Comparing Safety and Efficacy Outcomes of Gastric Bypass and Sleeve Gastrectomy in Patients With Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis

Sleeve Gastrectomy (SG) could be done by the removal of a big portion of the stomach, leading to reduced amounts of food taken as a result of the smaller stomach size. In contrast, Roux-en-Y Gastric Bypass (RYGB) can be done by creating a small stomach pouch and rerouting a part of the small intestine, employing combined mechanisms of restriction and malabsorption to limit food intake and modify nutrient absorption. Our aim is to identify the most effective and safest surgical intervention for individuals with both Type 2 Diabetes Mellitus (T2DM) and obesity, considering both short and long-term outcomes. We will assess participants undergoing either SG or RYGB to determine the optimal surgical approach. We made a thorough search of PubMed, Cochrane Library, Scopus, and Web of Science databases up to November 2023. Our focus was on randomized controlled trials (RCTs) comparing the safety and efficacy of RYGB and SG in T2DM regarding any extractable data. We excluded studies of other designs, such as cohorts, case reports, case series, reviews, in vitro studies, postmortem analyses, and conference abstracts. Utilizing Review Manager 5.4, we performed a meta-analysis, combining risk ratios (RR) with a 95% confidence interval (CI) conducted for binary outcomes, while mean with SD and 95% CI are pooled for the continuous ones. The total number of participants in our study is 4,148 patients. Our analysis indicates superior outcomes in the group undergoing RYGB surgery compared to the SG group (RR = 0.76, 95% (CI) (0.66 to 0.88), P = 0.0002). The pooled data exhibited homogeneity (P = 0.51, I2 = 0%) after employing the leave-one-out method. For the 1-3 year period, six studies involving 332 patients with T2DM yielded non-significant results (RR = 0.83, 95% CI (0.66 to 1.06), P = 0.14) with homogeneity (P = 0.24, I2 = 28%). Conversely, the 5-10 year period, with six studies comprising 728 DM patients, demonstrated significant results (RR = 0.69, 95% CI (0.56 to 0.85), P = 0.14) and homogeneity (P = 0.84, I2 = 0%). In terms of total body weight loss, our findings indicate significantly higher weight loss with RYGB (mean difference (MD) = -6.13, 95% CI (-8.65 to -3.6), P > 0.00001). However, pooled data exhibited considerable heterogeneity (P > 0.00001, I2 = 93%). Subgroup analyses for the 1-3 year period (five studies, 364 DM patients) and 5-10 year period (six studies, 985 DM patients) also revealed significant differences favoring RYGB, with heterogeneity observed in both periods (1-3 years: P > 0.00001, I2 = 95%; 5-10 years: P = 0.001, I2 = 75%). RYGB demonstrated significant long-term improvement in diabetes remission and superior total body weight loss compared to SG. While no notable differences were observed in other efficacy outcomes, safety parameters require further investigation. no significant distinctions were found in any of the safety outcomes: hypertension (HTN), high-density lipoprotein (HDL), hyperlipidemia, fasting blood glucose, vomiting, low-density lipoprotein (LDL), and total cholesterol. Further research is essential to comprehensively assess safety outcomes for both surgical approaches.

Is phenytoin a safe agent for staple line recovery after gastric sleeve surgery in rats?

BACKGROUND

The most challenging and mortal complication of gastric sleeve surgery (SG) is staple line leakage. Although many agents have been used for increasing tissue healing on the stapler line, there is still no consensus on its effectiveness and efficacy. The aim of study is to determine the effect of phenytoin on the healing process of gastric sleeve surgery in rats.

METHODS

On the 10th post-operative day, the effects of phenytoin on bursting pressure in the stapler line were evaluated along-side pathohistological examinations. To investigate the molecular impact of phenytoin on the expression of TGF-β, VEGF, FGF2, and p53 genes, quantitative real-time polymerase chain reaction was utilized. In addition, gene expressions at the protein level were deter-mined by immunohistochemical analysis.

RESULTS

No signs of intra-abdominal leakage were observed in the resected samples. A statistically essential extend in stable line bursting pressure measure was observed between the control group and the group treated with phenytoin application. Pathohisto-logical results indicate that the mean score of collagens of the study group (3.2±0.42) was significantly higher than the control group (2.3±0.48) (P=0.003). In addition, the mean epithelization score of the study group (3.4±0.52) was significantly higher than the control group (2.1±0.57) (P=0.001). mRNA of TGFβ, FGF2, VEGF, and p53 genes drastically increased phenytoin treated group. High FGF2 protein expression levels were determined from phenytoin use compared to the control group.

CONCLUSION

Molecular studies suggest that phenytoin may increase the healing process of Gastric sleeve following SG in rats and may become a new agent for the prevention of human gastric leaks.

Situs Inversus Totalis in Laparoscopic Sleeve Gastrectomy: A Case Report

Obesity is a pathology that is increasing in incidence globally and threatens public health. Currently, one of its most effective treatments is bariatric surgery, which has shown the best long-term results. One of the most frequently performed surgical procedures in this area is laparoscopic sleeve gastrectomy (LSG) or vertical sleeve. It is a restrictive technique that has had positive results in weight loss. Situs inversus totalis (SIT) is a strange condition with a low incidence in which thoracic and abdominal organs are on the opposite side of the already-known anatomic site, seen on a sagittal plane. The high demand for laparoscopic bariatric surgeries predisposes surgeons to find rare congenital anomalies in patients. Low prevalence and the anatomic mirror image condition may be challenging even for expert surgeons. Medical teams need to have knowledge of these cases and adjust the technique and procedure to complete the surgery without complications. We present a SIT case successfully treated with LSG in a male patient in Mexico.

Post-gastric Sleeve Surgery Chronic Symptoms From a Sample of Patients in Saudi Community

BACKGROUND

A common bariatric procedure known as gastric sleeve surgery can cause significant weight loss and co-morbid condition alleviation. However, patients could experience persistent problems such as gastrointestinal, musculoskeletal/neural, and psychiatric disorders after surgery. This study aims to identify the most prevalent chronic symptoms following sleeve gastrectomy among a sample of Saudi patients and the impact these symptoms have on patients' lives.

METHODOLOGY

Patients who underwent gastric sleeve surgery at the Ensan Clinic, a facility specializing in gastroenterology, were the subjects of this retrospective cohort analysis. The study population consisted of patients who underwent gastric sleeve surgery, showed up for follow-up after the procedure, and met the inclusion and exclusion criteria. The data collection sheet is divided into seven sections. Sociodemographic information was required in the first section, gastric sleeve surgery information in the second, vital signs in the third, lab results in the fourth, past medical history in the fifth, current treatments in the sixth, and postoperative complications and chronic symptoms in the seventh and final sections.

RESULTS

In 117 patients, the study evaluated the effects of gastric sleeve surgery. Participants had an average age of 40.21 years, and 61.5% were female. Regarding persistent symptoms after surgery, a sizable percentage of patients mentioned digestive issues such as GERD (44.4%), dyspepsia (60.7%), vomiting (23.1%), nausea (39.3%), and abdominal distention (45.3%). A total of 34.2% of patients reported experiencing anxiety, compared to 11.1% who said they had depression or 2.6% who said they had social issues. A few patients reported experiencing neurological or musculoskeletal issues, including exhaustion (7.7%), faintness (5.1%), back or joint discomfort (7.7%), and shortness of breath (8.5%).

CONCLUSION

After undergoing gastric sleeve surgery, a sizable proportion of patients complained of various chronic symptoms and nutritional inadequacies, primarily gastrointestinal problems and musculoskeletal/neurological issues. The study's findings show a connection between these symptoms and surgery.

The Effect of Sleeve Gastrectomy on Pregnancy Complications: A Cross-Sectional Study in Saudi Arabia

BACKGROUND

Obesity is defined as abnormal or excessive fat accumulation that may impair health. Until recently, the only effective method for treating morbid obesity over the long term was bariatric surgery (BS). During pregnancy, obesity is correlated with higher risks for numerous complications, including gestational diabetes mellitus, pre-eclampsia, mortality, and large-for-gestational-age neonates. The most commonly reported complications among women who underwent sleeve gastrectomy and experienced pregnancy were placental bleeding, oligohydramnios, urinary tract infection, appendicitis, and recurrent abortions.

OBJECTIVES

We aim to estimate the consequence of sleeve gastrectomy and its relation with pregnancy outcomes among women in Saudi Arabia.

METHODOLOGY

This study adopted a quantitative, descriptive, cross-sectional design. It was conducted in Saudi Arabia between February and May 2023 among women who became pregnant after undergoing sleeve gastrectomy.  Result: Anemia was experienced by 78.8% of the patients during pregnancy. In our study, 18% of the individuals experienced complications during or right after delivery, with postpartum hemorrhage being the most frequent (43.1%). We discovered that pre-eclampsia and delivering a baby small for gestational age were considerably more common in pregnant women who smoked (p ≤ 0.05). On the other hand, no significant association was discovered between any comorbidity and mode of delivery, birth weight, child complications, or difficulties that occurred during or right after labor.

CONCLUSION

We concluded that weight gain after sleeve gastrectomy negatively impacted pregnancy and increased the probability of several complications for the mother and fetus. Healthcare providers must inform every woman undergoing BS about the possible complication of an unhealthy lifestyle after the procedure.

Gastric Staple Line Reinforcement With Ligation Clips for Hemostasis in Laparoscopic Sleeve Gastrectomy

INTRODUCTION

In Pakistan and worldwide, there is a lack of literature on the role of ligation clips in controlling hemostasis in laparoscopic sleeve gastrectomy. ligation clips are being used to secure hemostasis and act as staple line reinforcement to prevent intra-operative and postoperative bleeding. Data can be utilized to reflect the role of staple line reinforcement with ligation clips so as to guide surgeons about its safety and efficacy.

METHODOLOGY

This retrospective observational study was conducted at the Shalamar Hospital, Lahore, Pakistan, and included 120 patients. The patients' demographic parameters, BMI, intra-operative and postoperative bleeding in terms of hematemesis, melena, and fall in hemoglobin (Hb) postoperatively were compared to preoperative Hb and recorded.

RESULT

One hundred and twenty cases of laparoscopic sleeve gastrectomy (LSG) were included with a mean age of 44.77±12.05 years. The mean BMI was 52.06±13.85 preoperatively. The mean drop in hemoglobin was 0.04±0.26 with a p-value of 0.07, which is statistically insignificant. Among 120 cases, two (1.7%) patients reported episodes of melena, and four (3.3%) patients reported hematemesis. Postoperative hypotension was recorded in six (5%) patients and eight (6.7%) patients had postoperative tachycardia.

CONCLUSION

This study shows ligation clip application along the staple line is an effective means of hemostasis similar to suture application.

Prevalence of Symptomatic Gallbladder Disease After Bariatric Surgery: A Literature Review

Introduction Gallbladder disease (GBD) encompasses several medical conditions, including gallbladder stone formation, biliary colic, and cholecystitis. These conditions may arise following bariatric surgery, including bypass or laparoscopic sleeve gastrectomy (LSG). The development of GBD after surgery may be attributed to various factors, including the formation of stones shortly after the procedure, the exacerbation of existing stones due to the surgery, or inflammation of the gallbladder. Rapid weight loss after surgery has also been proposed as a contributing factor. Methodology This observational study consisted of a review of retrospective hospital patient medical records of 350 adult participants who underwent LSG, with 177 participants included in the study after excluding those with cholecystectomy or GBD prior to surgery. The participants were followed for a median of two years, during which we recorded any hospitalizations, emergency department visits, clinic visits, and incidents of cholecystectomy or abdominal pain due to GBD. The participants were grouped into two: those with GBD and those without GBD after bariatric surgery, and quantitative data were summarized using mean and standard deviations. The data were analyzed using IBM SPSS Statistics for Windows, Version 20.0. (IBM Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp), with a statistical significance of P<0.05. Results In our retrospective study of 177 patients who underwent LSG, the incidence of GBD after bariatric surgery was 4.5%. Most patients with GBD after bariatric surgery were White, but this difference was not statistically significant. Patients with type 2 diabetes had a higher incidence of GBD after bariatric surgery than those without diabetes (8.3% vs. 3.6%, P=0.355). Patients with HTN had a lower incidence of GBD after bariatric surgery than those without HTN (1.1% vs. 8.2%, P=0.032). Anti-hyperglycemia medication use did not significantly increase the risk of GBD after bariatric surgery (7.5% vs. 3.8%, P=0.389). None of the patients on weight loss medication developed GBD after bariatric surgery, compared to 5% of patients who did not take weight loss medication. Our sub-data analysis showed that patients who developed GBD after bariatric surgery had a high BMI (above 40 kg/m2) before surgery, which decreased to 35 kg/m2 and below 30 kg/m2 at six months and 12 months post-surgery, respectively. Conclusions Our findings demonstrate that the prevalence of GBD after LSG is low and comparable to the general population without LSG. Thus, LSG does not increase the risk of GBD. We found that rapid weight loss after LSG is a significant risk factor for GBD. These findings suggest that patients who undergo LSG should be informed of the risks of GBD and undergo careful screening before surgery to detect any pre-existing gallbladder issues. Overall, our study highlights the importance of continued research into the factors associated with GBD after bariatric surgery and the need for standardized prophylactic measures to prevent this potentially serious complication.

Osteomalacia induced peripheral neuropathy after obesity reduction surgery

Osteomalacia and rickets are important reversible causes of debilitating muscular weakness and bony pains in India among all socio-economic strata and at all ages. Osteomalacia after bariatric surgery is documented in literature. Most reports on osteomalacic weakness note myopathic pattern on electromyography. We present the case of a young obese girl from a good socio-economic status who developed severe muscular weakness after sleeve gastrectomy surgery. The patient was found to have osteomalacia with normal vitamin B12 and folate levels. Electrodiagnostic studies demonstrated neuropathic pattern while radiological tests confirmed osteopenia and Looser's zones. Specific vitamin D supplementation was associated with improvement though contribution of other micronutrients in diet cannot be ruled out. Relevance of vitamin D deficiency and urgent need for its correction in the population all over the world and especially in Asia is an emerging health issue. Peripheral motor neuropathy is a rare, seldom reported presentation of osteomalacia.