One Anastomosis Gastric Bypass for Revision of Restrictive Procedures: Mid-Term Outcomes and Analysis of Possible Outcome Predictors

Purpose

Revisional one anastomosis gastric bypass (OAGB) for insufficient weight reduction following primary restrictive procedures is still investigated. We report mid-term outcomes and possible outcome predictors.

Materials and Methods

Single-center retrospective comparative study of revisional OAGB outcomes (2015–2018) following laparoscopic adjustable gastric banding (LAGB) and sleeve gastrectomy (SG); silastic ring vertical gastroplasty (SRVG) is separately discussed.

Results

In all, 203 patients underwent revisional OAGB following LAGB (n?=?125), SG (n?=?64), and SRVG (n?=?14). Comparing LAGB and SG, body mass index (BMI) at revision were 41.3?±?6.6 and 42?±?11.2 kg/m² (p?=?0.64), reduced to 31.3?±?8.3 and 31.9?±?8.3 (p?=?0.64) at mid-term follow-up, respectively. Excess weight loss (EWL)?>?50% was achieved in?~?50%, with EWL of 79.4?±?20.4% (corresponding total weight loss 38.5?±?10.4%). SRVG patients had comparable outcomes. Resolution rates of type 2 diabetes (T2D) and hypertension (HTN) were 93.3% and 84.6% in LAGB compared with 100% and 100% in SG patients (p?=?0.47 and p?=?0.46), respectively.

In univariable analysis, EWL?>?50% was associated with male gender (p?<?0.001), higher weight (p?<?0.001), and BMI (p?=?0.007) at primary surgery, and higher BMI at revisional OAGB (p?<?0.001). In multivariable analysis, independent predictors for EWL?>?50% were male gender (OR?=?2.8, 95% CI 1.27–6.18; p?=?0.01) and higher BMI at revisional OAGB (OR?=?1.11, 95% CI 1.03–1.19; p?=?0.006).

Conclusion

Revisional OAGB for insufficient restrictive procedures results in excellent weight reduction in nearly 50% of patients, with resolution of T2D and HTN at mid-term follow-up. Male gender and higher BMI at revision were associated with EWL?>?50% following revisional OAGB. Identification of more predictors could aid judicious patient selection.

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Secondary Hyperparathyroidism Before and After Bariatric Surgery: a Prospective Study with 2-Year Follow-Up

Purpose

Secondary hyperparathyroidism (SHPT) is linked to obesity. Bariatric surgery may be associated with calcium and vitamin D deficiencies leading to SHPT. This study aimed to detect the prevalence of SHPT before and after bariatric surgery.

Methods

This prospective study assessed the prevalence of SHPT after sleeve gastrectomy (SG, n = 38) compared to one-anastomosis gastric bypass (OAGB, n = 86). All patients were followed up for 2 years. Bone mineral density (BMD) was assessed using dual-energy X-ray absorptiometry.

Results

Of the 124 patients, 71 (57.3%) were females, and 53 (42.7%) were males, with a mean age of 37.5 ± 8.8 years. Before surgery, 23 patients (18.5%) suffered from SHPT, and 40 (32.3%) had vitamin D deficiency. The prevalence of SHPT increased to 29.8% after 1 year and 36.3% after 2 years. SHPT was associated with lower levels of vitamin D and calcium and higher reduction of BMD in the hip but not in the spine. After 2 years, SHPT was associated with a significantly lower T-score in the hip. SHPT and vitamin D deficiency were significantly more common in patients subjected to OAGB compared to SG (p = 0.003, and p < 0.001, respectively). There is a strong negative correlation between vitamin D levels and parathormone levels before and after surgery.

Conclusion

Prevalence of SHPT is high in obese patients seeking bariatric surgery, especially with lower vitamin D levels. Bariatric surgery increases the prevalence of SHPT up to 2 years. Gastric bypass is associated with a higher risk of developing SHPT compared to SG.

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Once in a Bile — the Incidence of Bile Reflux Post-Bariatric Surgery

Purpose

Excellent metabolic improvement following one anastomosis gastric bypass (OAGB) remains compromised by the risk of esophageal bile reflux and theoretical carcinogenic potential. No ‘gold standard’ investigation exists for esophageal bile reflux, with diverse methods employed in the few studies evaluating it post-obesity surgery. As such, data on the incidence and severity of esophageal bile reflux is limited, with comparative studies lacking. This study aims to use specifically tailored biliary scintigraphy and upper gastrointestinal endoscopy protocols to evaluate esophageal bile reflux after OAGB, sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB).

Methods

Fifty-eight participants underwent OAGB (20), SG (15) or RYGB (23) between November 2018 and July 2020. Pre-operative reflux symptom assessment and gastroscopy were performed and repeated post-operatively at 6 months along with biliary scintigraphy.

Results

Gastric reflux of bile was identified by biliary scintigraphy in 14 OAGB (70%), one RYGB (5%) and four SG participants (31%), with a mean of 2.9% (SD 1.5) reflux (% of total radioactivity). One participant (OAGB) demonstrated esophageal bile reflux. De novo macro- or microscopic gastroesophagitis occurred in 11 OAGB (58%), 8 SG (57%) and 7 RYGB (30%) participants. Thirteen participants had worsened reflux symptoms post-operatively (OAGB, 4; SG, 7; RYGB, 2). Scintigraphic esophageal bile reflux bore no statistical association with de novo gastroesophagitis or reflux symptoms.

Conclusion

Despite high incidence of gastric bile reflux post-OAGB, esophageal bile reflux is rare. With scarce literature of tumour development post-OAGB, frequent low-volume gastric bile reflux likely bears little clinical consequence; however, longer-term studies are needed.

Clinical Trial Registry

Australian New Zealand Clinical Trials Registry number ACTRN12618000806268.

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The Relationship Between Percentage Weight Loss and World Health Organization-Five Wellbeing Index (WHO-5) in Patients Having Bariatric Surgery

Purpose

The association between bariatric surgery outcome and depression remains controversial. Many patients with depression are not offered bariatric surgery due to concerns that they may have suboptimal outcomes. The aim of this study was to investigate the relationship between baseline World Health Organization-Five Wellbeing Index (WHO-5) and percentage total weight loss (%TWL) in patients after bariatric surgery.

Materials and Methods

All patients were routinely reviewed by the psychologist and screened with WHO-5. The consultation occurred 3.5?±?1.6 months before bariatric surgery. Body weight was recorded before and 1 year after surgery. A total of 45 out of 71 (63.3%) patients with complete WHO-5 data were included in the study. Data analysis was carried out with IBM SPSS Statistics (version 27) to determine the correlation between baseline WHO-5 and %TWL in patients having bariatric surgery.

Results

Overall, 11 males and 34 females were involved with mean age of 47.5?±?11.5 and BMI of 46.2?±?5.5 kg/m². The %TWL between pre- and 1-year post-surgery was 30.0?±?8.3% and the WHO-5 Wellbeing Index mean score was 56.5?±?16.8. We found no correlation between %TWL and the WHO-5 Wellbeing Index (r?=?0.032, p?=?0.83).

Conclusion

There was no correlation between the baseline WHO-5 Wellbeing Index and %TWL 1-year post-bariatric surgery. Patients with low mood or depression need to be assessed and offered appropriate treatment but should not be excluded from bariatric surgery only based on their mood.

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Long-term Remission of Type 2 Diabetes and Patient Survival After Biliopancreatic Diversion with Duodenal Switch

Purpose

This study investigates the long-term effects of biliopancreatic diversion with duodenal switch (BPD-DS) on patients with advanced type 2 diabetes mellitus (T2DM) while paying special attention to preoperative diabetes severity.

Materials and Methods

A retrospective analysis was conducted using prospective and current data on patients who underwent an open BPD-DS 6–12 years ago. Patients were stratified according to preoperative diabetes severity into 4 groups (group 1: oral antidiabetic drugs only; group 2: insulin?<?5 years; group 3: insulin 5–10 years; group 4: insulin?>?10 years). The primary endpoint was T2DM remission rate 6–12 years after BPD-DS as a function of preoperative diabetes severity.

Results

Ninety-one patients with advanced T2DM were included. Sixty-two patients were available for follow-up (rate of 77%). Follow-up was performed (mean?±?SD) 8.9?±?1.3 years after surgery. Glycated hemoglobin (HbA_1c) levels were 9.4?±?2.0% before surgery and decreased to 5.1?±?0.8% after 1 year and 5.4?±?1.0% after 6–12 years. Insulin discontinuation rate after surgery as well as the rate of long-term remission decreased steadily from groups 1 to 4, while long-term mortality increased. T2DM remission rates were 93%, 88%, 45%, and 40% in groups 1, 2, 3, and 4, respectively. Late relapse of T2DM occurred in 3 patients (5%).

Conclusions

BPD-DS causes a rapid and long-lasting normalization of glycemic metabolism in patients with advanced T2DM. T2DM remission rate after 6–12 years varies significantly (from 40% to more than 90%) and is highly dependent on preoperative diabetes severity.

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One-Anastomosis Gastric Bypass Versus Roux-en-Y Gastric Bypass as Revisional Surgery After Sleeve Gastrectomy: a Systematic Review and Meta-analysis

The demand for revisional bariatric surgery after sleeve gastrectomy (SG) has increased, but the ideal procedure remains unclear. A systematic review and meta-analysis were performed to compare the outcomes of weight loss and safety of one-anastomosis gastric bypass (OAGB) and Roux-en-Y gastric bypass (RYGB) as revisional procedures for failed SG. Four retrospective comparative studies were included, comprising 499 individuals. Patients submitted to OAGB had a more significant total weight loss (TWL) (MD =  − 5.89%; 95% CI − 6.80 to − 4.97) after revisional surgery. Overall early complication rate was similar between procedures (RD = 0.04; 95% CI: − 0.05 to 0.12). Limited and heterogeneous data prevent meaningful conclusions, but the present analysis suggests that OAGB has a better TWL after revisional surgery.

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The Potential of Semaglutide Once-Weekly in Patients Without Type 2 Diabetes with Weight Regain or Insufficient Weight Loss After Bariatric Surgery—a Retrospective Analysis

Purpose

About 20–25% of patients experience weight regain (WR) or insufficient weight loss (IWL) after bariatric metabolic surgery (BS). Therefore, we aimed to retrospectively assess the effectiveness of adjunct treatment with the GLP-1 receptor agonist semaglutide in non-diabetic patients with WR or IWL after BS.

Materials and Methods

Post-bariatric patients without type 2 diabetes (T2D) with WR or IWL (n?=?44) were included in the analysis. The primary endpoint was weight loss 3 and 6 months after initiation of adjunct treatment. Secondary endpoints included change in BMI, HbA1c, lipid profile, hs-CRP, and liver enzymes.

Results

Patients started semaglutide 64.7?±?47.6 months (mean?±?SD) after BS. At initiation of semaglutide, WR after post-bariatric weight nadir was 12.3?±?14.4% (mean?±?SD). Total weight loss during semaglutide treatment was???6.0?±?4.3% (mean?±?SD, p?<?0.001) after 3 months (3.2 months, IQR 3.0–3.5, n?=?38) and???10.3?±?5.5% (mean?±?SD, p?<?0.001) after 6 months (5.8 months, IQR 5.8–6.4, n?=?20). At 3 months, categorical weight loss was?>?5% in 61% of patients,?>?10% in 16% of patients, and?>?15% in 2% of patients. Triglycerides (OR?=?0.99; p?<?0.05), ALT (OR?=?0.87; p?=?0.05), and AST (OR?=?0.89; p?<?0.05) at baseline were negatively associated with weight loss of at least 5% at 3 months’ follow-up (p?<?0.05).

Conclusion

Treatment options to manage post-bariatric excess weight (regain) are scarce. Our results imply a clear benefit of adjunct treatment with semaglutide in post-bariatric patients. However, these results need to be confirmed in a prospective randomized controlled trial to close the gap between lifestyle intervention and revision surgery in patients with IWL or WR after BS.

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Biochemical Markers and Obstructive Sleep Apnea Risk in Individuals After Long-Term Bariatric Surgery

Background

Individuals who have undergone long-term bariatric surgery may be at increased obstructive sleep apnea (OSA) risk. The purpose of this study was to estimate the frequency of OSA risk and its associations, via biochemical markers, in patients who have undergone long-term bariatric surgery.

Methods

This cross-sectional study evaluated patients after 5 years or more post Roux-en-Y gastric bypass. Biochemical markers, anthropometrics, and OSA risk, via the STOP-Bang score screening tool, were evaluated. Independent Student t, Pearson’s chi-squared, or correlation tests were applied, according to total OSA risk score groups or its isolated components.

Results

Among the 77 patients evaluated (88.3% female; body mass index?=?32.7?±?5.8 kg/ m²; postoperative time?=?9.9?±?3.1 years), 36 were at risk for OSA. OSA risk score was positively correlated to high-sensitivity C-reactive protein levels (r²?=?0.270; p?=?0.025), triglycerides (r²?=?0.338, p?=?0.004), total cholesterol (r²?=?0,262; p?=?0,028), and HbA1c (r²?=?0.332; p?=?0.005). Compared to each counterpart, basal insulin and triglycerides were higher among those who self-reported witnessed apnea (12.8?±?6.5 vs 8.1?±?3.8, p?=?0.013; 136.4?±?41.1 vs 88.5?±?34.8, p?=?0.001, respectively), while levels of total cholesterol and LDL-C were higher in participants who reported tiredness (183.9?±?27.0 vs 164.8?±?33.4, p?=?0.005; 105.9?±?24.4 vs 92.0?±?26.6, p?=?0.018). Participants with snoring also had higher levels of triglycerides (107?±?41.1 vs 83.7?±?33.9, p?=?0.010).

Conclusions

OSA risk was highly prevalent among patients who had undergone long-term bariatric surgery, as noted via increased STOP-Bang scores, as were isolated components related to inflammatory markers and lipid and glycemic profile.

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Analysis of the Factors Contributing to Bariatric Success After Laparoscopic Redo Bariatric Procedures: Results from Multicenter Polish Revision Obesity Surgery Study (PROSS)

Introduction

With continuously growing number of redo bariatric surgeries (RBS), it is necessary to look for factors determining success of redo-surgeries.

Patients and methods

A retrospective cohort study analyzed consecutive patients who underwent RBS in 12 referral bariatric centers in Poland from 2010 to 2020. The study included 529 patients. The efficacy endpoints were percentage of excessive weight loss (%EWL) and remission of hypertension (HT) and/or type 2 diabetes (T2D).

Results

Group 1: weight regain

Two hundred thirty-eight of 352 patients (67.6%) exceeded 50% EWL after RBS. The difference in body mass index (BMI) pre-RBS and lowest after primary procedure < 10.6 kg/m2 (OR 2.33, 95% CI: 1.43–3.80, p = 0.001) was independent factor contributing to bariatric success after RBS, i.e., > 50% EWL.

Group 2: insufficient weight loss

One hundred thirty of 177 patients (73.4%) exceeded 50% EWL after RBS. The difference in BMI pre-RBS and lowest after primary procedure (OR 0.76, 95% CI: 0.64–0.89, p = 0.001) was independent factors lowering odds for bariatric success.

Group 3: insufficient control of obesity-related diseases

Forty-three of 87 patients (49.4%) achieved remission of hypertension and/or type 2 diabetes. One Anastomosis Gastric Bypass (OAGB) as RBS was independent factor contributing to bariatric success (OR 7.23, 95% CI: 1.67–31.33, p = 0.008), i.e., complete remission of HT and/or T2D.

Conclusions

RBS is an effective method of treatment for obesity-related morbidity. Greater weight regain before RBS was minimizing odds for bariatric success in patients operated due to weight regain or insufficient weight loss. OAGB was associated with greater chance of complete remission of hypertension and/or diabetes.

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Vitamin D Supplementation and Its Relationship with Loss of Visceral Adiposity

Purpose

An inverse relationship between vitamin D (VD) nutritional status and obesity is frequent, and the distribution of body fat is an important aspect to assess the risks of obesity-related metabolic dysfunction. The purpose of the study was to evaluate the relationship between serum VD concentrations and body fat reduction after 12 months of bariatric surgery, using two different vitamin D3 (VD3) supplementation protocols.

Material and Methods

A randomized controlled trial consisted of 41 patients divided into G1 (800 IU/day) and G2 (1800 IU/day) according to the VD3 supplementation. At baseline (T0) and follow-up (T1), 25(OH)D, waist circumference (WC), visceral adiposity index (VAI), body adiposity index (BAI), and waist/height ratio (WHtR) were evaluated.

Results

In T0, the mean of 25(OH)D was lower in G2 compared to that in G1 (22.6 vs 23.6 ng/mL; p?=?0.000). At T1, it had a significant increase in G2 (32.1 vs 29.9 ng/mL; p?=?0.000), with 60% sufficiency. A significant negative correlation was observed between VAI, BAI, and WHtR with 25(OH)D in G2 (r?=????0.746, p?=?0.024; r?=????0.411, p?=?0.036; r?=????0.441, p?=?0.032) after surgery. Higher mean changes from baseline of visceral fat loss, represented by VAI, were observed in G2 (176.2?±?149.0–75.5?±?55.0, p?=?0.000).

Conclusion

Patients submitted to the 1800 IU/day protocol, 12 months after the surgical procedure, had a higher percentage of sufficient vitamin D levels compared to those submitted to the 800 IU/day protocol. Additionally, higher dose supplementation promoted a significant improvement in VAI.

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One-Anastomosis Gastric Bypass Revision for Gastroesophageal Reflux Disease: Long Versus Short Biliopancreatic Limb Roux-en-Y Gastric Bypass

Purpose

One-anastomosis gastric bypass (OAGB) may be associated with refractory gastroesophageal reflux disease (GERD). The nature of this GERD remains unclear. This complication can be treated either with an additional enteroenterostomy without shortening of gastric pouch (long biliopancreatic limb Roux-en-Y gastric bypass (L-BPL-RYGB)) or revision to conventional short biliopancreatic limb Roux-en-Y gastric bypass (S-BPL-RYGB). The objective of this study is to compare the aforementioned procedures in terms of efficacy on GERD symptoms.

Materials and Methods

Retrospective analysis between October 2012 and June 2020.

Results

Fifty-two patients underwent OAGB revision to S-BPL-RYGB (n = 21) or L-BPL-RYGB (n = 31) secondary to GERD. Investigation with pH impedance prior to revision was performed in 15 patients showing biliary reflux (BR) in 7 (46.6%), acid reflux (AR) in 6 (40%), and no confirmation in 2. Patients with AR had a revision to S-BPL-RYGB, whereas patients with BR underwent L-BPL-RYGB. Among the patients without pH metry results (n = 37), S-BPL-RYGB was performed for associated disabling digestive disorders or nutritional deficiencies. GERD was treated in 68% of patients with L-BPL-RYGB versus 95% of patients after S-BPL-RYGB. Patients, whose decision for revisional procedure was based on the results of pH impedance testing, did not reveal refractory GERD.

Conclusion

L-BPL-RYGB seems appropriate in patients with BR, whereas conversion to S-BPL-RYGB should be preferred if AR is present.

Graphical Abstract

     

Complications Post Abdominoplasty After Surgical Versus Non-surgical Massive Weight Loss: a Comparative Study

Purpose

This study aims to investigate the rate of short- and long-term complications as well as the need for operative revisions after abdominoplasty for patients following surgical versus non-surgical weight loss methods.

Methods

This is a retrospective chart review that enrolled consecutive patients undergoing abdominoplasty across a 5-year period, aged 18 years and above, opting for abdominoplasty after weight loss achieved through bariatric surgery or diet and exercise alone.

Results

A total of 364 patients lost weight through bariatric surgery and 106 by diet and exercise alone. There were no significant differences in comorbidity status, but past body mass index (BMI) was higher for the surgical weight loss (SW) group (47.6 ± 10.2 and 40.4 ± 8.6, respectively; p value < 0.0001). Percent excess weight loss (EWL) was 68 ± 14.5 for the SW group and 55.7 ± 19.4 for the NSW group, p value < 0.0001. Pre- and postoperative blood hemoglobin levels were significantly lower in the SW group (p < 0.05). Neither short-term complications (thromboembolic events, wound complications, or infections) nor long-term complications (umbilical deformity, delayed wound healing, or infection) and operative revisions were significantly different across both groups (p > .05).

Conclusion

Bariatric surgery does not increase the risk of short- or long-term complications or the need for operative revision after abdominoplasty.

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Effect of Dexmedetomidine Compared to Remifentanil During Bariatric Surgery on Postoperative Nausea and Vomiting: a Retrospective Study

Purpose

Postoperative nausea and vomiting (PONV) occurs frequently after bariatric surgery and is a major cause of adverse outcomes. This retrospective study investigated whether opioid-restricted total intravenous anesthesia using dexmedetomidine as a substitute for remifentanil can reduce PONV in bariatric surgery.

Materials and Methods

The electronic medical records of adult patients who underwent laparoscopic bariatric surgery between January and December 2019 were reviewed. The patients were divided into two groups according to the agents used for anesthesia: Group D, propofol and dexmedetomidine; Group R, propofol and remifentanil.

Results

A total of 134 patients were included in the analyses. The frequency of postoperative nausea was significantly lower in Group D than that in Group R until 2 h after discharge from the postanesthesia care unit (PACU) (P?=?0.005 in the PACU, P?=?0.010 at 2 h after PACU discharge) but failed to significantly reduce the overall high incidence rates of 60.5% and 65.5%, respectively (P?=?0.592). Postoperative pain score was significantly lower in Group D until 6 h after PACU discharge. The rates of rescue antiemetic and analgesic agent administration in the PACU were significantly lower in Group D than those in Group R.

Conclusion

Opioid-restricted total intravenous anesthesia using dexmedetomidine reduces postoperative nausea, pain score, antiemetic, and analgesic requirements in the immediate postoperative period after bariatric surgery.

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Prospective Randomized Comparison of Linear Endostaplers During Laparoscopic Sleeve Gastrectomy

Purpose

The development of Laparoscopic Linear Endostaplers (LLES) is crucial in minimally invasive approaches in bariatric surgery, but there have been very few published studies comparing 6-row LLES in Laparoscopic Sleeve Gastrectomy (LSG). The objective of this study was to compare two 6-row LLES in LSG.

Methods

A total of 60 patients were prospectively randomized to undergo LSG with either Medtronic Endo GIA? Tri-Staple technology (MTS) or AEON ? Endostapler(Lexington Medical) LLES. The measured parameters included patient demographics, comorbidity indices, LLES and specimen characteristics, postoperative symptoms, hospital stay, and total adverse events (AEs). Intraoperative bleeding was evaluated using five laparoscopic and corresponding endoscopic images of staple line before clip application, compared with a 1–5 Visual Analogue Scale (VAS), assessed by an independent bariatric surgeon who was blinded to the LLES used. Images of all cases were reviewed on the same day to increase test–retest reliability.

Results

Both groups were similar in patient demographics. Compared to MTS, AEON LLES group had significantly lower bleeding VAS scores in 4/5 laparoscopic images (pre-pyloric: 1.7?±?0.7 vs. 2.36?±?0.76, p?=?0.0007, mid-sleeve: 1.46?±?0.62 vs. 1.86?±?0.68, p?=?0.019, proximal sleeve: 1.6?±?0.77 vs. 2.0?±?0.83, p?=?0.038, gastro-esophageal junction: 1.43?±?0.67 vs. 1.86?±?0.77, p?=?0.014) and 3/5 endoscopic images (pre-pyloric: 1.56?±?0.56 vs. 2.36?±?0.76, p?=?0.006, incisura: 1.66?±?0.54 vs. 2.0?±?0.52, p?=?0.021, mid-sleeve: 1.63?±?0.49 vs. 2.0?±?0.45, p?=?0.005). There was no statistical difference in other parameters.

Conclusion

Both devices were equally safe and effective in terms of LLES and specimen characteristics, patient symptoms, hospital stay, and AEs. Bleeding VAS scores were significantly lower, favoring the AEON LLES.

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Racial Differences in Bariatric Surgical Approach: a Cross-Sectional National Inpatient Sample Analysis

Purpose

Although racial inequalities in referral and access to bariatric surgical care have been well reported, racial difference in the selection of surgical techniques is understudied. This study examined factors associated with the utilization of the two main bariatric surgical techniques: laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB).

Materials and Methods

The National Inpatient Sample database was queried for patients who underwent elective LSG or LRYGB for the treatment of severe obesity. Chi-square tests and multivariable logistic regression assessed associations of surgical approach with patient and facility characteristics. Sensitivity analyses examined the following body mass index (BMI) subgroups:?<?40.0 kg/m², 40.0–44.9 kg/m², 45.0–49.9 kg/m², and?≥?50.0 kg/m².

Results

Within the final cohort (N?=?86,053), 73.0% (N?=?62,779) underwent LSG, and 27.0% (N?=?23,274) underwent LRYGB. Patients with BMI 45.0–49.9 kg/m² (OR?=?0.85) and BMI?≥?50.0 kg/m² (OR?=?0.80) were less likely to undergo LSG than patients with BMI 40.0–45.0 kg/m² (all p?<?0.001). However, Black (OR?=?1.74) and White Hispanic patients (OR?=?1.30) were more likely to undergo LSG than White non-Hispanic patients (all p?<?0.005). In the BMI?≥?50.0 kg/m² group, Black patients were still more likely to undergo LSG compared to White non-Hispanic patients (OR?=?1.69, p?<?0.001), while Asians/Pacific Islanders were less likely to receive LSG than White non-Hispanic patients (OR?=?0.41, p?<?0.05).

Conclusion

In this observational study, we identified racial differences in the selection of common bariatric surgical approaches across various BMI categories. Future investigations are warranted to study and to promote awareness of the racial/ethnic influence in attitudes on obesity, weight loss, financial support, and surgical risks during bariatric discussions with minorities.

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Nutritional Deficiencies Among Adolescents Before and After Sleeve Gastrectomy: First Study with 9-Year Follow-up

Background

Globally, only two studies appraised the long-term nutritional status of adolescents after laparoscopic sleeve gastrectomy (LSG).

Methods

Retrospective chart review of all adolescents aged ≤ 18 years who underwent LSG with ≥ 5 years follow-up and had no subsequent revisional surgery (N = 146). We assessed 15 nutritional parameters preoperatively and at 1, 3, 5, 7, and 9 years post surgery.

Results

Mean age was 16.51 ± 1.29 years, 51% were males. We identified three patterns:

1. 1)

   Significant worsening of preoperative deficiencies: 4.7% and 0.8% of the sample exhibited zinc and vitamin B12 deficiencies, worsening to 20.8% and 12.8% at 1 year, respectively. Likewise, 0.7% of the sample had low total protein, worsening to 8.3% at year 3. A total of 32.4% of females had preoperative low hemoglobin worsening to 57.9% at year 5.

2. 2)

   Significant improvement: the percentage of males with preoperative low hemoglobin (5.6%) was reduced to 4.1% and 5.1% at years 1 and 3, respectively.

3. 3)

   Persistent deficiency: all (100%) of adolescents had preoperative vitamin D deficiency that persisted through years 3 and 9 at 90.5% and 100%, respectively. The most common complications were food intolerance (51%), vomiting (47.5%), gastritis/ esophagitis (35.7%), and gastroesophageal reflux disease (20.3%). We observed one case of Wernicke’s encephalopathy. Across the 9 years, 15.4% of the adolescents underwent intra-abdominal surgeries where 12.6% had cholecystectomy and one patient had appendectomy.

Conclusion

Adolescents had several preoperative nutritional deficiencies, most of which worsened or persisted on the long term. This is the first study among adolescents to assess such deficiencies beyond 5 years.

Graphical Abstract

     

Maternal Nutritional Status and Pregnancy Outcomes Post-bariatric Surgery

Obesity in childbearing women leads to pregnancy-related complications such as gestational diabetes mellitus, pregnancy-associated hypertensive disorders, and macrosomia. Weight loss helps reduce these complications. Studies show bariatric surgery reduces obesity-related complications during and after pregnancy. However, bariatric surgery might be associated with adverse outcomes, such as low birth weight and small-for-gestational-age infants. In addition, several studies suggest pregnancy occurring less than a year post-bariatric surgery adversely affects pregnancy outcomes and causes micronutrients deficiency since the dramatic weight loss occurs in the first year. These adverse outcomes may lead to nutritional malabsorption, such as anemia and low vitamin B12 and folic acid levels. The review aims to overview obesity-related complications during pregnancy and the benefits and risks of bariatric surgery on pregnancy outcomes and maternal nutrition status.

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Single- Versus Double-Anastomosis Duodenal Switch: Outcomes Stratified by Preoperative BMI

Purpose

Describe and analyze the safety and weight loss performance of biliopancreatic diversion and duodenal switch (BPD-DS) and single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S), verifying any possible superiority according to preoperative BMI.

Methods

Retrospective review of patients who underwent primary SADI-S or BPD-DS in three bariatric centers. Study groups were further stratified according to preoperative BMI (subgroup 1: BMI < 50; subgroup 2: 50 ≤ BMI < 55; subgroup 3: BMI ≥ 55).

Results

Four hundred and sixty patients underwent BPD-DS (n = 220) or SADI-S (n = 240). The mean LOS was 3.48 ± 3.7 and 3.13 ± 2.3 days for BPD-DS and SADI-S respectively (p = 0.235). The mean operative time was shorter in the SADI-S group (167.25 ± 33.6 vs 140.85 ± 56.7 min) (p < 0.00). The mean %EWL was 44.2, 62.4, and 69.4 for the BPD-DS group and 48.4, 64.5, and 67.1 for the SADI-S group at 6, 12, and 24 months respectively. The mean %TBWL was 25, 35.9, and 40.3 for the BPD-DS group, and 26.2, 35, and 36.9 for the SADI-S group at 6, 12, and 24 months respectively. Overall complication rates were comparable between BPD-DS and SADI-S groups (14% vs 18%) (p = 0.219). SADI-S showed greater emergency department visits (17% vs 7%) (p = 0.005); similar readmission rates (6% vs 7%) (p = 0.80); similar reoperation rates (3% vs 7%) (p = 0.102); and similar mortality rate (0.9% vs 0.4%), after BPD-DS and SADI-S respectively.

Conclusion

BPD-DS achieved greater %TBWL at 2 years, but no superiority was perceived among study subgroups. SADI-S and BPD-DS showed similar overall complication rates.

Graphical abstract

     

Early Bleeding After Laparoscopic Roux-en-Y Gastric Bypass: Incidence,Risk Factors,and Management — a 21-Year Experience

Purpose

Morbidity and mortality associated with bariatric surgery are considered low. The aim of this study is to assess the incidence, clinical presentation, risk factors, and management of early postoperative bleeding (POB) after laparoscopic Roux-en-Y gastric by-pass (RYGB).

Materials and Methods

Retrospective analysis of prospectively collected data of consecutive patients who underwent RYGB in 2 expert bariatric centers between January 1999 and April 2020, with a common bariatric surgeon.

Results

A total of 2639 patients underwent RYGB and were included in the study. POB occurred in 72 patients (2.7%). Intraluminal bleeding (ILB) was present in 52 (72%) patients and extra-luminal bleeding (ELB) in 20 (28%) patients. POB took place within the first 3 postoperative days in 79% of patients. The most frequent symptom was tachycardia (63%). Abdominal pain was more regularly seen with ILB, compared to ELB (50% vs. 20%, respectively, p?=?0.02). Male sex was an independent risk factor of POB on multivariate analysis (p?<?0.01). LOS was significantly longer in patients who developed POB (8.3 vs. 3.8 days, p?<?0.01). Management was conservative for most cases (68%). Eighteen patients with ILB (35%) and 5 patients with ELB (25%) required reoperation. One patient died from multiorgan failure after staple-line dehiscence of the excluded stomach (mortality 0.04%).

Conclusion

The incidence of POB is low, yet it is the most frequent postoperative complication after RYGB. Most POB can be managed conservatively while surgical treatment is required for patients with hemodynamic instability or signs of intestinal obstruction due to an intraluminal clot.

Graphical abstract