Esophageal and gastric malignancies after bariatric surgery: a retrospective global study

BackgroundBariatric surgery can influence the presentation, diagnosis, and management of gastrointestinal cancers. Esophagogastric (EG) malignancies in patients who have had a prior bariatric procedure have not been fully characterized.ObjectiveTo characterize EG malignancies after bariatric procedures.SettingUniversity Hospital, United Kingdom.MethodsWe performed a retrospective, multicenter observational study of patients with EG malignancies after bariatric surgery to characterize this condition.ResultsThis study includes 170 patients from 75 centers in 25 countries who underwent bariatric procedures between 1985 and 2020. At the time of the bariatric procedure, the mean age was 50.2 ± 10 years, and the mean weight 128.8 ± 28.9 kg. Women composed 57.3% (n = 98) of the population. Most (n = 64) patients underwent a Roux-en-Y gastric bypass (RYGB) followed by adjustable gastric band (AGB; n = 46) and sleeve gastrectomy (SG; n = 43). Time to cancer diagnosis after bariatric surgery was 9.5 ± 7.4 years, and mean weight at diagnosis was 87.4 ± 21.9 kg. The time lag was 5.9 ± 4.1 years after SG compared to 9.4 ± 7.1 years after RYGB and 10.5 ± 5.7 years after AGB. One third of patients presented with metastatic disease. The majority of tumors were adenocarcinoma (82.9%). Approximately 1 in 5 patients underwent palliative treatment from the outset. Time from diagnosis to mortality was under 1 year for most patients who died over the intervening period.ConclusionThe Oesophago-Gastric Malignancies After Obesity/Bariatric Surgery study presents the largest series to date of patients developing EG malignancies after bariatric surgery and attempts to characterize this condition.     

Three-year follow-up of bone status in male patients after bariatric surgery—a prospective single-center cohort study

BackgroundIn women, bariatric surgery (BS) leads to a decline in bone mineral density (BMD) and may ultimately lead to premature osteoporosis. The impact in men is largely unknown.ObjectiveTo assess the effect of BS on bone metabolism in males.SettingSingle-center prospective cohort study.MethodsTwenty-four male BS candidates were prospectively enrolled. Anthropometric characteristics, serum gonadal hormones, markers of bone metabolism, and BMD were measured at baseline, 6-, 12- and 36-months postoperatively.ResultsRoux-en-Y gastric bypass (RYGB) and adjustable gastric banding (AGB) were performed in 15 and 9 patients, respectively. Nineteen patients completed the 3-year follow-up. At 3 years, BMD of the right and left femur had decreased by 9.1 ± 7.2% and 9.4 ± 5.8% for RYGB and by 6.7 ± 3.9% and 4.5 ± 2.8% for AGB. Radius BMD had decreased by 14.0 ± 5.6% for RYGB and 5.9 ± 4.1% for AGB, i.e., significantly stronger for RYGB (P = .006). Serum parathyroid hormone increased in both groups and 13 of 19 patients developed Vitamin D deficiency. A significant increase of the bone resorption marker was seen only during the first year despite continuation of bone loss. Four patients developed de novo osteopenia or osteoporosis. No fractures were observed.ConclusionThere are strong indications that male bone metabolism response after BS differs from female metabolism. The most affected site is the radius. In males, the cause of this BMD loss seems multifactorial, including mechanical unloading, hyperparathyroidism, and hypogonadism. However, clinical relevance remains unknown and therefore studies with longer-term follow-up are necessary.     

Gastrointestinal quality of life before and short- and long-term after Roux-en-Y gastric bypass for severe obesity

BackgroundOverall quality of life (QoL) is generally improved after bariatric surgery. Gastrointestinal (GI) symptoms including abdominal pain have been reported in up to >30% of patients after Roux-en-Y gastric bypass (RYGB), and may negatively influence QoL, especially GI-QoL.ObjectivesTo evaluate the evolution of GI symptoms and GI-QoL short- and long-term after RYGB.SettingTwo public hospitalsMethodsCandidates for bariatric surgery (n = 128, BMI = 44.2 ± 7.4) or patients who had undergone RYGB 2–4 years (n = 161, BMI = 29.3 ± 15.9) and 5–10 years (n = 121, BMI = 31.3 ± 6.5) before were invited to complete a questionnaire combining 3 validated questionnaires (GIQLI, GSRS, and PCS) specifically designed to evaluate GI-QoL. Scores were compared between the preoperative, early, and late postoperative periods.ResultsThe GIQLI score improved from 88.1 before surgery to 118.6 (P < .0001) and 109.7 (P < .0001) in the early and late postoperative periods respectively. GSRS score improved from 15.6 to 10.1 (P = .0001) and 12.8 (P = .012), and PCS-score improved from 19 to 4.5 (P = .0001) and 8.3 (P = .0001), respectively. The GI subscore of the GIQLI improved from 57.4 to 62.1 (P = .007) in the early period but was not significantly different in the late period (59.3 versus 57.4, P = .3). The psychological impact of GI symptoms decreased at both postoperative time points.ConclusionGI-QoL is markedly improved after RYGB, and this improvement persists up to 10 years. GI symptoms decrease early after surgery and do not worsen in the longer term. Their psychological impact is markedly reduced.     

One- versus two-stage conversions of adjustable gastric bands: an analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database

BackgroundLaparoscopic adjustable gastric bands (AGB) are converted at high rates to secondary bariatric procedures. The available literature on the safety of converting in 1- versus 2-stage processes has not included large databases.ObjectiveTo evaluate the safety of a 1- versus 2-stage conversion of AGB.SettingMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), United States.MethodsThe MBSAQIP database for the years 2020 and 2021 was evaluated. One-stage AGB conversions were identified using Current Procedural Terminology codes and database variables. Multivariable analysis was performed to determine whether 1- or 2-stage conversions were associated with 30-day serious complications.ResultsThere were 12,085 patients who underwent conversion from previous AGB to sleeve gastrectomy (SG) (63.0%) or Roux-en-Y gastric bypass (RYGB) (37.0%), of whom 41.0% underwent conversion in 1 stage and 59.0% in 2 stages. Patients who underwent 2-stage conversions had higher body mass indexes. Rates of serious complications were higher for patients undergoing RYGB compared with SG (5.2% versus 3.3%, P < .001) but were similar between 1-stage and 2-stage conversions in both cohorts. In both cohorts, there were similar rates of anastomotic leaks, postoperative bleeding, reoperation, and readmissions. Mortality was rare and similar between conversion groups.ConclusionsThere was no difference in outcomes or complications in 30 days between 1- and 2-stage conversions of AGB to RYGB or SG. Conversions to RYGB have higher complication and mortality rates than to SG, but there was no statistically significant difference between staged procedures. One- and 2-stage conversions from AGB are equivalent in safety.     

Bariatric revisional surgery for gastrogastric fistula following Roux-en-Y gastric bypass positively impacts weight loss

BackgroundGastrogastric fistula (GGF) is a rare complication from Roux-en-Y gastric bypass (RYGB). It is a known risk factor associated with weight recidivism and an indication for Bariatric Revisional Surgery (BRS).ObjectivesThe primary outcome of this study is to evaluate perioperative outcomes and the long-term total body weight loss (TBWL) outcomes following revision.SettingSingle Academic Institution, Center of Bariatric Excellence.MethodsWe selected patients who had primary bariatric surgery and BRS from 2003 to 2020, followed by BRS for GGF. Patients’ demographics, perioperative outcomes, and TBWL were analyzed.ResultsOne hundred five patients underwent BRS for GGF. Mean body mass index (BMI) at index operation and revision was 51.6 ± 10.1, and 42.4 ± 11.2 respectively. Ninety percent of patients had open primary RYGB, and 69% had open revisional surgery. The median length of stay after BRS was 3 days. The 30-day reintervention rate was 19%. The 30-day readmission rate was 34%. Of the 77 patients included for weight loss analysis, the mean %TBWL after primary RYGB was 34% ± 14. The total mean %TBWL at the time of revision was 18.8%, translating into a weight regain of 13.6% ± 9.5. The total mean %TBWL after revision was 37.6% ± 11.4, translating into TBWL of 18.8% ± 9.4 after revision when compared to TBWL at revision time.ConclusionsOur results demonstrate that revision for GGF can be safely performed, however is associated with higher morbidity than primary bariatric surgery. Revision for GGF results in significant long-term weight loss.     

Predictive value of preoperative DeMeester score on conversion to Roux-en-Y gastric bypass for gastroeosophageal reflux disease after sleeve gastrectomy

BackgroundObesity is well known to increase the risk of gastroesophageal reflux disease (GERD). The impact of sleeve gastrectomy (SG) on GERD is still discussed but seems to be associated with the development of de novo GERD or the exacerbation of preexisting GERD.ObjectiveThe objective of this study was to evaluate the impact of preoperative pH monitoring, using the DeMeester score (DMS), on the risk of conversion to Roux-en-Y gastric bypass (RYGB) after SG.SettingUniversity Hospital in Nantes, France.MethodsThis monocentric study reported the results of a retrospective chart review of 523 obese individuals treated between 2011 and 2018. All patients underwent primary bariatric surgery; 95% had undergone an SG. GERD diagnosis was established with preoperative DMS based on 24-hour esophageal pH monitoring.ResultsPreoperative DMS was identified in 423 patients (86%). Sixty-seven patients (14%) underwent a second bariatric procedure; among them, 36 (54%) have been converted to RYGB because of GERD. There was no significant difference between preoperative DMS (16.1 ± 22 versus 13.7 ± 14, P = .37) in patients undergoing conversion for GERD and the nonconverted ones. The sensitivity, specificity, positive predictive, and negative predictive values of the preoperative DMS for predicting conversion to RYGB were 25%, 66%, 7%, and 4%, respectively. In patients who underwent a conversion for GERD, DMS (P < .002), rates of esophagitis (P = .035), and hiatal hernia (P = .039) significantly increased after SG.ConclusionPreoperative DMS alone is not predictive of the risk of conversion of SG to RYGB for GERD.     

Conversion of laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass: patterns predicting persistent symptoms after revision

BackgroundLaparoscopic sleeve gastrectomy (LSG) is the most common bariatric operation performed. However, it is not without its drawbacks and patients may develop gastroesophageal reflux (GERD) after LSG. There are limited data available to guide treatment choice for patients suffering these sequelae.ObjectiveThis study was undertaken to evaluate the success of conversion to Roux-en-Y gastric bypass (RYGB) in treating GERD symptoms after LSG.SettingSingle bariatric center, United States.MethodsAnalysis of a prospectively maintained clinical database was performed. Outcomes studied included heartburn-related quality of life score (GERD-HRQL), anti-secretory usage, and body mass index (BMI).ResultsA total of 54 patients met inclusion criteria during the review period. Of these, 41 patients (76%) underwent conversion for indication including GERD. Mean BMI at conversion was 33.8 ± 5.61 and was found to be significantly reduced at 12 months after conversion (n = 26; 63%; P < .001) and at long-term follow-up (n = 37; 90%) (P ≤ .001; mean follow-up period: 33.3 mo). Mean GERD-HRQL at time of conversion was 31.5 ± 11.4. Conversion to RYGB produced a significant reduction of HRQL at 6 months after conversion (n = 30; 73%) (mean: 5.6, P < .001) and long-term follow-up (n = 38; 93%) (mean: 7.3, P < .001. mean follow-up period: 15.1 mo). Prior to conversion, 32 patients (78%) required antisecretory therapy for GERD and after conversion, 12 of these patients (38%) required antisecretory therapy (P < .001). These 12 patients were found to exhibit a significantly (P = .005) smaller decrease in GERD-HRQL after revision compared with their peers who were liberated from antisecretory therapy. Preoperative symptoms were compared between these 2 groups. Delayed onset of GERD symptoms after LSG (>3 mo) was found to be a significant risk factor for continued antisecretory dependence after conversion to RYGB.ConclusionConversion of LSG to RYGB quantitatively reduces GERD symptoms, and results in a modest but significant amount of weight loss. While there was a significant improvement in HRQL after revision, a subgroup of patients continued to be antisecretory-dependent and showed a limited improvement in HRQL. This limited response was predicted by a gradual onset of GERD symptoms prior to revision. An interval of 3 months or greater between LSG and onset of symptoms was found to be a significant risk factor for limited response to conversion.     

Outcomes of bariatric surgery in extreme obesity: results from the United Kingdom National Bariatric Surgery Registry for patients with a body mass index >70 kg/m2

BackgroundBariatric and metabolic surgery (BMS) is an established safe, effective, and durable treatment for obesity and its complications. However, there is still a paucity of evidence on surgery outcomes in patients suffering from extreme obesity.ObjectivesThis study aimed to evaluate outcomes of BMS in weight loss and the resolution of co-morbidities in patients with a body mass index (BMI) ≥70kg/m².SettingNational Health Service and private hospitals in the United Kingdom.MethodsThis cohort study analyzed prospectively collected records from the UK National Bariatric Surgery Registry of patients with a BMI ≥70 kg/m² undergoing Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), or adjustable gastric band (AGB) between January 2009 and June 2014.ResultsThere were 230 patients (64% female) eligible for inclusion in the study: 22 underwent AGB; 102 underwent SG, and 106 underwent RYGB. Preoperative weight and BMI values were comparable (76 ± 7 kg/m² for AGB; 75 ± 5 kg/m² for SG; 74 ± 5 kg/m² for RYGB). The median postoperative follow-up was 13 months for AGB (10–22 mo), 18 for SG (6–28 mo), and 15 for RYGB (6–24 mo). Patients undergoing RYGB and SG exhibited the greatest postoperative total body weight loss (35 ± 13% and 31 ± 15%, respectively; P = .14), which led to postoperative BMIs of 48 ± 10 kg/m² and 51 ± 11 kg/m², respectively (P = .14). All procedures conferred a reduction in the incidence of co-morbidities, including type 2 diabetes, and led to improved functional statuses. The overall complication rate was 7%, with 3 deaths (1%) within 30 days of surgery.ConclusionThis study found that primary BMS in patients with a BMI >70kg/m² has an acceptable safety profile and is associated with good medium-term clinical outcomes. RYGB and SG are associated with better weight loss and great improvements in co-morbidities than AGB. Given the noninferiority of SG outcomes and SG’s potential for further conversion to other BMS procedures if required, SG may be the best choice for primary BMS in patients with extreme obesity.     

One-year weight loss after primary or revisional Roux-en-Y gastric bypass for failed adjustable gastric banding

BackgroundAdjustable gastric banding has been widely used in Europe, but recently gastric bypass (Roux-en-Y gastric bypass [RYGB]) has become the procedure of choice. With a gastric banding failure rate of nearly 40% at 5 years, the need for revisional surgery is increasing. The effect of a failed previous bariatric surgery on the weight loss curve after RYGB is still a controversial issue.MethodsA total of 259 patients underwent RYGB from 2003 to 2007, 58 after failed gastric banding and 201 as primary surgery. All the procedures were laparoscopically performed by the same surgeon at a single institution. The postoperative course and the percentage of excess weight loss were compared between the 2 groups.ResultsThe 2 groups were similar in age and initial body mass index (46.3 ± 7.2 kg/m² for revision versus 47.7 ± 6.7 kg/m² for primary RYGB). In contrast, the prerevision body mass index was 43.2 ± 7.0 kg/m². Revisional RYGB required a significantly longer operative time (128.3 ± 25.9 minutes versus 89.0 ± 14.7 minutes, P <.0001) and the morbidity was greater (8.6% versus 5.5%), but no patient died in the postoperative period after revision. As determined from the initial body mass index, the 1-year percentage of excess weight loss was comparable between the 2 groups (66.1% ± 26.8% and 70.4% ± 18.9%).ConclusionWhen RYGB is performed after an adjustable gastric band failure to restore weight loss or because of a complication, the weight loss curve is similar to that after primary RYGB. Therefore, the strategy of adjustable gastric banding first is an option that does not seem to preclude satisfactory weight loss after revision to RYGB.     

Conversion from one-anastomosis gastric bypass to Roux-en-Y gastric bypass: when and why—a single-center experience of all consecutive OAGB procedures

BackgroundOne-anastomosis gastric bypass (OAGB) is a well-established treatment method in patients with morbid obesity. Its long-term impact on de novo reflux, anastomotic complications, and malnutrition needs further evaluation. Roux-en-Y gastric bypass (RYGB) is a technically feasible procedure in revisional bariatric surgery. This study presents our institutional data on conversion from OAGB to RYGB.ObjectiveTo determine the reasons for conversion, preoperative endoscopic findings, and feasibility of revisional bariatric surgery after OAGB.SettingUniversity hospital in AustriaMethodsRetrospective analysis of a prospectively fed database. All patients undergoing OAGB between January 2012 and December 2019 were included. Screening was carried out for all patients needing conversion to RYGB. Percent total weight loss, percent excess weight loss, time to conversion, postoperative complications, and reasons for conversion were assessed.ResultsEighty-two of 1,025 patients who underwent OAGB were converted laparoscopically to RYGB. Seven patients were converted early because of anastomotic/gastric tube leakage. Median time to late conversion was 29.1 ± 24.3 months, mean percent excess weight loss was 86.6% ± 33.1% and percent total weight loss was 35.1% ± 13.5%. Forty-two patients were converted because of reflux, 11 because of persistent marginal ulcers, 10 because of anastomotic stenosis, 9 because of malnutrition, and 3 because of weight regain. Seven patients showed Barrett’s metaplasia in biopsies at the gastroesophageal junction before conversion.ConclusionLaparoscopic conversion from OAGB to RYGB is technically feasible with a moderate rate of postoperative complications. Severe (bile) reflux is a serious long-term complication after OAGB, with 4.1% of patients needing conversion to RYGB. Endoscopy after OAGB in patients showing clinical symptoms of gastroesophageal reflux disease is strongly advised to detect underlying pathologic changes.     

Comparison of weight loss and body composition changes with four surgical procedures

BackgroundA paucity of information is available on the comparative body composition changes after bariatric procedures. The present study reports on the body mass index (BMI) and body composition changes after 4 procedures by a single group.MethodsAt the initial consultation, the weight and body composition of the patients undergoing 4 different bariatric procedures were measured by bioimpedance (Tanita 310). Follow-up examinations were performed at 1 year and at subsequent visits after surgery. Analysis of variance was used to compare the postprocedure BMI and body composition. Analysis of covariance was used to adjust for baseline differences.ResultsA total of 101 gastric bypass (GB) patients were evaluated at 19.1 ± 10.6 months, 49 biliopancreatic diversion with the duodenal switch (BPD/DS) patients at 27.5 ± 16.3 months, 41 adjustable gastric band (AGB) patients at 21.4 ± 9.2 months, and 30 sleeve gastrectomy (SG) patients at 16.7 ± 5.6 months (P <.0001). No differences were found in patient age or gender among the 4 groups. The mean preoperative BMI was significantly different among the 4 groups (P <.0001): 61.4 kg/m², 53.2, 46.7, and 44.3 kg/m² for the SG, BPD/DS, GB, and AGB group, respectively. The postoperative BMI adjusted for baseline differences was 27.8 (difference 23.6 ± 8.3), 32.5 (difference 15.6 ± 5.0), 37.2 (difference 18.2 ± 8.2), and 39.5 kg/m² (difference 7.5 ± 4.3) for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The percentage of excess weight loss was 84%, 70%, 49%, and 38% for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The postoperative percentage of body fat adjusted for baseline differences was 25.7% (23.9% ± 7.0%) 32.7% (16.1% ± 10.5%) 37.7% (16.7% ± 5.6%), and 42% (6.0% ± 6.8%) for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The lean body mass changes were reciprocal.ConclusionAlthough the BPD/DS procedure reduced the BMI the most effectively and promoted fat loss, all the procedures produced weight loss. The AGB procedure resulted in less body fat loss within 21.5 months than SG within 16.7 months. Longer term observation is indicated.     

Revisional surgery after failed gastric banding: results of one-stage conversion to RYGB in 195 patients

BackgroundThe most performed restrictive bariatric procedure is the laparoscopic adjustable gastric band (LAGB). With many patients still receiving a LAGB in Europe and the United States, inevitably, the number of complications also increases. For many complications revisional bariatric surgery is necessary. In this study, the outcomes of one-stage LAGB conversion to a Roux-en-Y gastric bypass (RYGB) at our institution are presented. The objective of this study was to investigate the safety and efficiency of RYGB performed as a one-stage procedure after failed LAGB.MethodsPatients were retrospectively selected using a prospectively collected database. The gastric band had to be in situ for at least 1 year and minimum postoperative follow-up was 12 months. The revisional RYGB had to be performed as a 1-step procedure.ResultsA total of 195 patients were included while 3 were lost to follow up. Overall, 178 (91%) procedures were performed without perioperative complications, and only 8 (4%) patients required reoperation within 30 days. The mean follow-up was 40 months (±24) after RYGB. Mean excess weight loss (EWL) increased from 25% (±26/-50- 120%) to 60% (±21.2/0- 130), 65% (±23.5/0- 131), 63% (±24.2/2- 132), 60% (±24.1/0- 111) and 53% (±28.7/-39- 109) in the first 5 postoperative years.ConclusionConverting a gastric band to a RYGB in a one-stage procedure is safe and feasible, with acceptable complication rates when performed in a specialized institution. The RYGB conversion results in a good EWL of 65% after 2 years. However, proper patient selection is of the utmost importance.     

Perioperative and 1-year outcomes of bariatric surgery in septuagenarians: implications for patient selection

BackgroundAlthough bariatric surgery is an effective treatment for obesity, utilization of bariatric procedures in older adults remains low. Previous work reported higher morbidity in older patients undergoing bariatric surgery. However, the generalizability of these data to contemporary septuagenarians is unclear.ObjectivesWe sought to evaluate differences in 30-day outcomes, 1-year weight loss, and co-morbidity remission after bariatric surgery among 3 age groups as follows: <45 years, 45–69 years, and ≥70 years.SettingStatewide quality improvement collaborative.MethodsUsing a large quality improvement collaborative, we identified patients undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between 2006 and 2018. We used multivariable logistic regression models to evaluate the association between age cohorts and 30-day outcomes, 1-year weight loss, and co-morbidity remission.ResultsWe identified 641 septuagenarians who underwent SG (68.5%) or RYGB (31.5%). Compared with 45–69 year olds, septuagenarians had higher rates of hemorrhage (5.1% versus 3.1%; P = .045) after RYGB and higher rates of leak/perforation (.9% versus .3%; P = .044) after SG. Compared with younger patients, septuagenarians lost less of their excess weight, losing 64.8% after RYGB and 53.8% after SG. Remission rates for diabetes and obstructive sleep were similar for patients aged ≥70 years and 45–69 years.ConclusionsBariatric surgery in septuagenarians results in substantial weight loss and co-morbidity remission with an acceptable safety profile. Surgeons with self-imposed age limits should consider broadening their selection criteria to include patients ≥70 years old.     

Results of Bariatric Surgery for Morbid Obesity in Patients Older than 50 Years

Background: Surgery is increasingly used for weight loss in morbidly obese patients. The authors evaluated the safety and efficacy of bariatric surgery in patients older than 50 years. Methods: Prospective data on 62 consecutive patients (Male = 13, Female = 49) undergoing bariatric procedures between 1985-1994 were reviewed. Mean followup was 30 ± 2 months (3-48 months). All data are mean ± sem. Results: Age was 57 ± 1 year (range 50-71 years). Patients had a mean preoperative weight of 125 ± 4 kg (275 ± 9 lb) and 119 ± 6% excess body weight. A total of 68 procedures were performed: vertical banded gastroplasty (VBG = 23), Roux-en-Y gastric bypass (RYGB = 43), and biliopancreatic diversion (BPD = 2). Six patients were converted to RYGB (5) and BPD (1) after failed VBG. Hospital mortality was nil. Complications were wound infection (5), pulmonary (4), gastric leak (2), abscess (1) and others (4). Mean weight loss at 3 years was 55 ± 7 and 33 ± 6% of percent excess body weight for RYGB and VBG, respectively. Postoperative use of medications for arthritis, diabetes mellitus and asthma was reduced by 23%, 62% and 100%, respectively. Satisfaction with the outcome of treatment and weight loss was reported by 81% of patients. Six patients that were converted from jejunoileal bypass (metabolic complications) to VBG gained weight. Conclusions: Bariatric surgery is safe and well tolerated in morbidly obese patients older than 50 years. Weight loss parallels that of younger populations and is greater in patients treated with RYGB in this subgroup. Age should not be a contraindication to bariatric surgery provided the patient has obesity-related medical morbidity. Control of obesity-related co-morbid conditions is improved by weight loss.     

The Improvement of Gastroesophageal Reflux Disease and Barrett’s after Bariatric Surgery

Obesity and gastroesophageal reflux disease (GERD) are prevalent in Western populations. In obese patients, high-resolution manometry often shows altered gastroesophageal pressure gradients, promoting retrograde gastric content flow into the esophagus and esophagogastric junction disruption, leading to a hiatal hernia. Hernia recurrence is higher in the obese, and recurrence is seen regardless of the operative approach used. Bariatric surgery is the gold-standard treatment for GERD in obese patients, and symptom improvement varies depending on the specific bariatric procedure performed, Roux-en-Y (RYGB), laparoscopic adjustable gastric banding (LAGB), or sleeve gastrectomy (SG). Studies have shown these surgeries significantly improve GERD, but RYGB had the greatest effect. Limited data is available examining the progression or regression of Barrett’s following bariatric surgery. We currently recommend RYGB for morbidly obese patients with Barrett’s esophagus.     

Self-report of gastrointestinal side effects after bariatric surgery

BackgroundData on gastrointestinal (GI) side effects of bariatric surgery are limited because of incomplete reporting, cross-sectional samples, and nonstandardized assessments.ObjectiveTo report on GI side effects over the first 6 months after Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB).SettingAcademic medical center, United States.MethodsOne hundred forty-four patients completed a standardized clinical interview 6 months after operation, including questions on the occurrence and frequency of episodes of dumping syndrome, vomiting, and plugging for each of the past 6 months; monthly rates were stable, so results were averaged over the entire period. Although data were collected as part of a randomized controlled trial, randomization group and the interaction of group by surgical procedure were not related to GI side effects. Thus, results are reported by procedure only (RYGB, n = 87; LAGB, n = 56).ResultsRYGB patients had a higher preoperative body mass index (BMI) than LAGB patients (46.8±6.8 versus 43.5±4.8 kg/m², respectively; P = .001), were more likely to report dumping (45.7% versus 4.7%, P<.0001), and were less likely to report plugging (45.7% versus 79.1%, P = .0005). Vomiting did not differ significantly by procedure (68.6% versus 65.1%, P = .7). Most patients experienced each GI side effect less than once per week.ConclusionAlthough self-reported GI side effects were common over the first 6 months after operation, the frequency of episodes was relatively low. Longer-term follow-up is needed to determine whether symptoms worsen or improve over time.     

Sleeve gastrectomy and Roux-en-Y gastric bypass in the treatment of type 2 diabetes. Two-year results from a Swedish multicenter randomized controlled trial

BackgroundObesity is a world-wide epidemic and it is a risk factor for type 2 diabetes (T2D). Few randomized controlled studies have compared the 2 most common surgical procedures, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) in the treatment of obese patients with T2D.ObjectivesTo compare diabetes remission rates (glycosylated hemoglobin ≤6.0%, without diabetes medications) in obese T2D patients (body mass index, 35–50) undergoing RYGB or SG.SettingThree University Hospital clinics and 1 Regional Hospital in Sweden.MethodsForty-nine patients with T2D were included. Twenty-five were randomized to RYGB and 24 to SG. There was no difference between groups regarding patient characteristics, duration of T2D, overall usage of antidiabetic medications, or glycosylated hemoglobin levels. All patients (100%) completed 1-year follow-up and 47 (95.9%) 2-year follow-up.ResultsRemission of T2D was not significantly different between the RYGB and SG, reaching 44% and 46% (n = 25 and n = 24, respectively, P = .897, power = .80) at 1 year, and 48% and 55% (n = 25 and n = 22, respectively, P = .654) at 2 years of follow-up. Similarly, mean glycosylated hemoglobin was improved in both groups at 1 and 2 years, with no significant differences between the groups (RYGB baseline versus 1 yr; mean ± standard deviation: 7.9 ± 1.5 versus 5.8 ± .6%, P < .0001; versus 2 yr: 5.9 ± .7%, P < .0001; SG baseline versus 1 yr: 8.2 ± 1.9 versus 5.9 ± .7%, P < .0001; versus 2 yr: 5.9 ± 1.1%, P < .0001). Total weight loss was not different but percentage excess weight loss was higher after RYGB compared with SG both at 1 and 2 years; mean ± standard deviation: 78 ± 22 versus 60 ± 22%, and 76 ± 24 versus 54 ± 21%, respectively (P < .01 for both). Waist circumference also decreased significantly more in the RYGB group.ConclusionsDespite superior excess weight loss after RYGB, T2D remission rates did not differ significantly between RYGB and SG after 2 years. Long-term follow-up data are needed to define the role of SG in the treatment of patients with obesity and T2D.     

Is age a real or perceived discriminator for bariatric surgery? A long-term analysis of bariatric surgery in the elderly

BackgroundBariatric surgery is the most effective treatment of obesity. There are few studies evaluating long-term outcomes in elderly patients.ObjectivesOur study was designed to evaluate the safety and long-term outcomes of bariatric surgery in the elderly compared with a contemporary medically managed cohort.SettingUniversity hospital.MethodsThree hundred thirty-seven patients age ≥60 who underwent a sleeve gastrectomy or Roux-en-Y gastric bypass between January 2007 and April 2017 were identified (ElderSurg) and compared with a matched cohort of medically managed elderly patients with obesity (ElderNonSurg).ResultsThirty-two patients underwent laparoscopic sleeve gastrectomy, 190 underwent laparoscopic Roux-en-Y gastric bypass, and 115 underwent open Roux-en-Y gastric bypass. The cohort was a mean of 64.4-years old, 75.4% female, mean preoperative body mass index was 46.9, and 62.6% had type 2 diabetes. During a median follow-up period of 56.2 months (confidence interval 49.5–62.9), mean percent excess weight loss (EWL) at nadir was 72.1 ± 24.7% and EWL at 36 months or beyond was 60.9 ± 27.6%. On regression analysis, diabetes, body mass index, and laparoscopic sleeve gastrectomy were negatively associated with EWL at all time periods (P < .05). Mean %EWL was greater for Roux-en-Y gastric bypass compared with laparoscopic sleeve gastrectomy (61.7 versus 41.2; P = .039). Diabetes remission rate was 45.8%. There was a statistically significant decrease in the risk of death in ElderSurg (hazard ratio .584, 95% confidence interval .362–.941) compared with ElderNonSurg.ConclusionsOur study supports that bariatric surgery is safe in elderly patients with effective long-term control of obesity, diabetes, and with improved overall survival.     

Safety of bariatric surgery in patients older than 65 years

BackgroundThe increase in life expectancy along with the obesity epidemic has led to an increase in the number of older patients undergoing bariatric surgery. There is conflicting evidence regarding the safety of performing bariatric procedures on older patients.ObjectiveThe purpose of this study was to compare the safety of laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) for older patients (>65 yr).SettingNationwide analysis of accredited centers.MethodsThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 to 2017 database was used to identify nonrevisional laparoscopic RYGB and SG procedures. Comparisons were made based on patient age. Clinical outcomes included postoperative events and mortality.ResultsThere was a total 13,422 and 5395 matched pairs for SG and RYGB in comparing patients aged 18 years to those aged 65 and >65 years, respectively, and 5395 matched RYGB and SG procedures performed in patients >65 years. The complication rate was higher in older patients undergoing RYGB compared with SG (risk difference = 2.39%, 95% confidence interval: 1.57%–3.21%, P < .0001). When comparing older to younger patients, the older group had a higher complication rate for SG but not for RYGB (SG: risk difference = 1.01%, 95% confidence interval: .59%–1.43%, P < .0001, RYGB: risk difference = .59%, 95% confidence interval: ?.29% to 1.47%, P = .2003).ConclusionsOverall complication rates of bariatric surgery are low in patients >65 years. SG appears to have a favorable safety profile in this patient population compared with RYGB. The overall complication rate for RYGB is not significantly different between the older and younger groups.     

Bariatric surgery decreased the serum level of an endotoxin-associated marker: lipopolysaccharide-binding protein

BackgroundRecent studies have shown serum lipopolysaccharide binding protein (LBP) is associated with obesity and related metabolic disorder. Bariatric surgery can significantly reduce weight, but reports about the change of LBP after bariatric surgery are limited. We investigated LBP concentration and its associations with clinical variables.MethodsWe enrolled 178 obese patients receiving different bariatric surgeries and 38 normal weight individuals. Fasting blood samples were collected at baseline in all and 1 year after surgery in obese individuals. The serum LBP concentration was measured.ResultsThe percentage of excess weight loss of mini-gastric bypass, Roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric band were 72.0±20.0%, 65.5±23.0%, 67.2±18.4%, and 16.1±14.3%, respectively. Serum LBP levels were higher in the obese participants than in the normal weight participants (49.9±15.7 versus 25.2±7.5 μg/mL; P<.001) at baseline and significantly decreased to 35.1±22.6 μg/mL after bariatric surgery (P<.001) in the obese group. In the bariatric participants, after multivariate analyses, preoperative LBP and the change of LBP with surgery were independently associated only with high sensitive C-reactive protein (hs-CRP) (P<.001) and the change of hs-CRP (P = .012), respectively, while none of the postoperative variables was independently associated with LBP.ConclusionLBP is associated with body mass index and hs-CRP. Bariatric surgery significantly decreased the serum level of LBP. The relationship between LBP and hs-CRP disappeared after bariatric surgery. (Surg Obes Relat Dis 2014;0:000–000.) © 2014 American Society for Metabolic and Bariatric Surgery. All rights reserved.