Kidney transplantation after sleeve gastrectomy in the morbidly obese candidate: results of a 2-year experience

BackgroundMorbid obesity serves as a barrier to kidney transplantation (KT) due to potential suboptimal posttransplant outcomes. Laparoscopic sleeve gastrectomy (LSG) has previously been shown to improve transplant eligibility through weight loss.ObjectivesWe aimed to examine the role LSG plays in improving patient outcomes postrenal transplantation, including possible impact on new-onset diabetes after transplant (NODAT).SettingUniversity Hospital.MethodsA single-center analysis was performed identifying all patients who underwent KT after LSG from 2011 to 2017 (n = 41). Exclusion criteria included type I diabetes and previous pancreas transplantation. NODAT was defined as a new insulin requirement after KT. Delayed graft function was defined as need for dialysis within the first week after KT. Mean posttransplant follow-up period was 22 months.ResultsForty-one patients underwent KT after LSG after median time of 16 months. Median age of postLSG patients undergoing KT was 56.0 years at time of KT. Average body mass index decreased by 9 from the time of LSG to KT, and no patients regained weight at 1-year follow-up. After LSG, the number of patients with hypertension (85.4% versus 48.5%) and the number of antihypertensive medications used decreased significantly (1.6 versus .6) at time of KT (P < .001 each). At 1-year follow-up, the improvement in hypertension persisted (51.2% versus 48.5%, P = nonsignificant). The average insulin regimen decreased from 33.0 ± 51.6 to 11.7 ± 21.5 units at KT (P < .001). This improvement also persisted at 1-year follow-up (11.9 versus 11.7 units, P = nonsignificant). Zero patients suffered NODAT over the follow-up period (versus institutional rate of NODAT at 15.8%). One patient developed delayed graft function (2.4%, versus institutional rate of 13.3%). After 1 year postKT, there was 1 graft loss (2.4%) and no mortality.ConclusionThis is the largest reported series of KT after planned LSG in morbidly obese patients. Our results confirm excellent posttransplant outcomes among patients who otherwise would have been denied KT eligibility.     

Laparoscopic Sleeve Gastrectomy as an Isolated Bariatric Procedure: Intermediate-Term Results from a Large Series in Three Austrian Centers

BACKGROUND: Gastric sleeve resection was initially planned as the first step of bilio-pancreatic diversion with duodenal switch but it continues to emerge as a restrictive bariatric procedure on its own. We describe intermediate results in a series of 126 laparoscopic sleeve gastrectomies (LSG) compiled from three bariatric centers in eastern Austria. METHODS: The stomach was laparoscopically reduced to a "sleeve" along the lesser curvature over a 48-Fr bougie. Special attention was placed on complete resection of the gastric fundus. RESULTS: After a mean follow-up of 19.1 months, patients had lost between 2.3 and 27 kg/m(2) or between 6.7% and 130% of their excessive weight. Sixty four percent of the patients lost >50% of their excess weight within an average of 20 months. Seven percent of the patients had an excess weight loss <25% and were therefore considered as failures. The only major surgical complication was leakage of the staple-line needing revision (three times). There were no operative mortalities. CONCLUSION: The final place of LSG in bariatric surgery is still unclear, but our results and those of others show that LSG can be a viable alternative to established procedures.     

Bariatric surgery trends: an 18-year report from the International Bariatric Surgery Registry

BACKGROUND: The epidemic of morbid obesity has increased bariatric procedures performed. Trend analyses provide important information that may impact individual practices. METHODS: Patient data from 137 surgeons were examined from 1987 to 2004 (41,860 patients) using Cochran-Armitage Trend test and Generalized Linear Model. RESULTS: Over an 18-year period, surgeon preference for combined restrictive-malabsorptive procedures increased from 33% to 94%, while simple gastric restriction decreased correspondingly (P < .0001). Surgeons per worksite doubled and cases per surgeon increased 71%. Laparoscopic procedures increased to 24%. The percentage of males, mean operative age, and initial body mass index (BMI) increased significantly (P < .0001). Postoperative hospital stay decreased from 5.0 to 3.9 days (P < .0001). The most common procedure in 2004 was Roux-en-Y gastric bypass (RYGB) (59%). CONCLUSION: Bariatric surgery patients are now older and heavier, length of stay is shorter, and the laparoscopic approach is more frequent. From 1987 to 2004, the general trend shows a clear preference for combined restrictive-malabsorptive operations.     

山东省减重与代谢手术病例注册系统初次报告(2019)

目的:统计分析山东地区减重手术开展情况。方法:基于山东省减重与代谢手术病例注册系统(SDBMSR),统计分析截至2019年12月31日减重与代谢手术情况,并对患者人口学信息、肥胖相关疾病、手术信息等进行统计学描述与分析。结果:SDBMSR共收集来自山东省10个地市、14个分中心提供的531例登记数据。对有效数据进行分析,患者术前BMI为41.5(26.2,106.0)kg/m^2,女213例(64.4%),平均(31.5±8.8)岁;男118例(35.6%),平均(31.0±9.3)岁。数据库所有数据手术方式均为腹腔镜袖状胃切除术。39.6%的患者术前合并2型糖尿病,52.9%的患者术前合并阻塞性睡眠呼吸暂停综合征,24.9%的患者术前合并多囊卵巢综合征。结论:SDBMSR为山东省减重与代谢手术的大数据登记与质量控制工作奠定了坚实基础。基于目前数据,腹腔镜袖状胃切除术是山东省减重与代谢手术的主流术式。     

Analysis of the results of sleeve gastrectomy for morbid obesity and the role of ghrelin

To evaluate the effectiveness of laparoscopic sleeve gastrectomy (LSG), a relatively new bariatric surgical procedure associated with duodenal switch (DS), we analyzed the findings of ten published studies on LSG. No relationship was found between the excess weight loss and the size of the bougie or the follow-up period. The amount of gastric fundus removed may be an important consideration because most ghrelin-producing cells are in the fundus; however, there is insufficient evidence that lowered ghrelin is the sole reason for the resulting weight loss after this procedure. Laparoscopic sleeve gastrectomy is still considered experimental by many, but the initial results are promising, with one study even suggesting long-term results comparable with those of other bariatric procedures. Ghrelin may play a role in the weight loss associated with LSG, but is unlikely to be the sole reason for its success.     

Deciphering the Sleeve: Technique,Indications, Efficacy,and Safety of Sleeve Gastrectomy

Some institutions perform sleeve gastrectomy (SG) as the initial operation for high-risk, high body mass index patients planning a definitive weight loss operation in 12–18 months. Other institutions consider SG a viable alternative to other bariatric operations. SG is frequently debated among the bariatric surgeons. Many questions remain about the current state of SG. Should it be performed as a definitive weight loss procedure or as a bridge for another bariatric procedure? Is there a specific BMI at which point SG should be encouraged? Is the weight loss comparable to other bariatric procedures? Is there a higher risk of gastric leak? What is the appropriate sleeve size? What are the hormonal benefits? Does SG predispose to gastroesophageal reflux disease? What is the mechanism of weight loss? Are long-term results available? And what are the complications? We conducted an extensive literature review aiming to resolve these commonly asked questions.     

Single-stage conversions from failed gastric band to sleeve gastrectomy versus Roux-en-Y gastric bypass: results from the United Kingdom National Bariatric Surgical Registry

Background

For patients in whom laparoscopic adjustable gastric band has failed, conversion to Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy are both options for further surgical treatment. There are limited data comparing these 2 procedures. The National Bariatric Surgery Registry is a comprehensive United Kingdom–wide database of bariatric procedures, in which preoperative demographic characteristics and clinical outcomes are prospectively recorded.

Laparoscopic single-anastomosis duodenal-jejunal bypass with sleeve gastrectomy (SADJB-SG): Surgical risk and long-term results

Background

Single-anastomosis duodeno-jejunal bypass with sleeve gastrectomy (SADJB-SG) was developed as a simplified technique of DJB-SG, but long-term data are lacking.

Bariatric surgery reduces the risk of developing type 2 diabetes in severe obese subjects undergoing sleeve gastrectomy

Background

Obesity is a major independent risk factor for developing type 2 diabetes (T2D).

Hybrid vaginal MA-NOS sleeve gastrectomy: technical note on the procedure in a patient

Background  Standard sleeve gastrectomy for the morbidly obese is feasible and safe using the hybrid transvaginal minilaparoscopic-assisted natural orifice surgery (MA-NOS) with available laparoscopic/endoscopic instruments and technology as illustrated by this technical report on a female patient. Methods  The intervention was a transvaginal sleeve gastrectomy in a 67-year-old woman who was hypertensive, noninsulin-dependent with diabetes with morbid obesity (BMI, 37). Operative field view was maintained at all times with a gastroscope introduced through a transvaginal trocar. The surgeon positioned himself at the right side of the patient using a 2-mm needle port/mini-grasper placed in the left upper quadrant for traction of the greater curvature of the stomach. A 12-mm umbilical trocar was used as the port for insertion of the LigaSure device used for division of the short gastric vessels and the Endo-GIA stapler for creation of the gastric tube. The first assistant used a second mini-grasper for liver retraction and stomach positioning. The resected stomach was retrieved through the vagina. There were no intraoperative complications. The operative time was 150 minutes. Results  The advantages of minimally invasive surgery seemed to be enhanced with this hybrid laparoscopic approach. Postoperative course was uneventful. All component steps of a laparoscopic sleeve gastrectomy (LSG) were reproduced. The patient was discharged on the third postoperative day. Conclusions  Transvaginal hybrid MA-NOS sleeve gastrectomy is both feasible and safe. The hybrid technique ensured safety during the performance of the procedure. MA-NOS is a potential option to avoid abdominal incisions and related complications for the laparoscopic resection of large intra-abdominal organs. Combined hybrid laparoscopic NOS for humans is currently a safe and reliable approach for major surgery through the NOS approach in female patients. Hybrid surgery allows controlled implementation of NOS techniques in clinical practice, providing a stepwise progression to the pure NOS approach once the appropriate technology has been developed. Additionally, it is the best way to stimulate the active development and evaluation of the underpinning technologies and instruments for these novel endoscopic surgical approaches. Appropriate clinical indications for these new procedures are yet to be defined. LSG is associated with short-term excess weight loss and resolution of comorbidities comparable to those obtained with other restrictive procedures. The performance of sleeve gastrectomy is an option in selected patients undergoing bariatric surgical treatment, particularly in the super obese and those who are considered high risk because of comorbid disease.     

Characterizing Bariatric Surgery Utilization and Complication Rates in the Adolescent Population

Introduction

Bariatric surgery is an increasingly common treatment of morbid obesity in the United States and has demonstrated effective weight loss and improvement of comorbidities. We used the National Surgical Quality Improvement Program (NSQIP) data to characterize bariatric surgery utilization and complication rates in the adolescent population.

Outcomes of Roux-en-Y gastric bypass versus sleeve gastrectomy in super-super-obese patients (BMI ≥60 kg/m2): 6-year follow-up at a single university

Background

Among the population of morbidly obese people, super-super-obese (SSO) individuals (body mass index >60 kg/m²) present a treatment challenge for bariatric surgeons.

Obesity and Obstructive Sleep Apnea-Hypopnea Syndrome: the Impact of Bariatric Surgery

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is characterized by successive episodes of cessation or decrease in respiratory airflow, in which obesity is an important risk factor. The prevalence of the disease in morbidly obese patients is ∼70%. Treatment is based on the use of continuous positive airway pressure (CPAP) and weight loss in obese patients.Weight loss by dieting often produces unsatisfactory results, and the use of CPAP does not show good adherence because of being long-term and uncomfortable. Bariatric surgery has emerged as the treatment for morbid obesity and various associated co-morbidities. This article reviews the principal studies that evaluate the modifications in obstructive sleep apnea after bariatric surgery, showing that surgery is an effective treatment for the management of OSAHS in morbidly obese patients.     

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.     

Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass in patients with gastroesophageal reflux disease: results of a multicenter study

BackgroundThe main side effect of long-term laparoscopic sleeve gastrectomy is the onset of severe gastroesophageal reflux disease (GERD).ObjectivesThe aim of this study was to evaluate the effectiveness of gastric bypass conversion in controlling postsleeve GERD.SettingUniversity Hospital and Private Hospital, France and Private Hospital, Italy.MethodsThis retrospective multicenter study included patients who underwent laparoscopic sleeve gastrectomy and suffered from postoperative GERD, who did not respond to medical treatment and were converted to laparoscopic Roux-en-Y gastric bypass. The study involved 2 French university hospitals, 4 French private centers, and an Italian public hospital.ResultsA total of 80 patients were reviewed. Treatment of a hiatal hernia was performed during laparoscopic sleeve gastrectomy in 3 patients, while 19 patients were operated for hiatal hernia during conversion to bypass (P = .0004). Six months after surgery, 23 of 80 patients maintained reflux symptomatology with a daily frequency, for which continued proton pump inhibitor treatment was required. The persistence of GERD was significantly more frequent among patients with previous gastric banding (n = 19) compared with patients with no history of gastric banding (n = 4, P = .02). In other words, the likelihood of having poor clinical success from conversion of the sleeve to bypass because of intractable GERD was 3 times higher if the patient had a history of gastric banding (relative risk = 2.89, odds ratio = 3.69).ConclusionThe results of this study show that, despite the conversion, the symptomatology of GERD does not always disappear, especially in patients with previous gastric banding.     

Changes in Depression Following Gastric Banding: A 5- to 7-year Prospective Study

Background Long-term outcomes of gastric banding regarding depression and predictors of change in depression are still unclear. This prospective, controlled study investigated depression and self-acceptance in morbidly obese patients before and after gastric banding. Methods A total of 248 morbidly obese patients (mean body mass index [BMI] = 46.4, SD = 6.9) seeking gastric banding completed questionnaires for symptoms of depression (Beck Depression Inventory) and self-acceptance. One hundred twenty-eight patients were treated with gastric banding and 120 patients were not. After 5 to 7 years, patients who either had (n = 40) or had not (n = 42) received gastric banding were reassessed. Results In the preoperative assessment, 35% of all obese patients suffered from clinically relevant depressive symptoms (BDI score ≥18). The mean depression score was higher and the mean self-acceptance score was lower than those of the normal population. Higher preoperative depression scores were observed among patients living alone and who had obtained low levels of education. After 5 to 7 years, patients with gastric banding had lost significantly more weight than patients without gastric banding (mean BMI loss 10.0 vs. 3.3). Gastric banding patients improved significantly in depression and self-acceptance, whereas no change was found in patients without gastric banding. Symptoms of depression were more reduced in patients who lost more weight, lived together with a partner, and had a high preoperative depression score. Conclusion Morbid obesity is associated with depressive symptoms and low self-acceptance. Gastric banding results in both long-term weight loss and improvement in depression and self-acceptance.     

Laparoscopic Sleeve Gastrectomy with Duodeno-Jejunal Bypass: A New Surgical Procedure for Weight Control. Feasibility and Safety Study in a Porcine Model

Background  One limit of the Roux-en-Y gastric bypass (GBP) is the preclusion of exploring the bypassed stomach with conventional endoscopy and radiological studies. In this study, we explored the feasibility, safety, and weight progression of a new bariatric procedure that eliminates this inconvenience. Methods  Eleven 40- to 50-kg Yorkshire pigs underwent laparoscopic sleeve gastrectomy and Roux-en-Y duodeno-jejunal bypass (SG-DJBP). Weight was monitored at postoperative days 15 and 30 and after 3 months; weight progression was compared with an identical group that underwent a sham procedure or GBP. At autopsy, surgical site was evaluated at microscopic and macroscopic level. Results  Mean operating time was 66 ± 5.76 min. All the survivors tolerated the procedure well, except one subject that experienced a gastric leak from the stapler line. The SG-DJBP had a had significantly slower weight gains than the sham group (P = 0.005). The absence of histological abnormalities in the duodenal wall was confirmed at autopsy. Conclusion  SG-DJBP is feasible and produces effects of weight progression comparable to those of GBP. Being a combination of previously standardized procedures, we are confident to propose this procedure as a bariatric alternative in humans. Long-term follow-up will be required to establish the efficacy on weight loss in humans. Funding/Grant support: None Conflicts of interest: None     

Bariatric surgery in the super-super morbidly obese: outcome analysis of patients with BMI >70 using the ACS-NSQIP database

BackgroundBariatric surgery offers patients short- and long-term benefits to their health and quality of life. Currently, we see more patients with superior body mass index (BMI) looking for these benefits. Evidence-based medicine is integral in the evaluation of risks versus benefit; however, data are lacking in this high-risk population.ObjectivesTo assess the morbidity and mortality of patients with BMI ≥70 undergoing bariatric surgery.SettingUniversity Hospital, Bronx, New York, United States using national database.MethodsUsing the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database for years 2005 to 2016, we identified patients who underwent primary laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass. Patients with BMI ≥70 were assigned to the BMI >70 (BMI70+) cohort and less obese patients were assigned to the BMI <70 (U70) cohort. Length of stay and 30-day morbidity and mortality were compared.ResultsA total of 163,413 patients underwent non-revisional bariatric surgery. Of those, 2322 had a BMI ≥70. BMI70+ was associated with increased mortality (.4% versus .1%, P = .0001), deep vein thrombosis (.6% versus .3%, P = .007), pulmonary (1.9% versus .5%, P = .0001), renal (.9% versus .2%, P = .0001), and infectious complications (1.1% versus .4%, P = .0001). BMI70+ patients had longer mean length of stay (2.6 versus 2.1 d, P = .0001) and operative time (126.1 versus 114.5 min, P = .0001). There was no statistically significant difference in the number of myocardial infarctions (.1% versus .1%, P = .319), pulmonary embolisms (.3% versus .2%, P = .596), and transfusion requirements (.1% versus .1%, P = .105) between groups.ConclusionsEvaluation of risk and benefit is performed on a case-by-case basis, but evidence-based medicine is critical in empowering surgeons and patients to make informed decisions. The overall rate of morbidity and mortality for BMI70+ patients undergoing bariatric surgery was increased over U70 patients but was still relatively low. Our study will allow surgeons to incorporate objective data into their assessment of risk for super-obese patients pursuing bariatric surgery.     

Comparative analysis of the single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) to established bariatric procedures: an assessment of 2-year postoperative data illustrating weight loss,type 2 diabetes,and nutritional status in a single US center

BackgroundThe sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and single-anastomosis duodenal-ileal bypass with SG (SADI-S) are recognized bariatric procedures. A comparison has never been made between these 3 procedures and especially in different body mass index (BMI) categories.ObjectiveThe study aimed to analyze a large cohort of patients undergoing either laparoscopic (L) SG, LRYGB, or LSADI-S to evaluate and compare weight loss and glycosylated hemoglobin level. The secondary aim was to compare the nutritional outcomes between LRYGB and LSADI-S.SettingPrivate practice, United States.MethodsThis is a retrospective review of 878 patients who underwent LSG, LRYGB, or LSADI-S from April 2014 through October 2015 by 5 surgeons in a single institution. For weight loss analysis, the patients were categorized into 4 different categories as follows: patients regardless of their preoperative BMI, patients with preoperative BMI <45 kg/m², patients with preoperative BMI 45 to 55 kg/m², and patients with preoperative BMI >55 kg/m².ResultsA total of 878 patients were identified for analysis. Of 878 patients, 448 patients, 270 patients, and 160 patients underwent LSG, LRYGB, and LSADI-S, respectively. Overall, at 12 and 24 months, the weight loss was highest with LSADI-S, followed by LRYGB and LSG in all 4 categories. At 2 years, the patients lost 19.5, 16.1, and 11.3 BMI points after LSADI-S, LRYGB, and LSG, respectively. In addition, the weight loss was highest in patients with preoperative BMI <45 kg/m² and lowest in patients with preoperative BMI >55 kg/m² at 12 and 24 months. Also, there were no statistically significant differences between the nutritional outcomes between LRYGB and LSADI-S. The LSADI-S had significantly lower rates of abnormal glycosylated hemoglobin than LRYGB and LSG at 12 months (P < .001).ConclusionsThe weight loss outcomes and glycosylated hemoglobin rates were better with LSADI-S than LRYGB or LSG. The nutritional outcomes between LRYGB and LSADI-S were similar.