Early morbidity and mortality of laparoscopic sleeve gastrectomy and gastric bypass in the elderly: a NSQIP analysis

BackgroundEven though the U.S. population is aging, outcomes of bariatric surgery in the elderly are not well defined. Current literature mostly evaluates the effects of gastric bypass (RYGB), with paucity of data on sleeve gastrectomy (SG). The objective of this study was to assess 30-day morbidity and mortality associated with laparoscopic SG in patients aged 65 years and over, in comparison to RYGB.MethodsThe National Surgical Quality Improvement Program (NSQIP) database was queried for all patients aged 65 and over who underwent laparoscopic RYGB and SG between 2010 and 2011. Baseline characteristics and outcomes were compared. P value<.05 was considered significant. Odds ratios (OR) with 95% confidence interval (CI) were reported when applicable.ResultsWe identified 1005 patients. Mean body mass index was 44±7. SG was performed in 155 patients (15.4%). The American Society of Anesthesiology physical classification of 3 or 4 was similar between the 2 groups (82.6% versus 86.7%, P = .173). Diabetes was more frequent in the RYGB group (43.2% versus 55.6%, P = .004). 30-day mortality (0.6% versus 0.6%, OR 1.1, 95% CI .11–9.49), serious morbidity (5.2% versus 5.6%, OR .91, 95% CI .42–0.96), and overall morbidity (9% versus 9.1%, OR 1.0, 95% CI .55–1.81) were similar.ConclusionIn elderly patients undergoing laparoscopic bariatric surgery, SG is not associated with significantly different 30-day outcomes compared to RYGB. Both procedures are followed by acceptably low morbidity and mortality.     

Safety and short-term outcomes of laparoscopic sleeve gastrectomy for patients over 65 years old with severe obesity

Background

Laparoscopic sleeve gastrectomy (LSG) is a widely accepted, stand-alone bariatric operation. Data on elderly patients undergoing LSG are scarce.

腹腔镜胃袖状切除术近期并发症与处理对策

腹腔镜胃袖状切除术由于技术相对简单、安全,并具有很好地减重与改善代谢效果,成为目前最常见的减重手术术式。美国胃袖状切除占所有减重手术方式的61.4%,而国内该手术比例高达95%。该手术最常见的近期并发症包括胃漏、出血及术后呕吐。目前减重手术在全国范围内逐渐普遍开展,充分认识及很好地处理这些并发症,注重细节、规范操作,对于做好腹腔镜胃袖状切除术,避免手术并发症发生,保证手术安全具有重要意义。     

Five-year results of laparoscopic sleeve gastrectomy

BackgroundLaparoscopic sleeve gastrectomy (LSG) is gaining popularity, but studies reporting long-term results are still rare. The objective of this study was to present the 5-year outcome concerning weight loss, modification of co-morbidities, and late complications.MethodsThis is a retrospective analysis of a prospective cohort with a minimal follow-up of 5 years. A total of 68 patients underwent LSG either as primary bariatric procedure (n = 41) or as redo operation after failed laparoscopic gastric banding (n = 27) between August 2004 and December 2007. At the time of LSG, the mean body mass index (BMI) was 43.0±8.0 kg/m², the mean age 43.1±10.1 years, and 78% were female. The follow-up rate was 100% at 1 year postoperatively, 97% after 2 years, and 91% after 5 years; the mean follow-up time was 5.9±0.8 years.ResultsThe average excessive BMI loss was 61.5%±23.4% after 1 year, 61.1%±23.4% after 2 years, and 57.4%±24.7% after 5 years. Co-morbidities improved considerably; a remission of type 2 diabetes could be reached at 85%. The following complications were observed: 1 leak (1.5%), 2 incisional hernias (2.9%), and new-onset gastroesophageal reflux in 11 patients (16.2%). Reoperation due to insufficient weight loss was necessary in 8 patients (11.8%).ConclusionsLSG was effective 5.9 years postoperatively with an excessive BMI loss of almost 60% and a considerable improvement or even remission of co-morbidities.     

腹腔镜袖状胃切除术在治疗单纯性肥胖症中的应用

肥胖目已成为当今世界日益普遍的健康问题,随着人们对于肥胖症的重视和科技的发展,减肥方式也在逐渐演变.近年来,袖状胃切除术的广泛应用使其已经成为全世界使用量排名第2位的减重手术方式.本文就有关袖状胃切除术治疗肥胖症的适应证与禁忌证、手术方式、手术效果、并发症等方面作一综述.     

Laparoscopic sleeve gastrectomy in management of weight regain after failed laparoscopic plication

INTRODUCTIONWeight regain after bariatric surgery remains a challenging problem with regard to its surgical management.PRESENTATION OF CASEA 30 year-old-female patient with weight regain after failed laparoscopic gastric plication and previous gastric banding was evaluated in a tertiary-care university setting. Her last body mass index was calculated as 40.4 kg/m². Preoperative ultrasonography revealed cholelithiasis. Laparoscopic sleeve gastrectomy with cholecystectomy was planned as a redo surgery. A floopy and plicated stomach with increased wall thickness of the greater curvature was seen. After adhesiolysis between the plicated part of stomach and the surrounding omental tissues, concomitant laparoscopic sleeve gastrectomy and cholecystectomy were performed. She was discharged on the 4th post-operative day without any complaint. At the postoperative 3rd month, her body mass index was recorded as 24 kg/m².DISCUSSIONRedo surgery of morbid obesity after failed bariatric surgery is a technically demanding issue. Type of the surgical treatment should be decided by the attending surgeon based on the morphology of the remnant stomach caused by previous operations.CONCLUSIONAs a redo surgery after failed laparoscopic gastric plication and gastric banding procedures, laparoscopic sleeve gastrectomy may be regarded as a safe and feasible approach in experienced hands.     

Midterm outcomes of sleeve gastrectomy in the elderly

Background

The increase in life expectancy presents health systems with a growing challenge in the form of elderly obesity. Bariatric surgery has been shown to be a safe and effective treatment for obesity with reduction of excess weight and improvement in obesity-related co-morbidities. However, only recently have surgeons begun performing these operations on elderly patients on a larger scale, making data regarding mid- and long-term outcomes scarce. The objective of this study was to evaluate the safety and midterm efficacy of laparoscopic sleeve gastrectomy (LSG) in patients aged ≥60 years.

Gastroesophageal reflux disease complicating laparoscopic sleeve gastrectomy: current knowledge and surgical therapies

BackgroundLaparoscopic sleeve gastrectomy (LSG) is currently the most commonly performed bariatric procedure worldwide. However, the incidence of gastroesophageal reflux disease (GERD) after LSG is high.ObjectivesThe aim of this systematic review was to identify the optimal surgical strategy for treating GERD after LSG.SettingWest China Hospital, Sichuan University, Chengdu, China.MethodsA systematic literature search was performed to identify studies on surgical treatments for GERD after LSG. The effectiveness and safety profile of surgical management on GERD after LSG were analyzed.ResultsA total of 40 articles enrolling 2049 patients were included in this review. Surgical strategies to prevent GERD after LSG were mainly of 2 types: concomitant LSG + antireflux procedures (hiatal hernia repair or fundoplication) and secondary procedures (conversion to Roux-en-Y gastric bypass [RYGB] or repeat sleeve gastrectomy). The short-term remission or improvement rate of GERD was 34.6%–100% after concomitant LSG + antireflux procedures. The postoperative complication rate was the same (3.0%) for both LSG + antireflux procedures and LSG alone. The remission or improvement rate of GERD was 57.1%–100% after conversion to RYGB and 100% after repeat sleeve gastrectomy.ConclusionsThe effectiveness and safety profile of concomitant LSG + antireflux procedures is uncertain. However, secondary operations after LSG, such as conversion to RYGB, appear to provide good results. The data overall are heterogeneous, with imprecise methods of documenting and defining GERD complicating LSG. More cohort studies or RCT studies of high quality with long-term follow-up are needed in the future.     

Outpatient laparoscopic sleeve gastrectomy in a free-standing ambulatory surgery center: First 250 cases

BackgroundA growing body of evidence supports the laparoscopic sleeve gastrectomy (LSG) as a safe and effective procedure for sustained weight loss and amelioration of weight-related co-morbidities. Procedures performed in ambulatory surgery centers (ASC) can provide several advantages over hospital-based surgery. We present our results of 250 consecutive patients undergoing LSG in an ASC. The objective of this study was to assess the safety and efficacy of outpatient LSG in a freestanding ASC.MethodsData was collected prospectively from 250 consecutive patients who underwent LSG at a freestanding ASC. Patients were excluded from the ASC if they weighed>450 pounds, if anticipated operative time was>2 hours, if the patient had impaired mobility limiting early ambulation, or if there were medical problems requiring postoperative monitoring beyond 23 hours. Revisions were not included in this study.ResultsMean age was 47 years (range, 23–74 yr). Mean preoperative body mass index (BMI) was 43 kg/m² (29–71 kg/m²). Mean operative time was 60 minutes (31–161 min). Mean recovery room time was 131 minutes (30–385 min). Mean percent excess weight loss (%EWL) was 60% at 1 year and 63% at 2 years. Nine patients (3.6%) were readmitted within 30 days. Two patients (.8%) were transferred from the ASC to a hospital. There was 1 staple line leak (.4%). There were no open conversions and no deaths.ConclusionsLSG can be performed safely in a freestanding ASC in select patients with outcomes comparable to the inpatient standard. Additional studies are needed to formulate selection criteria and guidelines to maximize patient safety and outcomes.     

Routine upper gastrointestinal swallow studies after laparoscopic sleeve gastrectomy are unnecessary

Background

Laparoscopic sleeve gastrectomy has gained popularity among bariatric surgeons. The purpose of this study was to evaluate the usefulness of early upper gastrointestinal (UGI) contrast studies in the detection of postoperative complications.

Methods

Radiographic reports were reviewed from April 2006 to January 2013. During that time, 161 patients underwent laparoscopic sleeve gastrectomy. All patients were submitted to UGI examination on postoperative day (POD) 1.

Results

Among the 161 patients who underwent UGI, no contrast leaks were found on POD 1. Three patients (1.9%) developed stapler line leaks near the gastroesophageal junction, which were diagnosed on PODs 3, 4, and 10. Gastroesophageal reflux in 5 patients (3.1%) and delayed gastroesophageal transit in 10 patients (6.2%) were detected.

Conclusions

The results of this study show that UGI series on POD 1 cannot assess the integrity of the gastric remnant. Early UGI series are not required as routine procedures in all operated patients. Computed tomographic swallow studies should be performed in patients who postoperatively develop clinical signs and symptoms of complications such as tachycardia, pain, or fever.     

Banded versus nonbanded laparoscopic sleeve gastrectomy: 5-year outcomes

Background/ObjectivesLaparoscopic sleeve gastrectomy (SG) is the most commonly performed bariatric/metabolic operation. However, inadequate long-term weight loss remains a problem in some cases, possibly from gastric-sleeve dilation. Adding a reinforcing ring around the proximal gastric sleeve has been proposed, but relevant data are scant. We performed the largest, longest-term study yet of banded SG (BSG) compared to nonbanded SG.SettingUniversity hospital.MethodsIn 2012, 68 patients at our institution underwent BSG, and 152 underwent SG. Data were prospectively collected into a standardized database from both cohorts during in-person visits at 0, .5, 1, 2, 3, 4, and 5 postoperative years, enabling this retrospective matched cohort study.ResultsThe groups were extremely well-matched at baseline for all relevant characteristics. Operative time was longer and blood loss greater with BSG, but these differences were clinically inconsequential. The only major perioperative complications were 1 hemorrhage in each group. Follow-up at 5 years was 81% for BSG and 67% for SG. Weight loss was equivalent between groups at 6 and 12 months. Thereafter, weight loss was substantially greater following BSG compared to SG at 2, 3, 4, and 5 years, with the magnitude of difference increasing at each successive year. At 5 years, total body mass index decrease was 33.0 ± 12.0% for BSG versus 21.7 ± 18.2% for SG (P = .0001). No major late complications occurred in either group. At 5 years, BSG patients reported minimal food intolerances, rare postprandial vomiting, and almost no heartburn.ConclusionsBSG is safe and produces substantially more weight loss than nonbanded SG at 2 through 5 postoperative years, with minimal side effects.     

Changes in bone mineral density following laparoscopic sleeve gastrectomy: 2-year outcomes

BackgroundEmerging evidence suggests that sleeve gastrectomy (SG) leads to significant bone mineral density (BMD) losses, but there is a paucity of studies evaluating skeletal consequences beyond 12-months post-operatively.ObjectivesTo evaluate BMD changes 2 years postoperatively.SettingA university hospital.MethodsThirty-three women (mean age: 34.4 ± 12.3 years) who underwent SG and completed 24 months of follow-up were evaluated prospectively at baseline and at 3 (M3), 6 (M6), 12 (M12), and 24 (M24) months postoperatively. Data collected included BMD at the total hip, femoral neck, and lumbar spine measured by dual-energy x-ray absorptiometry and anthropometrics, biochemical, nutritional, and physical activity parameters.ResultsAt M24, patients achieved a mean body mass index and excess weight loss of 32.4 ± 5.1 kg/m² and 64.5 ± 21.4%, respectively; however, weight stabilized at M12. Femoral neck BMD decreased significantly from baseline to M24 (.924 ± .124 versus .870 ± .129 g/cm², P < .001), with no change between M12 and M24 (P = .273). Total hip BMD decreased significantly from baseline to M24 (1.004 ± .105 versus .965 ± .132 g/cm², P < .001) but increased between M12 and M24 (P = .001). No significant changes were noted in lumbar spine BMD. The percentage of changes in the femoral neck and the total hip BMD from baseline to M24 positively correlated with postoperative excess weight loss (r = .352, P = .045, and r = .416, P = .018, respectively).ConclusionDespite notable weight loss, women who underwent SG experienced significant bone loss at the total hip and femoral neck more than 2 years postoperatively. Future studies should investigate intervention strategies to attenuate skeletal deterioration after SG.     

Nephrolithiasis after bariatric surgery: A comparison of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy

IntroductionLaparoscopic Roux-en-Y gastric bypass (LRYGB) is known to increase risk for calcium oxalate nephrolithiasis due to hyperoxaluria; however, nephrolithiasis rates after laparoscopic sleeve gastrectomy (LSG) are not well described. Our objective was to determine the rate of nephrolithiasis after LRYGB versus LSG.MethodsThe electronic medical records of patients who underwent LRYGB or LSG between 2001 and 2017 were retrospectively reviewed.Results1,802 patients were included. Postoperative nephrolithiasis was observed in 133 (7.4%) patients, overall, and 8.12% of LRYGB (122/1503) vs. 3.68% of LSG (11/299) patients (P < 0.001). Mean time to stone formation was 2.97 ± 2.96 years. Patients with a history of UTI (OR = 2.12, 95%CI 1.41–3.18; P < 0.001) or nephrolithiasis (OR = 8.81, 95%CI 4.93–15.72; P < 0.001) were more likely to have postoperative nephrolithiasis.ConclusionThe overall incidence of symptomatic nephrolithiasis after bariatric surgery was 7.4%. Patients who underwent LRYGB had a higher incidence of nephrolithiasis versus LSG. Patients with a history of stones had the highest risk of postoperative nephrolithiasis.     

Laparoscopic single-port sleeve gastrectomy for morbid obesity: preliminary series

BackgroundLaparoscopic sleeve gastrectomy has been recently proposed as a sole bariatric procedure because of the resulting considerable weight loss in morbidly obese patients. Traditionally, laparoscopic sleeve gastrectomy requires 5–6 skin incisions to allow for placement of multiple trocars. With the introduction of single-incision laparoscopic surgery, multiple abdominal procedures have been performed using a sole umbilical incision, with good cosmetic outcomes. The purpose of our study was to evaluate the feasibility and safety of laparoscopic single incision sleeve gastrectomy for morbid obesity.MethodsA total of 8 consecutive patients underwent laparoscopic single-incision sleeve gastrectomy at the Operative Unit of Bariatric Surgery of the University of Rome Tor Vergata from March 2009 to June 2009.ResultsOf the 8 patients, 5 were women and 3 were men, with a mean age of 44.4 years. The mean preoperative body mass index was 56.2 kg/m². The mean operative time was 128 minutes. The mean postoperative stay was 2.4 days. The mean postoperative body mass index was 49.3 kg/m² at a mean follow-up period of 3.6 months. The mean percentage of excess weight loss was 33% for the same period.ConclusionsLaparoscopic single-incision sleeve gastrectomy seems to be safe, technically feasible, and reproducible. A randomized trial comparing single-incision sleeve gastrectomy and conventional sleeve gastrectomy might be needed to evaluate the postoperative results in relation to the development of abdominal wall complications.     

Impact on sleeve gastrectomy in patients with esophageal motor disorder

BackgroundGastroesophageal reflux disease (GERD) and esophageal motor disorders (EMD) are frequent conditions among patients with obesity. The effects of sleeve gastrectomy (SG) on esophageal function can worsen GERD, but little is known about its effects on EMD and the consequences of preexisting EMD on GERD after SG.ObjectivesTo study the postoperative outcomes of SG in a population of patients displaying preexisting EMD.SettingUniversity Hospital, France.MethodsPatients with EMD confirmed by high-resolution manometry who underwent a laparoscopic SG between 2010 and 2019 were retrospectively included in this monocenter study. GERD symptoms and high-resolution manometry results were recorded before surgery and during follow-up. Conversion to gastric bypass were also recorded.ResultsThirty-seven patients were included. Mean age was 52.6 ± 12.9 years. Most patients were female (70%). EMD were achalasia (19% of patients), hypercontractile (22%), hypocontractile (30%) and nutcracker esophagus (22%), and ineffective esophageal motility (8%). GERD symptoms were present in 10 patients (27%) preoperatively and 18 (49%) postoperatively. Achalasia was not resolved after SG and was constantly associated with disabling food blockage or GERD symptoms after surgery, and 3 of 4 patients with nutcracker esophagus had postoperative GERD symptoms and underwent gastric bypass.ConclusionsThis study is the largest to describe the course of GERD and EMD after SG in patients displaying preoperative EMD. Achalasia and nutcracker esophagus are associated with poorer postoperative outcomes, and another procedure such as a gastric bypass should be performed.     

Impact of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy on gut microbiota: a metagenomic comparative analysis

BackgroundBariatric surgery is an effective therapeutic procedure for morbidly obese patients. The 2 most common interventions are sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (LRYGB).ObjectivesThe aim of this study was to compare microbiome long-term microbiome after SG and LRYGB surgery in obese patients.SettingUniversity Hospital, France; University Hospital, United States; and University Hospital, Switzerland.MethodsEighty-nine and 108 patients who underwent SG and LRYGB, respectively, were recruited. Stools were collected before and 6 months after surgery. Microbial DNA was analyzed with shotgun metagenomic sequencing (SOLiD 5500 xl Wildfire). MSPminer, a novel innovative tool to characterize new in silico biological entities, was used to identify 715 Metagenomic Species Pan-genome. One hundred forty-eight functional modules were analyzed using GOmixer and KEGG database.ResultsBoth interventions resulted in a similar increase of Shannon’s diversity index and gene richness of gut microbiota, in parallel with weight loss, but the changes of microbial composition were different. LRYGB led to higher relative abundance of aero-tolerant bacteria, such as Escherichia coli and buccal species, such as Streptococcus and Veillonella spp. In contrast, anaerobes, such as Clostridium, were more abundant after SG, suggesting better conservation of anaerobic conditions in the gut. Enrichment of Akkermansia muciniphila was also observed after both surgeries. Function-level changes included higher potential for bacterial use of supplements, such as vitamin B12, B1, and iron upon LRYGB.ConclusionMicrobiota changes after bariatric surgery depend on the nature of the intervention. LRYGB induces greater taxonomic and functional changes in gut microbiota than SG. Possible long-term health consequences of these alterations remain to be established.