was not significantly correlated with EWL at 6 months (p = 0.349), 12 months (p = 0.468), or serious morbidity (p = 0.848) on unadjusted analysis. After adjusting, total GEARS score was not correlated with serious morbidity (p = 0.914); however, GEARS score did predict EWL at 6 (p < 0.001) and 12 months (p < 0.001). All GEARS subcomponent scores, bimanual dexterity, depth perception, efficiency, force sensitivity, and robotic control were predictive of EWL at 6 months (p < 0.001) and 12 months (p < 0.001) on multivariable analysis.

CONCLUSION

For patients undergoing sleeve gastrectomy, surgical skill as assessed by the GEARS score was correlated with EWL, suggesting that better performance of a sleeve gastrectomy can result in improved postoperative weight loss.

Factors and Outcomes Associated With Venous Thromboembolism Following Bariatric Surgery

BACKGROUND

The present national study characterized the incidence and factors associated with VTE following bariatric operations and its association with postoperative outcomes and resource use.

METHODS

Adults (≥18 years) undergoing elective sleeve gastrectomy or gastric bypass (laparoscopic and open) were identified in the 2016-2018 Nationwide Readmissions Database. International Classification of Diseases 10th Revision codes for deep venous thrombosis and/or pulmonary embolism were used to ascertain the presence of VTE. Multivariable linear and logistic models were developed to evaluate the independent association of VTE with outcomes of interest.

RESULTS

Of an estimated 537,522 patients meeting inclusion criteria, .55% developed VTE during index hospitalization (.14%) or within 90 days of index discharge (.41%). Compared to others, VTE patients were older (51.8 vs 44.9 years, P<.001), more commonly male (20.0% vs 31.5%, P<.001), and had gastric bypass (56.3% vs 31.9%, P<.001) or an open procedure (21.9% vs 2.6%, P<.001). After risk adjustment, several factors including increasing age, male gender, gastric bypass and open approach remained associated with increased odds of VTE. Patients with VTE during index hospitalization had greater odds of mortality (AOR 11.6, 95% CI: 6.12-22.19) and increased index LOS (β:+14.1 days, 95% CI: 11.7-16.5) and hospitalization costs (β: +$53,100, 95% CI: 43,100-63,500). Additionally, VTE patients had greater odds of readmission within 90 days (AOR 1.86, 95% CI: 1.40-2.47).

CONCLUSIONS

Although VTE is uncommon following bariatric operations, it is significantly associated with increased mortality, readmission, and resource use. Further research is necessary to ascertain optimal management of VTE for bariatric surgery patients.

Tulane STAR (Sending Texts, Advancing Results): impact of text messaging on bariatric post-operative protocol compliance

BACKGROUND

Text messaging is frequently employed in the outpatient setting to communicate with or send reminders to patients. However, there is a paucity of literature on the impact of text messaging on inpatient care. In this study, the use of text messaging in hospitalized patients is evaluated by assessing patient compliance to a post-operative bariatric protocol.

METHODS

This was a randomized controlled trial that studied compliance to a post-operative bariatric protocol in patients who underwent bariatric surgery at a tertiary, academic medical center between February and May 2021. Patients were randomized to either the control group, in which they received standard post-operative education alone or the Tulane Sending Texts, Advancing Results (STAR) intervention arm, in which participants received the same post-operative education along with two text message reminders to drink water, use their incentive spirometers, and ambulate (per post-operative instructions) on post-operative day (POD) # 0 and POD # 1. The primary outcome was compliance with the protocol, defined as the number of 1-oz cups of water consumed, incentive spirometry usage, and ambulation frequency and distance. Secondary outcomes include length of stay and complications.

RESULTS

A total of 35 patients were enrolled in the study (17 control, 18 STAR intervention). There was no significant difference in age, BMI, or type of surgery performed between the two groups. Clear liquid consumption was significantly higher in the STAR intervention group with an average of 27.7 ± 3.5 cups as compared to 18.2 ± 8.9 in the control group (p < 0.001). Similarly, statistically significant increases in incentive spirometry usage (p < 0.01) and ambulation distance and frequency (p < 0.02) were observed in the STAR intervention group.

CONCLUSIONS

While patients are in the hospital, text messaging can improve compliance to post-operative protocols. Peri-operative text messaging can enhance patient education and communication.

The Association Between Bariatric Surgery and Psychiatric Disorders: a National Cohort Study

PURPOSE

Previous studies have shown that bariatric surgery reduces the risk of cardiovascular outcomes. Less is known about the effects of bariatric surgery on psychiatric disorders. This cohort study compared the differential risk of psychiatric disorders between those who did and did not undergo bariatric surgery, from before until after the surgery.

MATERIALS AND METHODS

We used PearlDiver-Mariner, a national all-payor claims database. Patients were followed for 1 year before and after the index date and a difference-in-differences (DiD) study design was executed.

RESULTS

We included 56,661 bariatric surgery patients matched to 56,661 individuals with obesity. Among bariatric surgery patients, the risk of psychiatric was 18% 1 year before and increased to 70% 1 year after surgery. Among individuals with obesity, the risk of psychiatric disorders also increased from 1 year before to 1 year after, but by less (21% versus 46%). DiD analysis suggested that bariatric surgery was associated with a 27 percentage point differential increase in the risk of psychiatric disorders across all patients, representing a 135% relative increase. Results using 3 years as the pre- and post-periods lead to similar inferences.

CONCLUSION

Preexisting psychiatric disorders are similarly prevalent among bariatric surgery patients and individuals with obesity. The prevalence of psychiatric disorders increased over time for both groups, but to a larger extent among bariatric surgery patients. Adequate treatment for psychiatric disorders and appropriate implementation of behavioral health interventions may be needed to reduce the burden of psychiatric disorders following bariatric surgery.

Surgical Resection of Gastro-Pleural-Bronchial Fistula after Prolonged Endoscopic Treatments

Sleeve gastrectomy is the most commonly performed bariatric surgery in the United States. While complication rates are typically low, some studies have reported leaks in up to 2.4-5.3% of cases. Here, we examine such a case with subsequent failure of numerous endoscopic interventions ultimately necessitating formal resection of a gastro-Pleural-bronchial fistula.

Sedation in a patient with super obesity: Case report

Obesity is associated with increased morbidity and mortality. Sedation of the procedure for these patients can pose significant challenges. Conscious sedation is the cause of many potentially serious unplanned events during endoscopy. A case report of sedation with propanidid in a patient with super obesity for endoscopic procedure is presented. Propanidid has demonstrated its safety and efficacy in short procedures in obese people.

Long-Term (> 6 Years) Outcomes of Duodenal Switch (DS) Versus Single-Anastomosis Duodeno-Ileostomy with Sleeve Gastrectomy (SADI-S): a Matched Cohort Study

BACKGROUND

There are no comparative studies on the long-term outcomes after the primary traditional duodenal switch (DS) and single-anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S).

PURPOSE

This study aims to compare the long-term outcomes in a matched cohort.

SETTING

This study took place in a single private institute, in the USA.

MATERIALS AND METHODS

Data from 266 patients who underwent a primary laparoscopic traditional DS or primary laparoscopic SADI-S from September 2011 to December 2015 by four surgeons were used for a retrospective matched cohort. Data were obtained by matching every DS patient to a SADI-S patient of the same age, sex, and body mass index (BMI). In addition, only patients that were out at least 5 years and had a minimum 5-year follow-up were included in the study.

RESULTS

The matched cohort included 30 DS and 30 SADI-S patients. There were no statistically significant differences in the preoperative characteristics and baseline comorbidities between both groups. The SADI-S patients had significantly shorter operative time and length of stay. The overall long-term complications, especially the long-term Clavien-Dindo grade IIIb complications, were significantly fewer with SADI-S. At 6 years, the DS patients had statistically higher %EWL; however, the ending BMIs were statistically similar between both groups. There were no significant differences in the long-term comorbidity and nutritional outcomes of both groups. The long-term failure rates were comparable.

CONCLUSIONS

Most long-term outcomes of SADI-S were either similar or significantly better than DS. Part of the reasons could be the surgeon's learning curve and the small sample sizes of both groups.

Left gastric artery embolization for obesity treatment: a systematic review and meta-analysis of human and animal studies

PURPOSE

The main purpose of this systematic review was to reflect on recent literature on bariatric LGA embolization for obesity treatment and to compare this new procedure in human and animal studies.

METHODS

A systematic search of Scopus, MEDLINE, Web of Science, Embase, and Google Scholar was performed to identify human and animal studies employing bariatric LGA embolization to treat obesity. As well, Cochrane's Q test and the I² statistic were utilized to determine heterogeneity.

RESULTS

Nine human and four animal studies recruiting a total of 118 cases (n = 78 patients and n = 40 animals) were included in analysis. All assessments on body mass index (BMI), weight, and ghrelin levels had been fulfilled based on before-after (human studies) and intervention-control designs (animal studies) using bariatric LGA embolization. The findings suggested that bariatric LGA embolization had significantly decreased BMI (mean difference (MD): - 2.66, 95% confidence interval [CI] - 3.74, - 1.58, P < 0.001) and weight (MD: - 8.69, 95% CI - 10.48, - 6.89, P < 0.001) in humans. Although overall pooled estimate showed no significant changes in ghrelin levels following this procedure (Hedges' g statistic: - 0.91, 95% CI - 1.83, 0.01, P = 0.05) in humans, a significant reduction was observed in animal studies (MD: - 756.56, 95% CI - 1098.79, - 414.33, P < 0.001) along with a significant drop in weight (MD: - 7.64, 95% CI - 13.73, - 1.54, P < 0.001).

CONCLUSION

The present study concluded that ghrelin levels in humans had not been affected, although bariatric LGA embolization might significantly improve BMI and weight.

Challenges in management of nephrolithiasis in a patient with class III obesity (BMI 97)

Patients with severe obesity have an increased risk of renal and ureteral calculi formation, and therefore, increased risk of associated complications. Despite the expanding number of people with obesity, there remains a dearth of scientific literature and training in navigating the associated limitations of our healthcare system. We present a case of a patient with severe, class III obesity (BMI 97) who was transferred to our tertiary care center for treatment of obstructive kidney stone disease. We highlight challenges in caring for our patient and discuss our approach and lessons learned for care of this vulnerable bariatric population.

Contamination of single fluid-filled intragastric balloons with orogastric fluid is not associated with hyperinflation: an ex-vivo study and systematic review of literature

BACKGROUND

Spontaneous hyperinflation is reported to the Food and Drug Administration as a complication of intragastric balloons. It is postulated that orogastric contamination of the intragastric balloon may cause this phenomenon. We sought to investigate the effects of intentional balloon contamination with gastric contents on intragastric balloon perimeter and contents, whether methylene blue plays a role in preventing spontaneous hyperinflation, and review the available literature on spontaneous hyperinflation.

METHODS

Four pairs of balloons with different combinations of sterile saline, orogastric contaminants, and methylene blue were incubated in a 37 °C water bath for six months to simulate physiological conditions with serial measurements of balloon perimeter. Our findings were compared against a systematic review across multiple databases to summarize the available literature.

RESULTS

Balloon mean perimeter decreased from 33.5 cm ± 0.53 cm to 28.5 cm ± 0.46 cm (p < 0.0001). No significant differences were seen with the methylene blue group. Only 11 cases were found reported in the literature.

CONCLUSIONS

Despite contaminating intragastric balloons with gastric aspirates, hyperinflation did not occur, and other factors may be in play to account for this phenomenon, when observed. Rates of hyperinflation remain under-reported in the literature. Further controlled experiments are needed.

Five-Year Outcomes of Endoscopic Sleeve Gastroplasty for the Treatment of Obesity

BACKGROUND AND AIMS

The growing burden of obesity as a chronic disease necessitates a multifaceted approach to management. There has been an increase in the number of available endoscopic therapies for weight management with endoscopic sleeve gastroplasty (ESG) proving to be one of the best options. The long-term efficacy of ESG for management of obesity is not known. This study sought to assess the long-term safety and efficacy of ESG for treatment of obesity.

METHODS

This was a prospective cohort study. Participants underwent ESG in a single academic center, and were prospectively enrolled. All procedures were performed by the same therapeutic endoscopist. Patients with a body mass index of >30 kg/m2 (or >27 with comorbidities), who underwent ESG from August 2013 to August 2019 for treatment of obesity were enrolled. Patients were followed for up to 5 years after their procedure. The primary outcome was weight loss at 5 years after the procedure (% total body weight loss, TBWL) RESULTS: 216 patients (68% female) with a mean age of 46±13 years, and mean BMI of 39±6 kg/m² underwent ESG. Out of 216 patients, 203, 96, and 68 patients were eligible for a 1-, 3-, and 5-year follow up, with complete follow-up rates of 70%, 71%, and 82%, respectively. At 5 years, mean TBWL was 15.9% (95% CI, 11.7-20.5, p < .001) and 90 and 61% of patients maintained 5 and 10% TBWL, respectively. There was an overall rate of 1.3% moderate adverse events (AEs), without any severe or fatal AEs.

CONCLUSIONS

Our results suggest that ESG is safe and effective for treatment of obesity, with durable long-term results for at least up to 5 years after the procedure. This procedure should be considered as a reliable option for treatment of obesity.

Intragastric satiety-inducing device reduces food intake and suppresses body weight gain in a rodent model

BACKGROUND

An intragastric satiety-inducing device (ISD) (Full Sense Device; Baker, Foote, Kemmeter, Walburn, LLC, Grand Rapids, MI) is a novel weight-loss device, which may induce satiety by applying continuous pressure on the gastric cardia. This study investigated the effect of the ISD on food intake and body weight gain in a rodent model.

METHODS

Thirty-two male Sprague-Dawley rats (weight, 250-300 g) were randomly divided into four groups of eight individuals. Single-disk (SD) and double-disk (DD) group animals underwent peroral placement of a single- or double-disk ISD, respectively, under fluoroscopic guidance. The ISD comprised a 4 mm × 1.5 cm nitinol stent placed in the lower esophagus and one (single-disk) or two (double-disk) 2.5-cm-diameter star-shaped nitinol disks placed in the gastric fundus. Esophageal stent (ES) and sham-operated (SO) group animals underwent peroral placement of the ES part of the ISD and a sham operation, respectively.

RESULTS

Food intake was significantly different among the four groups over the 4-week study period (P < 0.001); food intake was significantly lower in the SD and DD groups than in the SO group (P = 0.016 and P = 0.002, respectively) but was not significantly different between the SD and DD groups (P > 0.999) and between the ES and SO groups (P = 0.677). Body weight was significantly different among the four groups by the end of the study period (P < 0.001); body weight was significantly lower in the DD group than in the SD, ES, and SO groups (P = 0.010, P < 0.001, and P < 0.001, respectively) and in the SD group than in the SO group (P = 0.001), but it was not significantly different between the ES and SO groups (P = 0.344).

CONCLUSION

ISD reduced food intake and suppressed body weight gain in a rodent model.

The Effect of Bariatric Surgery and Endoscopic Procedures on Gastroesophageal Reflux Disease

Obesity is a global epidemic posing a significant burden on patients and healthcare systems. Gastroesophageal reflux disease is associated with obesity and its prevalence is also growing worldwide. Numerous bariatric surgeries and endoscopic procedures have arisen to assist with weight loss and management of obesity-related conditions. However, the effect of these interventions on reflux is variable and the evidence is often conflicting. To date, Roux-en-Y gastric bypass remains the gold-standard for attaining both reflux and weight loss management, however novel endoscopic techniques are quickly becoming more prevalent as an alternative to surgery. This review aims to summarize currently available endoscopic and surgical weight loss procedures and their impact on reflux symptoms while emphasizing areas requiring additional investigation.

The Clinical and Metabolic Effects of Intragastric Balloon on Morbid Obesity and Its Related Comorbidities

Obesity is becoming increasingly prevalent worldwide, and its metabolic sequelae lead to a significant burden on healthcare resources. Options for the management of obesity include lifestyle modification, pharmacological treatment, surgery, and endoscopic bariatric therapies (EBTs). Among these, EBTs are more effective than diet and lifestyle modification and are less invasive than bariatric surgery. In recent years, there have been significant advances in technologies pertaining to EBTs. Of all the available EBTs, there is a significant amount of clinical experience and published data regarding intragastric balloons (IGBs) because of their comparatively long development period. Currently, the United States Food and Drug Administration (FDA) has approved three IGBs, including Orbera (Apollo Endosurgery, Austin, TX, USA), ReShape Duo (ReShape Medical, San Clemente, CA, USA), and Obalon (Obalon Therapeutics, Carlsbad, CA, USA). The aim of this review is to summarize the available literature on the efficacy of IGBs in weight loss and their impact on obesity-related metabolic diseases.

Robotic Revisional Bariatric Surgery: a High-Volume Center Experience

PURPOSE

The number of bariatric revisional procedures is growing. Scarce evidence is available regarding the role and postoperative outcomes of robotic-assisted revisional bariatric surgery (RRBS). The aim of this study is to evaluate the safety and postoperative outcomes of RRBS.

MATERIALS AND METHODS

A retrospective analysis of a prospectively collected database of patients who underwent RRBS between 2012 and 2019 was performed. Primary outcomes of interest were 30-day major morbidity, mortality, length of hospital stay (LOS), urgent reoperation rates, and percentage of total weight loss (%TWL).

RESULTS

RRBS was performed in 76 patients; among these 60 (78.9%) underwent conversion to Roux-en-Y gastric bypass (C-RYGB). Failed weight loss (76%) and gastroesophageal reflux (9.2%) were the main indications for revision. Primary bariatric procedures included gastric band (LAGB) (50%), sleeve gastrectomy (SG) (40.8%), and RYGB (6.6%). Major morbidity and mortality rates were 3.9% and 1.3%, respectively. Mean LOS was 2.1 days, and 3 patients (3.9%) required urgent reoperation. The %TWL at 3, 6, 12, and 24 months was 10.2%, 16.6%, 18.3%, and 22.4% respectively. Comparative analysis of C-RYGB after failed LAGB and SG showed similar morbidity. Higher readmission rates (SG: 22.2% vs. LAGB: 0%, p = 0.007) and lower %EWL at 3, 6, 12, and 24 months were found in C-RYGB after SG.

CONCLUSION

This is one of the largest single-center series of RRBS published in the literature; the data indicate that robotic approach for revisional bariatric surgery is safe and helps achieving further weight loss. RRBS outcomes might be influenced by the primary procedure.

Intususcepción como complicación de bypass en Y de Roux en pacientes embarazadas, una complicación infrecuente. Reporte de caso y revisión de la literatura

La obesidad es actualmente un problema de salud pública de ámbito internacional. Es considerada como la segunda causa de muerte prevenible en México, después del tabaquismo, según la Organización Mundial de la Salud. Actualmente, las opciones quirúrgicas son la gastrectomía en manga, el bypass gástrico o derivación gástrica, la banda gástrica y el bypass gástrico en omega, cada una con sus indicaciones. Se presenta el caso clínico de una paciente con intususcepción yeyuno-yeyunal secundaria a bypass gástrico en el embarazo.

Obesity is currently an international public health problem. It is considered the second preventable cause of death in Mexico, after smoking, according to the World Health Organization. Currently, surgical options are sleeve gastrectomy, gastric bypass or gastric derivation, gastric banding, and omega gastric bypass, each with specific indications. The objective of the article is to present the clinical case of a patient with jejuno-jejunal intussusception secondary to gastric bypass in pregnancy.

A Matched Cohort Comparison of Long-term Outcomes of Roux-en-Y Gastric Bypass (RYGB) Versus Single-Anastomosis Duodeno-ileostomy with Sleeve Gastrectomy (SADI-S)

BACKGROUND

The long-term effectiveness of Roux-en-Y gastric bypass (RYGB) and single-anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S) is unknown.

PURPOSE

Compare the long-term outcomes.

SETTING

Single private institute, USA.

MATERIALS AND METHODS

Data from 1254 patients who underwent primary RYGB or SADI-S were used for a retrospective matched cohort. Data were obtained by matching every RYGB patient to a SADI-S patient of the same sex, body mass index (BMI), and weight. Only patients out 5 years and had at least one > 5-year follow-up visit were included.

RESULTS

The matched cohort included 61 RYGB and 61 SADI-S patients. There was no statistical, demographic difference between the two groups. At 5 years, a 100% follow-up was available in each group. The intraoperative outcomes were significantly better with SADI-S. The 30-day readmission, reoperation, emergency department (ED) visits, and complication rates were statistically similar between the two groups. The long-term complication rates, Clavien-Dindo grade IIIb complications, and number of patients with more than one complication were significantly lower with SADI-S. Weight loss was significantly greater in the SADI-S group at 5 years. The long-term weight-loss failure rate was significantly higher in the RYGB group. The SADI-S procedure was associated with fewer reintervention through 6 years (14.7% patients vs. 39.3% patients, p = 0.001). Conversion or reversal of the procedure was required only in the RYGB group. There also was no significant difference in nutritional outcomes between the two procedures.

CONCLUSIONS

This study showed that problems, including long-term complications, reinterventions, weight-loss failure, and conversion, were more often associated with RYGB than with SADI-S. The SADI-S may be considered one of the viable alternatives to RYGB.

An evaluation of bariatric surgery in all military treatment facilities

BACKGROUND

Multiple bariatric databases have been formed, but there have been no comprehensive assessments of military treatment facilities (MTFs). MTFs have unique patients and coverage policies by Tricare insurance.

METHODS

MHS Mart (M2) was used to review the outpatient medical record, AHLTA, from October 2013 to December 2018 for type of bariatric procedure, demographics, military-specific data, comorbidities, and complications, which were identified by ICD code and CPT code, including a robotic modifier. MTFs were classified by volume as high (HV) with > 50 cases annually, moderate (MV) with 25 to 50 cases, and low (LV) with < 25 cases, as well as by the presence of surgical residencies.

RESULTS

Patients at MTFs were slightly younger and more female than by other database studies. The Army was the most common branch of service, and dependents of retirees were the most common beneficiary population. MTFs with residencies had slightly older patients and fewer Army patients. HV, MV, and LV MTFs had similar patients except for branch of service. Over time, the proportion of open gastric bypasses increased, biliopancreatic diversions with duodenal switches decreased, and robotic assistance increased 744%. MTFs with residencies performed more procedures than those without residencies, and with the exception of procedures utilizing robotic assistance, procedures were overall similar to those without residencies. HV MTFs performed most of the procedures annually, and their procedures were proportionately similar to MV and LV MTFs, with the exception of HV MTFs having a higher proportion of laparoscopic bypasses and robotic assistance.

CONCLUSION

MTFs largely perform similar procedures on similar patients relative to MBSAQIP and NSQIP studies. Robotic assistance increased significantly over time. Except for laparoscopic bypasses and procedures with robotic assistance, HV MTFs performed similar proportions of procedures to MV and LV MTFs. MTFs with residencies performed similar procedures to those without residencies.

Outcomes with Intra-gastric Balloon Therapy in BMI < 35 Non-morbid Obesity: 10-Year Follow-Up Study of an RCT

PURPOSE

Intra-gastric balloon (IGB) therapy is the most established endoscopic treatment of obesity, but there is a paucity of literature on long-term efficacy. This study aims to evaluate the short- and long-term weight loss efficacy of IGB.

MATERIALS AND METHODS

Double-blinded RCT with 6-month IGB vs with sham endoscopy, in body mass index (BMI) 27-35 patients. Anthropometric, fasting glucose, and lipid profile measurement as early outcomes (up to 2 years) and 10-year follow-up. Primary outcomes were total body weight loss (kg) and BMI. Secondary outcomes were new-onset diabetes mellitus, other new comorbidities, and willingness for further intervention.

RESULTS

Initial RCT recruited 99 patients (50 IGB vs 49 sibutramine group). Forty-nine patients (26 IGB vs 23 control group) participated in a 10-year review (follow-up rate of 51.6%). Total body weight loss at 6 (9.75 vs 7.48 kg, p = 0.03), 12 (6.52 vs 4.42 kg, p = 0.05), 18 (5.42 vs 3.57, p = 0.32), and 24 months (4.07 vs 2.93 kg, p = 0.56) favored the IGB group. Total weight loss (TWL) at 10 years (0.03 vs - 2.32 kg, p = 0.05) and %TWL (- 0.16 ± 12.8% vs - 2.84 ± 5.6%, p = 0.39) were not significantly different between groups. Follow-up BMI (30.97 ± 1.6 vs 30.38 ± 1.8 kg/m², p = 1.00) was similar. At 10 years, new-onset diabetes mellitus, sleep apnoea, metabolic syndrome, and arthralgia were not significant (p > 0.05). Twenty-three (81%) IGB group vs 13 (56%) control expressed a willingness for further intervention (p < 0.01).

CONCLUSION

IGB delivers weight loss to 2 years and is superior to control. However, new comorbidity development is not significantly different at 10 years. Patient that received IGB therapy were subsequently more willing for further bariatric metabolic intervention.

Assessment of a novel stapler performance for laparoscopic sleeve gastrectomy

BACKGROUND

Optimal stapler selection during laparoscopic sleeve gastrectomy requires careful balance between tissue compression, hemostasis, and mechanical integrity. Junctions along a staple line can further increase the risks of technical or mechanical staple line failures. The aim of this study was to compare two commonly utilized laparoscopic linear gastrointestinal staplers (Ethicon, Medtronic) with a novel linear stapler (Titan) designed to perform a sleeve gastrectomy with a single stapler firing.

METHODS

Excised gastric remnants from laparoscopic sleeve gastrectomy were utilized and tissue thickness was measured from fundus to antrum. An optimized experimental staple line was then created. The greater curve remnant was insufflated to determine the staple line burst pressure and location. The doubly stapled (clinical and experimental) gastric specimen underwent staple analysis for junctional location, malformation, and height.

RESULTS

The Titan stapler withstood a significantly higher burst pressure than both Ethicon and Medtronic linear cutting staplers. While the Medtronic and Ethicon staplers had a similar percentage of staples in junctions, the Titan stapler has no junctions. In considering the formation of all staples outside of junctions, the Medtronic and Titan staplers had no difference in percentage of malformed staples, while the Ethicon stapler had a significantly higher percentage. Additionally, there were no differences in mismatch between staple height and tissue thickness between experimental groups.

CONCLUSIONS

The Titan stapler conveys the mechanical benefits of higher burst pressure with the advantage of single load functionality. This single staple load eliminates staple line junctions without sacrificing the integrity of staple formation.

Robotic-assisted approaches to GERD following sleeve gastrectomy

BACKGROUND

Sleeve gastrectomy (SG) is the most common bariatric operation in the United States but increases the incidence of gastroesophageal reflux disease (GERD). The aim of our study was to describe our experience with robotic-assisted management of intractable GERD after SG.

METHODS

A systematic review of a prospectively maintained database was performed of consecutive patients undergoing robotic-assisted magnetic sphincter augmentation placement after sleeve gastrectomy (MSA-S group) or conversion to Roux-en-Y gastric bypass (RYGB group) for GERD from 2015 to 2019 at our tertiary- care bariatric center. These were compared to a consecutive group of patients undergoing robotic-assisted magnetic sphincter augmentation placement (MSA group) for GERD without a history of bariatric surgery from 2016 to 2019. The primary outcome was perioperative morbidity. Secondary outcomes were operative time (OT), 90-day re-intervention rate, length of stay, symptom resolution and weight change.

RESULTS

There were 51 patients included in this study; 18 patients in the MSA group, 13 patients in the MSA-S group, and 20 patients in the RYGB group. There was no significant difference in age, gender, ASA score, preoperative endoscopic findings, or DeMeester scores (P > 0.05). BMI was significantly higher in patients undergoing RYGB compared to MSA or MSA-S (P < 0.0001). There were significant differences in OT between the MSA and RYGB groups (P < 0.0001) and MSA-S and RYGB groups (P = 0.009), but not MSA group to MSA-S group (P = 0.51). There was no significant difference in intraoperative and postoperative morbidity (P = 1.0 and P = 0.60, respectively). 30-day morbidity: 5.6% (MSA), 15.4% (MSA-S) and 15% (RYGB). There was no difference on PPI discontinuation among groups, with more than 80% success rate in all.

CONCLUSIONS

The use of the robotic platform in the different approaches available for treatment of GERD after SG appears to be a feasible option with low morbidity and high success rate. Further data is needed to support our findings.

Bariatric Surgery Outcomes in Patients on Preoperative Therapeutic Anticoagulation: an Analysis of the 2015 to 2017 MBSAQIP

BACKGROUND

Obesity has been found to be an independent predictor of adverse cardiac and pulmonary embolic events. As the popularity of bariatric surgery grows, surgeons are encountering more patients taking therapeutic anticoagulation medications preoperatively. This study aims to assess the safety of bariatric surgery on these patients.

METHODS

Data was extracted from 2015 to 2017 using the MBSAQIP database. Included patients were those who underwent a primary LSG or LRYGB. A multivariable regression analysis was performed looking at 30-day outcomes for pre-operatively anticoagulated patients. A secondary propensity-matched analysis was performed comparing outcomes among patients undergoing LSG vs LRYGB.

RESULTS

A total of 430,396 patients were analyzed, 11,013 (2.56%) of which were taking anticoagulation medications pre-operatively. Absolute 30-day complication rates (8.73% vs 3.36%, p < 0.001), bleed rates (3.78% vs 0.88%, p < 0.001), leak rates (0.55% vs 0.41%, p = 0.021), cardiac event rates (0.43% vs 0.06%, p < 0.001), and venous thromboembolism rates (0.68% vs 0.25%, p < 0.001) were significantly higher among pre-operatively anticoagulated patients. On multivariable analysis, pre-operative anticoagulation was found to be an independent predictor of postoperative bleeding (OR 2.76, CI 2.43-3.14, p < 0.001) and mortality (OR 2.08, CI 1.49-2.90, p < 0.001). The LRYGB was associated with a significantly higher complication rate compared to the LSG (13.27% vs 7.40%, p < 0.001) in the propensity-matched cohorts.

CONCLUSIONS

Patients undergoing bariatric surgery on anticoagulation medications pre-operatively are at a significantly higher risk of adverse outcomes post-operatively. Patients who require long-term anticoagulation should undergo careful consideration before proceeding with bariatric surgery.

The value of a bariatric specific chart to initiate resuscitation of adult bariatric burns

INTRODUCTION

The prevalence of obese adults is rising across the world with a tripling of rates since 1975. The resuscitation of large burns in obese patients brings unique challenges leading some to advocate the use of a bariatric specific burn chart.

AIMS

We sought to determine whether bariatric burn specific charts can better estimate burn percentage to prevent under resuscitation. We also reviewed the impact of obesity upon the length of hospital stay, morbidity and mortality at our institution.

METHODS

A retrospective case note review, of patients identified from the prospective International Burns Injury Database (iBID), was undertaken of patients' ≥18 years of age with burns ≥15% of their total body surface area.

RESULTS

There were 79 overweight and 53 bariatric patients from a total of 232 patients identified. There was no statistical difference in burn percentage or fluid input estimation between the Lund & Browder and Neaman charts. Complications were seen in 51% of the normal weight patients. Obese patients had a similar incidence of death (24%) compared to the normal weight group (26%). The class I obese had the lowest complication rate at 28% and lowest mortality rate at 11%.

CONCLUSIONS

Bariatric specific charts did not demonstrate any benefits in optimising bariatric resuscitation. There appears to be a 'physiological benefit' in the class I obese who sustained burns undergoing resuscitation.

Perioperative Outcomes of Laparoscopic and Robotic Revisional Bariatric Surgery in a Complex Patient Population

BACKGROUND

Utilization of the robotic platform has become more common in bariatric applications. We aim to show that robotic revisional bariatric surgery (RRBS) can be safely performed in a complex patient population with perioperative outcomes equivalent to laparoscopic revisional bariatric surgery (LRBS).

METHODS

Retrospective review was conducted of adult patients undergoing laparoscopic revisional bariatric surgery (LRBS) or robotic revisional bariatric surgery (RRBS) at our institution from September 2007 to December 2016. Patients undergoing planned two-stage bariatric procedures were excluded.

RESULTS

A total of 84 patients who underwent LRBS (n = 66) or RRBS (n = 18) were included. The index operation was adjustable gastric banding (AGB) in 39/84 (46%), sleeve gastrectomy (VSG) in 23/84 (27%), Roux-en-Y gastric bypass (RYGB) in 13/84 (16%), and vertical banded gastroplasty (VBG) in 9/84 (11%). For patients undergoing conversion from AGB (n = 39), there was no difference in operative time, length of stay, or complications by surgical approach. For patients undergoing conversion from a stapled procedure (n = 45), the robotic approach was associated with a shorter length of stay (5.8 ± 3.3 vs 3.7 ± 1.7 days, p = 0.04) with equivalent operative time and post-operative complications. There were three leaks in the LRBS group and none in the RRBS group (p = 0.36). Major complications occurred in 3/39 (8%) of patients undergoing conversion from AGB and 2/45 (4%) of patients undergoing conversion from a stapled procedure (p = 0.53) with no difference by surgical approach.

CONCLUSIONS

RRBS is associated with a shorter length of stay than LRBS in complex procedures and has at least an equivalent safety profile. Long-term follow-up data is needed.

Left Gastric Artery Embolisation for the Treatment of Obesity: a Systematic Review

BACKGROUND

Endovascular left gastric artery (LGA) embolisation has gained significant attention in the treatment of obesity/morbid obesity and reduction of ghrelin. The objective of this systematic review is to evaluate the recent literature, strengths, limitations and practical aspects of this new procedure in combination with its physiological and anatomical paradigm.

METHODS

A systematic electronic search of literature from 1966 to June 2017 in Medline, CINHAL, Embase, Scopus and Cochrane library in English language and adult subjects was conducted. This search was conducted in accordance with Preferred Reporting in Systematic Review and Meta-Analysis (PRISMA) guidelines. Quality assessment of the articles was performed, using Oxford critical appraisal skills programme (CASP), and their recommendation for practice was examined through National Institute for health Care Excellence (NICE). Inter-related reliability (Cronbach's Alpha) was assessed between the two independent reviewers.

RESULTS

A total of n = 62 individuals were subjected to LGA embolisation. At 1-3 months, 7-11% and, at 12 months, 2% weight reduction was associated with ghrelin concentration reduction of 36% at 6 months. There was Haemoglobin A1c reduction (7.4 to 6.3%) and improved quality of life (SF-36 questionnaire) at 6 months (9.5 points) (range, 3.2-17.2). Despite immediate epigastric pain and mucosal ulceration, no long-term adverse outcome was identified. The overall length of stay was 2-3 days.

CONCLUSIONS

The outcome of this review (level of evidence 3) suggests LGA embolisation is feasible and effective and perhaps a safe procedure in the treatment of obesity and reduction of ghrelin. However, further trials are highly advocated.

Magnetic sphincter augmentation: a viable rescue therapy for symptomatic reflux following bariatric surgery

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are commonly performed bariatric procedures in obesity management. Gastroesophageal reflux disease (GERD) in this population has reported rates of 23-100%. GERD after LSG has been noted with recent studies demonstrating de novo reflux or symptom exacerbation despite weight loss. Fundoplication is not an option, and medically refractory GERD after LSG is usually treated with conversion to RYGB. GERD post-RYGB is a unique entity, and management poses a clinical and technical challenge. We evaluate safety and effectiveness of magnetic sphincter augmentation after bariatric surgery.

MATERIALS AND METHODS

A retrospective review of a prospectively maintained database was performed identifying patients that underwent LINX placement for refractory GERD after LSG, LRYGB, or duodenal switch across three institutions. Outcomes included complications, length of stay, PPI use, GERD-HRQL scores, and patient overall satisfaction.

RESULTS

From March 2014 through June 2018, 13 identified patients underwent LINX placement after bariatric surgery: 8 LSG, 4 LRYGB, and 1 duodenal switch. The patients were 77% female, with mean age 43 and average BMI 30.1. Average pre-operative DeMeester score was 24.8. Pre-operatively, 5 patients were on daily PPI, 6 on BID PPI, and 1 on PPI + H2 blocker. We noted decreased medication usage post-operatively, with 4 patients taking daily PPI, and 9 off medication completely. A GERD-HRQL score was obtained pre- and post-operatively in 6 patients with average reduction from 25 to 8.5 (p value 0.002). Two patients experienced complications requiring endoscopic dilation after LINX placement. 100% of patients reported overall satisfaction post procedure.

CONCLUSION

LINX placement is a safe, effective treatment option for surgical management of refractory GERD after bariatric surgery. It can relieve symptoms and obviate the requirement of high-dose medical management. Magnetic lower esophageal sphincter augmentation should be another tool in the surgeon's toolbox for managing reflux after bariatric surgery in select patients.

New Era: Endoscopic treatment options in obesity–a paradigm shift

The prevalence of obesity continues to rise, and along with it comes a multitude of health-related consequences. The healthcare community has consistently struggled with providing treatment options to obese patients, in part due to the reluctance of patients in pursuing the more effective (yet invasive) surgical approaches such as sleeve gastrectomy and Rou-en-Y gastric bypass. On the other hand, the less invasive approach such as lifestyle/behavioral interventions and pharmacotherapy (Orlistat, Phenteramine, Phentermine/Topiramate, Locaserin, Naltrexon/Buproprion, and Liraglutide) have very limited efficacy, especially in the morbidly obese patients. Despite our best efforts, the epidemic of obesity continues to rise and pose enormous costs on our healthcare system and society. Bariatric endoscopy is an evolving field generated to combat this epidemic through minimally invasive techniques. These procedures can be performed in an ambulatory setting, are potentially reversible, repeatable, and pose less complications than their invasive surgical counterparts. These modalities are designed to alter gut metabolism by means of space occupation, malabsorption, or restriction. In this review we will discuss different bariatric endoscopic options (such as intragastric balloons, endoscopic sleeve gastroplasty, endoscopic aspiration therapies and gastrointestinal bypass sleeves), their advantages and disadvantages, and suggest a new paradigm where providers may start incorporating this modality in their treatment approach for obese patients.

Bariatric peri-operative outcomes are affected by annual procedure-specific surgeon volume

BACKGROUND

There is limited data examining specific annual surgeon procedural volumes associated with improvement of postoperative outcomes following Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).

OBJECTIVES

Effect of surgeon volume on procedural outcomes.

METHODS

Using the SPARCS Administrative database, patients undergoing laparoscopic RYGB or SG between 2010-2014 were analyzed. Multivariable generalized linear mixed regression models were first used to analyze the influences of 3 yearly mean volumes (combined, RYGB and SG mean volumes) on each of three surgical outcomes: 30-day readmission, peri-operative complications, and extended length of stay (LOS), while accounting for patient specific variables.

RESULTS

A total of 46,511 laparoscopic bariatric procedures were included in the study. Risk for any complication and 30-day readmissions following RYGB decreased with increasing RYGB volume up to a specific volume and stayed similar afterward (OR 0.97, 95% CI 0.96-0.98 while volume < 247.9 cases/year and OR 0.99, 95% CI 0.98-0.99 while volume < 354.1 cases/year, respectively) while risk for extended LOS decreased with increasing combined bariatric mean volume up to a specific volume and stayed similar afterward (OR 0.9, 95% CI 0.85-0.95 while volume < 62.1 cases/year). Similar patterns were found for extended LOS and complications following SG (OR 0.82, 95% CI 0.72-0.93 while SG volume < 26.3 cases/year and OR 0.94, 95% CI 0.91-0.98 while combined volume < 62.1 cases/year, respectively), while 30-day readmission following SG significantly increased when combined bariatric volume being more than 138 cases/year (OR 1.10, 95% CI 1.00-1.21 while combined volume > 138 cases/year)).

CONCLUSIONS

Bariatric procedure peri-operative outcomes are affected by procedure-specific annual surgeons' volume.

Metabolic Syndrome Is a Significant Predictor of Postoperative Morbidity and Mortality Following Bariatric Surgery

INTRODUCTION/PURPOSE

Metabolic syndrome is commonly demonstrated in patients with morbid obesity undergoing bariatric surgery. The purpose of this study was to determine the effect of metabolic syndrome on morbidity and mortality following bariatric surgery.

MATERIALS AND METHODS

The National Surgical Quality Improvement Program (NSQIP) dataset was queried for patients who underwent bariatric surgical procedures between 2012 and 2014. Patient demographics, comorbid conditions, bariatric procedure type, and postoperative complications were analyzed. Metabolic syndrome was defined as having a body mass index > 30 kg/m² in the presence of the comorbid conditions of hypertension and diabetes. Regression analysis was used to determine the relationship between metabolic syndrome and postoperative morbidity and mortality.

RESULTS

During the study interval, 59,404 patients underwent bariatric surgery (Roux-en-Y gastric bypass = 28,263, sleeve gastrectomy = 30,239, revision = 422, and biliopancreatic diversion = 480). The mean body mass index was 45.9 kg/m², and the mean age was 45 years. Of the cohort, 30,104 (50.6%) patients had a diagnosis of hypertension, 16,558 (27.8%) had diabetes mellitus, and 12,803 (21.5%) met the criteria for metabolic syndrome. Patients with metabolic syndrome were more likely to have Roux-en-Y gastric bypass procedure, a history of congestive heart failure, severe COPD, renal failure, and diminished functional status (p < 0.0001). Morbidity was greater for patients with metabolic syndrome (7.5% vs. 5%; p < 0.0001), and patients in this subset also had a 3.2-fold increased risk of mortality (p < 0.0001).

DISCUSSION

Metabolic syndrome is prevalent in patients who undergo bariatric surgery. We have demonstrated that patients with the constellation of comorbid conditions defining metabolic syndrome are at an increased risk of morbidity and mortality following bariatric surgery. Patients and surgeons should be informed of the potential increased risk in this patient population.

Guideline Approaches for Cardioendocrine Disease Surveillance and Treatment Following Spinal Cord Injury

PURPOSE OF REVIEW

Persons with spinal cord injuries (SCI) commonly experience individual risks and coalesced health hazards of the cardiometabolic syndrome (CMS). This review will examinethe role of exercise and nutritional intervention as countermeasures to these disease risks.

RECENT FINDINGS

The CMS hazards of overweight/obesity, insulin resistance, hypertension, and dyslipidemia are strongly associated with physical deconditioning and are common after SCI. Both the CMS diagnosis and physical deconditioning worsen the prognosis for all-cause cardiovascular disease occurring early after SCI. Evidence supports a therapeutic role for physical activity after SCI as an effective countermeasure to these risks and often represents the first-line approach to CMS abatement. This evidence is supported by authoritative systematic reviews and associated guidelines that recommend specific activities, frequencies, and activities of work. In many cases, the most effective exercise programming uses more intense periods of work with limited rest. As SCI is also associated with poor dietary habits, including excessive energy intake and saturated fat consumption, more comprehensive lifestyle management incorporating both exercise and nutrition represents a preferred approach for overall health management.

SUMMARY

Irrespective of the interventional strategy, improved surveillance of the population for CMS risks and encouraged incorporation of exercise and nutritional management according to recent population-specific guidelines will most likely play an important role in the preservation of activity, optimal health, and independence throughout the lifespan.

Small Bowel Endoscopic Bariatric Therapies

Endoscopic bariatric therapies that emulate some of the principles of bariatric surgery have been developed as a less invasive option for the treatment of obesity and related comorbidities. Small bowel endoscopic bariatric therapies include bypass sleeves, incisionless anastomosis systems, and duodenal mucosal resurfacing. Clinical experience with small bowel devices suggests that endoscopic bariatric procedures can be safely implemented and that these devices are effective for both weight loss and metabolic improvement. Although the mechanisms behind these effects should be further elucidated, endoscopic bariatric therapies may be more effective and safer adjunctive interventions than lifestyle modifications and pharmacological regimens for patients with obesity or obesity-related comorbidities.

The prevalence of musculoskeletal injuries in bariatric surgeons

OBJECTIVE

To investigate the prevalence of musculoskeletal (MSK) injuries in bariatric surgeons around the world.

BACKGROUND

As the popularity of bariatric surgery increases, efforts into improving its patient safety and decreasing its invasiveness have also been on the rise. However, with this shift towards minimal invasiveness, surgeon ergonomic constraints have been imposed, with a recent report showing a 73-88% prevalence of physical complaints in surgeons performing laparoscopic surgeries.

METHODS

A web-based survey was designed and sent out to bariatric surgeons around the world. Participants were queried about professional background, primary practice setting, and various issues related to bariatric surgeries and MSK injuries.

RESULTS

There were 113 responses returned from surgeons from 34 countries around the world. 68.5% of the surgeons have had more than 10 years of experience in laparoscopic surgery, 65.8% in open, and 0.9% in robotic surgery. 66% of participants reported that they have experienced some level of discomfort/pain attributed to surgical reasons, causing the case load to decrease in 27.2% of the surgeons. It was seen that the back was the most affected area in those performing open surgery, while shoulders and back were equally as affected in those performing laparoscopic, and the neck for those performing robotic, with 29.4% of the surgeons reporting that this pain has affected their task accuracy/surgical performance. A higher percentage of females than males reported pain in the neck, back, and shoulder area when performing laparoscopic procedures. Supine positioning of patients evoked more discomfort in the wrists, while the French position caused more discomfort in the back region. A higher percentage of surgeons who did not exercise experienced more issues in the neck and back region, while those that exercised more than 3 h a week experienced issues in their shoulders and wrists in both open and laparoscopic approaches. Only 57.7% sought medical treatment for their MSK problem, of which 6.35% had to undergo surgery for their issue, of which 55.6% of those felt that the treatment resolved their problem.

CONCLUSION

MSK injuries and pain are a common occurrence among the population of bariatric surgeons (66%), and has the ability to hinder performance at work. Therefore, it is of importance to investigate ways in which to improve ergonomics for these surgeons as to improve quality of life.