Converting a Sleeve Gastrectomy to a Gastric Bypass for Weight Loss Failure—Is It Worth It?

Background

Sleeve gastrectomy (SG) is gaining popularity and has become the procedure of choice for many bariatric surgeons. Long-term weight loss failure is not uncommon. The preferred revisional procedure for these patients is still under debate.

Objective

The objective of this study was to assess the safety and efficacy of laparoscopic gastric bypass as a revisional surgery for sleeve gastrectomy patients with weight loss failure.

Setting

The study was done at a bariatric surgery center in a university hospital.

Methods

We reviewed our prospectively collected database and identified all patients who underwent conversion of a sleeve gastrectomy to a gastric bypass for weight loss failure. Data on patient demographics, baseline characteristics, and outcomes of bariatric surgery were retrieved.

Results

Twenty-three patients with a mean body mass index (BMI) of 41.6 kg/m2 (range 34.1–50.1 kg/m2) underwent conversion to a gastric bypass. Four patients underwent a gastric band prior to the sleeve gastrectomy, and two patients underwent a re-sleeve gastrectomy prior to conversion to a gastric bypass.At a mean follow-up of 24 months (range 9–46 months), the average body mass index (BMI) decreased to 33.8 kg/m2 and the excess body mass index loss (EBMIL) was 42.6%. Diabetes, hypertension, dyslipidemia, and obstructive sleep apnea resolved or improved in 44.4, 45.5, 50, and 50% of the patients, respectively. Three patients developed early postop complications (13%), while late complications occurred in four patients (17%).

Conclusion

Converting a sleeve gastrectomy to a gastric bypass for weight loss failure is safe, yet weight loss benefit is limited.

     

Micronutrient and Protein Deficiencies After Gastric Bypass and Sleeve Gastrectomy: a 1-year Follow-up

Background

Roux-en-Y gastric bypass (GBP) and sleeve gastrectomy (SG) have increased dramatically, potentially increasing the prevalence of nutritional deficiencies. The aim of this study was to analyze the effects of food restriction during the first year after bariatric surgery (BS) on nutritional parameters.

Methods

Twenty-two and 30 obese patients undergoing GBP and SG were prospectively followed at baseline and 3, 6, and 12 months after BS (N?=?14 and N?=?19 at T12). We evaluated food intake and nutrient adequacy (T0, T3, T12), as well as serum vitamin and mineral concentration (T0, T3, T6, T12).

Results

At baseline, GBP and SG patients had similar clinical characteristics, food intake, nutrient adequacy, and serum concentration. The drastic energy and food reduction led to very low probabilities of adequacy for nutrients similar in both models (T3, T12). Serum analysis demonstrated a continuous decrease in prealbumin during the follow-up, indicating mild protein depletion in 37 and 38 % of GBP patients and 57 and 52 % of SG patients, respectively, at T3 and T12. Conversely, despite the low probabilities of adequacy observed at T3 and T12, systematic multivitamin and mineral supplementation after GBP and SG prevented most nutritional deficiencies.

Conclusions

GBP and SG have comparable effects in terms of energy and food restriction and subsequent risk of micronutrient and protein deficiencies in the first year post BS. Such results advocate for a cautious monitoring of protein intake after GPB and SG and a systematic multivitamin and mineral supplementation in the first year after SG.

     

Matched Short-Term Results of SADI Versus GBP After Sleeve Gastrectomy

Background

The gastric bypass (GBP) is the most popular revisional technique after sleeve gastrectomy (SG). However, the results after revision are not always satisfactory in terms of additional weight loss and complications. The single anastomosis duodenoileal bypass (SADI) could be a valuable alternative.

Objective

This study is a retrospective matched-control study reviewing short-term results in terms of weight loss and comorbidities reduction of both SADI and GBP as a revisional procedure after primary sleeve gastrectomy. Complications and vitamin deficiencies will be evaluated as well.

Methods

Patients with a SADI procedure after a primary sleeve gastrectomy (SG) with a minimum follow-up of 1 year were included. Their results were retrospectively reviewed and matched with a cohort of GBP patient on age, BMI, and gender. Comparison was on comorbidities, weight loss, complications, and blood markers.

Results

A total of 64 patients were included, 32 SADI procedures and 32 matched gastric bypasses with no significant differences on baseline. No differences were found in terms of (additional) total weight loss. The operating time of the SADI was significantly longer (p?=?0.007). No clinically relevant differences were found concerning comorbidities or blood markers. In the SADI group, more defecation problems were reported and fewer vitamin deficiencies were encountered.

Conclusion

Based on a small group and short-term results, the SADI could be regarded as a safe alternative to a GBP following SG with a similar amount of additional weight loss and fewer post-operative early complications. Longer follow-up and larger studies are needed to determine its full potential.

     

Long-Term Outcomes of Three Types of Bariatric Surgery on Obesity and Type 2 Diabetes Control and Remission

Background

Different bariatric surgeries have demonstrated different effectiveness for weight loss and glucose control in obese persons with diabetes, over a short follow-up time. The aim of this study was to compare weight loss, glucose control, and diabetes remission in individuals with type 2 diabetes, after three types of bariatric surgery: gastric banding (GB), sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGB), with 5 years follow-up.

Methods

A retrospective study was conducted on bariatric surgeries performed during 2002–2011 in a large nationwide healthcare organization.

Results

Of 2190 patients, 64.8 % were women. The operations performed were 1027 GB, 1023 SG, and 140 RYGB. Mean BMI?±?SD at baseline, 1 year postoperatively, and 5 years postoperatively were 43.5?±?6.18, 37.1?±?6.35, and 35.5?±?6.48 for GB; 43.6?±?6.42, 34.4?±?6.08, and 35.3?±?6.7 for SG; and 42.8?±?5.81, 32.8?±?4.9, and 34.1?±?5.09 for RYGB. Mean HbA1c?±?SD at baseline, 1 year postoperatively, and 5 years postoperatively were 7.6?+?1.58, 6.5?+?1.22, and 6.8?+?1.48 for GB; 7.7?+?1.63, 6.4?+?1.18, and 6.7?+?1.57 for SG; and 8.0?+?1.78, 6.3?+?0.98, and 7.04?+?1.42 for RYGB. At 1 year follow-up, 53.2 % had achieved remission; at 5 years, 54.4 %. Remission rates at 5 years were similar for the three surgeries. Five-year remission was inversely associated with baseline HbA1c and with treatment with insulin at baseline and positively associated with BMI.

Conclusions

For all three surgeries, diabetes remission was higher than the baseline after 5 years; mean BMI and HbA1c decreased considerably during the first year postoperatively and remained lower than basal values throughout follow-up. Early improvements were greatest for RYGB, though the advantage over the other operations diminished with time.

     

Laparoscopic Conversion of Gastric Bypass Complication to Sleeve Gastrectomy: Technique and Early Results

Background

Laparoscopic gastric bypass is a commonly performed bariatric surgery for the treatment of morbid obesity. Revision surgery for patients who have gastric bypass complications is a challenge for bariatric surgeon. Our aim is to present the early results of the conversions of gastric bypass complications to sleeve gastrectomies.

Methods

From January 2001 to April 2015, 49 of 2382 gastric bypasses underwent revisional surgery to convert gastric bypasses to sleeve gastrectomies. The demographic data, surgical parameters, and outcomes were studied.

Results

The mean age of the study group was 35.0 years (range 20 to 55), and the average body mass index (BMI) prior to the reoperation was 25.3 kg/m². Seven patients had previous laparoscopic Roux-en-Y gastric bypasses (LRYGBs), and 42 had laparoscopic single anastomosis (mini-) gastric bypasses (LSAGBs). The main reasons for the revisions were malnutrition (58 %), weight regain (10 %), intolerance (18 %), and others (14 %). The revisional surgeries had longer operative times, greater blood loss, and longer flatus passage times than the primary gastric bypass surgeries. Four patients (8.1 %) developed major complications during revisional surgery, including three (6.1 %) cases of leakage and one (2.0 %) case of internal bleeding. No mortality was noted. After conversion to sleeve gastrectomy, the body weights of the patients remained stable, and all patients improved in terms of malnutrition, including anemia, hypoalbuminemia, and secondary hyperparathyroidism.

Conclusions

Conversion to sleeve gastrectomy is an effective and safe option for patients with gastric bypass complications. The conversions to sleeve gastrectomy resulted in significant improvements in malnutrition and maintained weight loss at the early follow-ups.

     

Destiny of Failed Adjustable Gastric Bandings: Do All the Patients Need Further Bariatric Surgery?

Purpose

The number of laparoscopic adjustable gastric banding (LAGB) removal has increased throughout the years. The aim of the study was to evaluate the outcomes in patients undergoing LAGB removal with or without further bariatric surgery.

Materials and Methods

Data prospectively collected from consecutive patients undergoing LAGB removal from 2008 to 2016 at our institution were retrospectively analyzed. Obesity-related comorbidities, complications, and body mass index (BMI) before removal and at 1-year follow-up were evaluated.

Results

A total of 156 patients were included in the study. Seventy-six patients had further surgery (SURG group): 55 underwent laparoscopic sleeve gastrectomy (LSG) and 21 laparoscopic Roux-en-Y gastric bypass (LRYGB). Eighty patients underwent only LAGB removal (No-SURG group). The mean BMI was lower in the No-SURG group (33.9 vs 36.3 kg/m², p =?0.0055). Reasons for removal were different in the two groups: dysphagia, frequent vomiting, and LAGB-related complications requiring urgent treatment occurred more commonly in the No-SURG group (p <?0.05): 71.3 vs 51.3%, 67.5% vs. 38.2%, 28.8% vs. 6.6%, respectively. At 1-year follow-up, 96.3% of No-SURG patients regained weight after LAGB removal; two (2.5%) patients showed new-onset comorbidities, four (5%) needed adjustments in pharmacological therapy, and four (5%) complained from persistence of GERD symptoms. Additional surgery provided significant weight loss: the mean %TWL was 23.7% after LSGs and 27.2% after LRYGBs.

Conclusions

LAGB is associated with a high rate of reoperation. Further bariatric surgery after LAGB removal should be considered due to weight regain, persistence of GERD symptoms, and new-onset comorbidities.

     

Cost-Effectiveness Analysis of Bariatric Surgery for Morbid Obesity

Background

In the USA, three types of bariatric surgeries are widely performed, including laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), and laparoscopic adjustable gastric banding (LAGB). However, few economic evaluations of bariatric surgery are published. There is also scarcity of studies focusing on the LSG alone. Therefore, this study is evaluating the cost-effectiveness of bariatric surgery using LRYGB, LAGB, and LSG as treatment for morbid obesity.

Methods

A microsimulation model was developed over a lifetime horizon to simulate weight change, health consequences, and costs of bariatric surgery for morbid obesity. US health care prospective was used. A model was propagated based on a report from the first report of the American College of Surgeons. Incremental cost-effectiveness ratios (ICERs) in terms of cost per quality-adjusted life-year (QALY) gained were used in the model. Model parameters were estimated from publicly available databases and published literature.

Results

LRYGB was cost-effective with higher QALYs (17.07) and cost ($138,632) than LSG (16.56 QALYs; $138,925), LAGB (16.10 QALYs; $135,923), and no surgery (15.17 QALYs; $128,284). Sensitivity analysis showed initial cost of surgery and weight regain assumption were very sensitive to the variation in overall model parameters. Across patient groups, LRYGB remained the optimal bariatric technique, except that with morbid obesity 1 (BMI 35–39.9 kg/m²) patients, LSG was the optimal choice.

Conclusion

LRYGB is the optimal bariatric technique, being the most cost-effective compared to LSG, LAGB, and no surgery options for most subgroups. However, LSG was the most cost-effective choice when initial BMI ranged between 35 and 39.9 kg/m².

     

Performance of the DiaRem Score for Predicting Diabetes Remission in Two Health Systems Following Bariatric Surgery Procedures in Hispanic and non-Hispanic White Patients

Objective

The objective of this study was to determine whether the DiaRem, a score that predicts type 2 diabetes (T2D) remission following roux-en-y gastric bariatric surgery (RYGB), also predicts remission following laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) in white and Hispanic patients.

Background

While bariatric surgery is highly effective in reversing insulin resistance, there are patients for whom surgery will not lead to remission. To date, there is no score for predicting remission following LAGB or LSG surgery. Additionally, there is little known about how to predict whether Hispanic patients will experience remission.

Methods

We conducted a retrospective cohort study of white and Hispanic patients with T2D who received bariatric surgery. There were 361 white and 130 Hispanic patients among whom 328 had RYGB surgery, 107 had LSG surgery, and 56 had LAGB surgery. We used age, diabetes treatment, and hemoglobin A1c to calculate DiaRem scores. Mann-Whitney U test was used to determine the association between DiaRem scores and remission. Area under the receiver operant curve (AUC) was used to assess the ability of the DiaRem to discriminate between patients who did and did not remit.

Results

The DiaRem was associated with partial remission in all surgery types for white and Hispanic patients (Mann-Whitney, p < 0.001). The DiaRem had moderate to high discriminant ability (AUC > 0.70) for all surgical and racial/ethnic groups.

Conclusions

The DiaRem distinguishes between patients likely and unlikely to experience remission, informing expectations of patients making T2D treatment decisions.

     

Diabetes Outcomes More than a Decade Following Sustained Weight Loss After Laparoscopic Adjustable Gastric Band Surgery

Background

Long-term outcome data are needed to define the role of bariatric surgery in type 2 diabetes (T2D). To address this, we collated diabetes outcomes more than a decade after laparoscopic adjustable gastric band (LAGB) surgery.

Method

Clinical and biochemical measures from 113 obese T2D patients who underwent LAGB surgery in 2003 and 2004 were analyzed. Diabetes remission was defined as HbA1c < 6.2% (44 mmol/mol) and fasting glucose < 7.0 mmol/L.

Results

Seventy-nine patients had weight data at 10 years and attained a median [Q1, Q3] weight loss of 16 [10, 21] percent. Sixty patients attended a follow-up assessment. Their baseline HbA1c of 7.8 [7.1, 9.3] percentage units (62 [54, 78] mmol/mol) had decreased to 6.6 [6.1, 8.4] (49 [43, 68] mmol/mol) despite no significant change in glucose-lowering therapy. Eleven patients (18%) were in diabetes remission and another 18 had HbA1c ≤ 6.5%. Significant improvements in physical measures of quality of life, blood pressure, and lipid profile were also observed but there was no change in the proportion of patients with albuminuria and a significant decline in estimated glomerular filtration rate. Twelve patients in the follow-up cohort (20%) required anti-reflux medication after surgery and 26 (43%) underwent gastric band revision surgery.

Conclusion

Weight loss for over 10 years after LAGB surgery delivers clinically meaningful improvements in HbA1c, blood pressure, lipids, and quality of life at the cost of a high rate of revision surgery and increased use of anti-reflux medication. These findings support the use of bariatric surgery as a long-term treatment for weight loss and wellbeing in patients with T2D.

Study Registration

Registered with the Australian Clinical trials registry as ACTRN12615000089538.

     

The Outcome of Bariatric Surgery in Patients Aged 75 years and Older

Background

Bariatric surgery has been shown to be safe and effective in patients aged 60–75 years; however, outcomes in patients aged 75 or older are undocumented.

Methods

Patients aged 75 years and older who underwent bariatric procedures in two academic centers between 2006 and 2015 were studied.

Results

A total of 19 patients aged 75 years and above were identified. Eleven (58%) were male, the median age was 76 years old (range 75–81), and the median preoperative body mass index (BMI) was 41.4 kg/m² (range 35.8–57.5). All of the bariatric procedures were primary procedures and performed laparoscopically: sleeve gastrectomy (SG) (n?=?11, 58%), adjustable gastric band (AGB) (n?=?4, 21%), Roux-en-Y gastric bypass (RYGB) (n?=?2, 11%), banded gastric plication (n?=?1, 5%), and gastric plication (n?=?1, 5%). The median operative time was 120 min (range 75–240), and the median length of stay was 2 days (range 1–7). Three patients (16%) developed postoperative atrial fibrillation which completely resolved at discharge. At 1 year, the median percentage of total weight loss (%TWL) was 18.4% (range 7.4–22.0). The 1-year %TWL varied among the bariatric procedures performed: SG (21%), RYGB (22%), AGB (7%), and gastric plication (8%). There were no 30-day readmissions, reoperations, or mortalities.

Conclusion

Our experience suggests that bariatric surgery in selected patients aged 75 years and older would be safe and effective despite being higher risk. Age alone should not be the limiting factor for selecting patients for bariatric surgery.

     

Compared to Sleeve Gastrectomy,Duodenal–Jejunal Bypass with Sleeve Gastrectomy Gives Better Glycemic Control in T2DM Patients,with a Lower β-Cell Response and Similar Appetite Sensations: Mixed-Meal Study

Background

Functional studies of how duodenal–jejunal exclusion (DJE) brings a superior glycemic control when added to sleeve gastrectomy in duodenal–jejunal bypass with sleeve gastrectomy (DJB-SG) patients, are lacking. To study this, we compared the appetite sensations and the β-cell response following a standard mixed meal in patients with DJB-SG, versus those with sleeve gastrectomy (SG) alone.

Methods

Twenty one patients who underwent DJB-SG and 25 with SG, who participated in mixed-meal tests (MMTT) preoperatively and at 1 year, with complete data were included and compared. Blood glucose, C-peptide, and insulin levels were estimated, along with the visual analogue scale (VAS) scoring of the six appetite sensations, as a part of the MMTT.

Results

At 1 year following surgery, compared to SG group, DJB-SG group had greater complete remission rates (HbA1C <6.0 %) of 62 versus 32 % (p?<?0.05), with similar total body weight loss (25.7 vs. 22 %). There were significantly lower post-prandial blood glucose and lower C-peptide levels during the MMTT in the patients with DJB-SG compared to SG group. There were no significant differences in the appetite sensations (mean VAS) scores between the groups.

Conclusion

The addition of DJE component to SG, as in DJB-SG, was associated with higher diabetes remission rates, lower glycemic fluctuations, and lower C-peptide levels. This may point to a β-cell preserving glucose control which could result in longer remission of type 2 diabetes mellitus (T2DM). This effect also may be unrelated to food intake as there were no significant differences in the appetite sensations.

     

Morbidity Rates and Weight Loss After Roux-en-Y Gastric Bypass,Sleeve Gastrectomy,and Adjustable Gastric Banding in Patients Older Than 60 Years old: Which Procedure to Choose?

Background

As life expectancy increases, more elderly patients fit into the criteria for bariatric procedures. The aim of our study is to evaluate and compare the safety and efficacy of Roux-en-Y gastric bypass (RYGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB) in patients older than 60.

Material and Methods

Between January 2005 and December 2013, 68 LAGB, 73 LSG, and 212 RYGB patients were 60 years or older at the time of primary procedure. A retrospective review was performed in these patients.

Results

Mean age and body mass index (BMI) was 62.7?±?2.2, 64.1?±?2.9, and 62.6?±?2.3 years and 42.7?±?5.6, 44.0?±?7.0, and 45.2?±?6.7 kg/m² for LAGB, LSG, and RYGB at the time of procedure, respectively.Seven (10.3 %) patients from the LAGB, 3 (4.1 %) from the LSG, and 29 (13.8 %) from the RYGB group required readmissions. Reoperation rate was 10.3, 1.4, and 9.5 % in LAGB, LSG, and RYGB, respectively. The difference in reoperation rates was statistically significant (p?<?0.03) while that in readmission rates was not (p?>?0.58). Procedure-related mortality rate was 1.4 % in the RYGB group, while no mortality was observed in LSG and LAGB groups. At 6, 12, and 18 months postoperatively, mean percentage of excess weight loss were highest in the RYGB group, followed by LSG and LAGB group (p?<?0.01). Mean number of comorbidities at the last follow-up significantly decreased in LSG and RYGB patients.

Conclusions

LSG showed the lowest readmission and reoperation rate, and RYGB patients had the highest mortality rate. Weight loss and comorbidity resolution were effectively achieved in RYGB and LSG patients.

     

Early hospital readmission after bariatric surgery

Background

With the rise in bariatric procedures being performed nationwide and the growing focus on quality and outcome measures, reducing early hospital readmission (EHR) rates has garnered great clinical interest. The aim of this study was to identify the incidence, reasons, and risk factors for EHR after bariatric surgery.

Methods

Using American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) dataset (2012–2013), patients with a diagnosis of obesity and body mass index ≥35 who underwent bariatric surgery were identified. EHR was defined as at least one hospitalization within 30 days of bariatric procedure. The association between readmission and patient factors was assessed using multivariable logistic regression analysis. In addition, reasons for readmission were sought.

Results

A total of 36,042 patients were identified. The overall EHR rate was 4.70 % [laparoscopic (lap) adjustable band 1.87 %, lap gastric bypass (GBP) 5.94 %, open GBP 7.86 %, and sleeve gastrectomy 3.73 %], and it occurred at the median of 11 days postoperatively. The rate of EHR significantly decreased from 2012 to 2013 (5.15 vs. 4.32 %, p < 0.001). The median age and BMI were 44 years and 44.7 kg/m², respectively, 78.99 % were female, and 70.78 % were white. The most common reason for readmission was nausea/vomiting (12.95 %), followed by abdominal pain (11.75 %) and dehydration (10.54 %). On multivariable analysis, factors most strongly associated with readmission were procedure type (lap band: reference; open GBP: OR 3.78, 95 % CI 2.47–5.80; lap GBP 3.18, 2.39–4.22; sleeve gastrectomy: 2.03, 1.52–2.71; all p < 0.001), steroid use (1.82, 1.33–2.48, p < 0.001), pre-discharge complication (1.64, 1.20–2.24, p < 0.001), and black population (1.51, 1.34–1.71, p < 0.001).

Conclusions

Bariatric centers should consider implementing standardized protocols for outpatient monitoring of patients identified to be at high risk of experiencing early readmission, which in turn would decrease overall costs and improve quality of care.

     

Effect of Surgeon Volume on Sleeve Gastrectomy Outcomes

Background

Prior studies have shown a relationship between surgeon volume and patient outcomes in Roux-en-Y gastric bypass (RYGB) patients. Laparoscopic sleeve gastrectomy (SG) is now the most common bariatric procedure, but there is a little data on surgeon volume and outcomes after SG. We examined the relationship between annual surgeon bariatric volume and 30-day complication rate after SG.

Methods

The Bariatric Outcomes Longitudinal Database for 2011 was used for this study. Using 50 annual cases as a cutoff point, surgeons were classified as low (LV-SG) or high volume SG (HV-SG) and low (LV-RYGB) or high volume RYGB (HV-RYGB) providers. Multivariable logistic regression models were used to examine the effect of surgeon volume on 30-day readmissions, reoperations, and complications following SG while controlling for patient demographics and comorbidities.

Results

We identified 16,547 SG patients. After controlling for baseline characteristics, HV-SG surgeons had lower rates of 30-day complications (OR 0.80, 95 % CI 0.64–0.92), reoperation (OR 0.69, 95 % CI 0.52–0.90), and readmission (OR 0.73, 95 % CI 0.61–0.88) compared to LV-SG surgeons. HV-RYGB surgeons had lower 30-day complication rates (OR 0.80, 95 % CI 0.69–0.92), but were without differences in reoperation (OR 0.82, 95 % CI 0.61–1.10) or readmission (OR 1.06, 95 % CI 0.88–1.27) compared to LV-RYGB surgeons.

Conclusions

High SG volume is associated with improved 30-day readmission, reoperation, and complication rates. Concurrent RYGB volume impacts the 30-day complication rate after SG, but does not affect the readmission or reoperation rate. Our findings suggest that SG-specific volume is important for optimal safety outcomes in SG patients.

     

Learning curve for laparoscopic sleeve gastrectomy: role of training in a high-volume bariatric center

Background

Since the great diffusion of laparoscopic treatment of obesity, there is a growing interest concerning the learning process for those surgeons who undertake the bariatric activity. However, papers analyzing the learning curve (LC) for sleeve gastrectomy (SG) are still scarce. This study aims to investigate whether the LC for SG of a novice bariatric surgeon might be positively influenced by the training in a high-volume bariatric center (HVBC).

Methods

Between October 2010 and January 2014, 128 patients underwent SG by the same young surgeon who previously attended a 2-year training in a HVBC. His LC has been divided into three consecutive periods: in the first period (1st–47th SGs) he operated in the HVBC, while in the second (48th–88th SGs) and third period (89th–128th SGs) he moved to a novel department where surgical and ancillary staff were initially not confident with bariatric procedures but progressively owned the proper experience. Preoperative characteristics, operative data, complications and postoperative results of the three periods were compared.

Results

Mean follow-up was 1 year. Preoperative patients’ characteristics were homogeneous. No significant differences have been registered among the three periods concerning operative data, mortality, intra- and post-operative complications, weight loss outcomes and comorbidities’ resolution. Post-operative follow-up rates at 6 and 12 months were 98.4 and 92.1 %, respectively.

Conclusions

Long-lasting fellowship in a HVBC might allow the novel bariatric surgeon to safely and proficiently overcome the LC for SG, even in a new established bariatric setting.

     

Long-Term (over 10 Years) Retrospective Follow-up of Laparoscopic Adjustable Gastric Banding

Background

Laparoscopic adjustable gastric banding (LAGB) placements have progressively decreased in recent years. This is related to poor long-term weight loss outcomes and necessity for revision or removal of these bands. Long-term outcome results following LAGB are limited. The aim of our study was to determine the long-term outcome after LAGB at our institution.

Objectives

The aim of our study was to determine the long-term outcome after LAGB at our institution.

Setting

The setting of this is Academic Center, Israel.

Methods

Patients who underwent LAGB between 1999 and 2004 were reviewed. Patient comorbidities and weight loss parameters were collected preoperatively and at defined postoperative periods. Improvement in weight loss was defined as percent excess weight lost, and improvement in comorbidities was defined based on standardized reporting definitions.

Results

In total, 74 (80%) patients who underwent LAGB met inclusion criteria. The mean age at LAGB placement was 50.5 ± 9.6 years, and the mean body mass index (BMI) was 45.5 ± 4.8 kg/m². Preoperative comorbidities were diabetes mellitus (13.5%), hypertension (32%), hyperlipidemia (12.1%), obstructive sleep apnea (5.4%), joints disease (10.8%), mood disorders (5.4%), and gastro-esophageal reflux disease (GERD) symptoms (8.1%). The mean follow-up was 162.96 ± 13.9 months; 44 patients (59.4%) had their band removed, and 22 (30%) had another bariatric surgery. The follow-up BMI was 35.7 ± 6.9 (p < 0.001), and the % total weight loss was 21.0 ± 0.13. There was no improvement in any of the comorbidities. GERD symptoms worsened at long-term follow-up (p < 0.001). Undergoing another bariatric procedure was associated with a higher weight loss (OR 12.8; CI 95% 1.62–23.9; p = 0.02).

Conclusion

LAGB required removal in the majority of our patients and showed poor resolution of comorbidities with worsening of GERD-related symptoms. Patients who go on to have another bariatric procedure have more durable weight loss outcomes.

     

Postoperative Bleeding and Leakage After Sleeve Gastrectomy: a Single-Center Experience

Background

Sleeve gastrectomy is being performed increasingly, mainly due to its low morbidity and mortality, but complications do occur. The aim of this study was to evaluate bleeding and leakage rates of primary and revisional sleeve gastrectomy in a personal series of 664 consecutive patients.

Methods

Medical charts of all patients undergoing a primary or revisional sleeve gastrectomy between August 2008 and December 2014 were reviewed retrospectively. Subgroup analysis compared bleeding in patients after reduced port versus multiport technique and primary versus revisional sleeve gastrectomy.

Results

A total of 664 sleeve gastrectomies (489 women and 175 men) were performed. Mean age and body mass index were 36.03?±?11.4 years and 42.9?±?8.3 kg/m², respectively. Mean operative time was 58.5?±?20.0 min, with a 0.15 % conversion rate. Mean hospital stay was 2.1?±?0.3 days. The overall 30-day complication rate was 7.5 %. Thirteen patients sustained postoperative bleeding (2 %), three of whom required reoperation (0.5 %). Staple line leakage and mortality were both nil in this series. No difference in postoperative complications was found between the subgroups.

Conclusions

In this single-surgeon, single-center experience, sleeve gastrectomy was a safe and effective bariatric procedure with a low complication rate. Staple line reinforcement by oversewing was associated with low bleeding complications and no leakage. The majority of patients with postoperative bleeding could be managed conservatively. In our experience, reduced port technique and revisional sleeve gastrectomy had similar complication rates compared to multiport and primary sleeve gastrectomy.

     

Prevalence of Barrett’s Esophagus in Bariatric Patients Undergoing Sleeve Gastrectomy

Background

The appearance and incidence of gastroesophageal reflux after sleeve gastrectomy is not yet resolved, and there is an important controversy in the literature. No publications regarding the appearance of Barrett’s esophagus after sleeve gastrectomy are present in the current literature.

Purpose

The purpose of this paper was to report the incidence of Barrett’s esophagus in patients submitted to sleeve.

Material and Methods

Two hundred thirty-one patients are included in this study who were submitted to sleeve gastrectomy for morbid obesity. None had Barrett’s esophagus. Postoperative upper endoscopy control was routinely performed 1 month after surgery and 1 year after the operation, all completed the follow-up in the first year, 188 in the second year, 123 in the third year, 108 in the fifth year, and 66 patients over 5 years after surgery.

Results

Among 231 patients operated on and followed clinically, reflux symptoms were detected in 57 (23.2 %). Erosive esophagitis was found in 38 patients (15.5 %), and histological examination confirmed Barrett’s esophagus in 3/231 cases (1.2 %) with presence of intestinal metaplasia.

Conclusion

Bariatric surgeons should be aware of the association of gastroesophageal reflux (GER) disease and obesity. Appropriate bariatric surgery should be indicated in order to prevent the occurrence of esophagitis and Barrett’s esophagus.

     

Factors Predicting Length of Stay Following Bariatric Surgery: Retrospective Review of a Single UK Tertiary Centre Experience

Background

Laparoscopic Roux Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are the most commonly performed bariatric procedures. Improvement in techniques and perioperative management of patients have resulted in shorter hospital stay and reduced overall costs. Many post-operative protocols aspire to post-operative day 1 discharge with studies showing reduction in length of stay without increasing complications. In this study, we investigate the factors predictive of early discharge at our high-volume bariatric centre.

Methods

A retrospective review of all patients who underwent bariatric surgery (RYGB or SG) at a single centre between January 2013 and December 2014 was undertaken. Routine preoperative investigations were performed and patient discussed at bariatric MDT. Post-operative management was as per standard protocols. Demographic data, type of surgery and post-operative data (length of stay, complications, readmission, reoperations) were analysed. Statistical analysis was performed using SPSS.

Results

Five hundred six patients underwent RYGB (407 (80.4%)) or SG (99 (19.6%)). The mean preoperative BMI was 45.9 (range 33.3–80.6). The median length of stay was 1 day (range 1–214 days; interquartile range 1–2 days) for RYGB and 2 days (range 1–8 days; interquartile range 1–3 days) for SG. Two hundred sixty-eight (52.9%) patients were discharged on post-operative day 1. The type of surgery and preoperative BMI were the only significant factors predicative of day 1 discharge after surgery. Patients undergoing SG were 3.3 times more likely to stay longer than 1 day after surgery (p?<?0.001). BMI <?50 is associated with day 1 discharge (p?=?0.030).

Conclusion

Early discharge, on post-operative day 1 appears to be safe and is not associated with a greater risk of readmission. Sleeve gastrectomy and a BMI >?50 are associated with an increased risk of failure to achieve day 1 discharge.

     

Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass

Introduction

A subset of patients undergoing laparoscopic sleeve gastrectomy (SG) require eventual conversion to Roux-en-Y gastric bypass (RYGB) due to complications from SG or to enhance weight loss. The aim of this study is to characterize the indications for conversion and perioperative outcomes in a large cohort of these patients at a single institution.

Methods

Patients who underwent revisional surgery to convert SG to RYGB at our institution from January 2008 through January 2017 were retrospectively reviewed.

Results

Eighty-nine patients with previous SG underwent conversion to RYGB as part of a planned two-stage approach to gastric bypass (n?=?36), for weight recidivism (n?=?11), or for complications related to SG (n?=?42). Complications from SG that warranted conversion included refractory GERD (40.5%), sleeve stenosis (31.0%), gastrocutaneous (16.7%), or gastropleural (7.1%) fistula, and gastric torsion (4.1%). The mean (SD) age was 47.2 years (11.4 years) and median BMI at the time of revision was 43.2 kg/m². A laparoscopic approach was successfully completed in 76 patients (85.4%), with an additional of four completed robotically (4.5%). The median length of stay was 3 days. Twenty-eight patients (31.5%) had complications which included surgical site infection (20.2%), re-operation (6.7%), anastomotic stricture (3.4%), and one pulmonary embolism. There were no mortalities with a median follow-up of 15 months.

Conclusions

Conversion of SG to RYGB is safe and technically feasible when performed for complications of SG or to enhance weight loss. This operation can be successfully performed laparoscopically with a low rate of conversion and reasonable complication profile.