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.

     

Early and Mid-term Outcomes of Single-Stage Laparoscopic Sleeve Gastrectomy

Background  

This is the largest single-centre series of single-stage laparoscopic sleeve gastrectomy (LSG) reporting on perioperative outcomes, weight loss, comorbidity resolution including urological outcomes and results in the super obese. Review of prospectively collected data for patients who underwent LSG from March 2007–August 2009.     

Laparoscopic Sleeve Gastrectomy: Co-morbidity Profiles and Intermediate-Term Outcomes

Background

Bariatric surgery is effective at achieving sustained weight loss and improving the control and resolution of obesity-related co-morbidities. Most studies that have demonstrated co-morbidity resolution in patients undergoing laparoscopic sleeve gastrectomy (LSG) only follow patients for the short term (less than 1 year) or follow a relatively small cohort (<100 patients) for the intermediate or long term (more than 5 years). We report our experience following a large cohort of morbidly obese patients who underwent LSG with intermediate-term follow-up.

Methods

We retrospectively reviewed 435 consecutive patients who underwent LSG from January 2004 to November 2013. Co-morbidities investigated included diabetes mellitus (DM), hypertension (HTN), and hyperlipidemia (HL). A co-morbidity was determined to be resolved if the patient was no longer taking any medication to treat that specific co-morbidity.

Results

Mean follow-up was 26?±?25 months (range?=?1–112). Mean postoperative total weight loss (%TWL) at 6, 12, 24, 36, 48, 60, and 72 months were 23.6, 29.9, 29.5, 25.2, 26.7, 25.4, and 24.3 %, respectively. The incidence of all three co-morbidities was found to be significantly lower at the last patient follow-up. The resolution rates for DM, HTN, and HL were 59, 31, and 50 %, respectively. In patients who continued to have co-morbidities, the mean numbers of medications for DM (1.2?±?0.7 vs. 0.5?±?0.7, p?<?0.0001), HTN (1.8?±?1.1 vs. 1.3?±?1.2, p?<?0.0001), and HL (0.9?±?0.7 vs. 0.6?±?0.6, p?<?0.0001) postoperatively were all significantly less.

Conclusions

LSG is effective at achieving significant and sustained weight loss, improvement in co-morbidity profiles, and a reduction in poly-pharmacy for these conditions over intermediate-term follow-up.

     

Bariatric Aftercare and Outcomes in the Medicaid Population Following Sleeve Gastrectomy

Background:

Medicaid patients tend to have poor access to care and suffer from more obesity and obesity-related co-morbidities compared to their privately insured counterparts. The impact of Medicaid status on outcomes after laparoscopic sleeve gastrectomy (LSG) is unknown. The aim of this study was to identify factors that influence outcomes following LSG in the adult Medicaid population of Louisiana with particular focus on adherence to bariatric aftercare attendance and access to care.

Methods:

A retrospective review of 63 Medicaid patients undergoing LSG was performed. Demographic data, access to care, weight, co-morbidities morbidity, and mortality were analyzed. Changes in weight and obesity-related co-morbidities were analyzed for patients with ≥12 months of follow-up. Regression analyses were used for estimating the relationships among variables.

Results:

The majority of patients were female and non-Caucasian. The mean age was 38.6 years. Morbidity was 16% and mortality was 0%. The average distance traveled to clinic was 71.9 miles. Within the first year only 10% of the patients attended all post-operative clinic visits. A multiple logistic model showed that the only predictor of clinic attendance was increased age. At a mean follow-up of 17.7 months, the mean percent excess body weight loss was 47.2%. Greater pre-surgical weight was the only variable associated with suboptimal weight loss. Improvement or resolution of all major co-morbidities was seen in 65% of patients.

Conclusion:

Medicaid patients had a poor attendance at bariatric surgery follow up appointments. Since long-term follow-up is critical, we needed to develop strategies that will optimize follow-up in this patient population.     

Pregnancy Outcomes after Laparoscopic Sleeve Gastrectomy in Morbidly Obese Korean Patients

Laparoscopic sleeve gastrectomy (LSG) is an effective procedure for treating morbid obesity, and the majority of female patients who received LSG were at childbearing age. Female patients, who successfully lost weight following LSG and became pregnant, need to be evaluated carefully. Information was gathered, through prospectively maintained database and phone interview, on women who underwent LSG from May 2003 to July 2011. A total of 136 women underwent LSG in this period. There were 13 (9.6 %) pregnancies in 12 patients after LSG. The age before surgery was 28.3?±?4.0. The mean weight and body mass index (BMI) before LSG were 95.3?±?9.4 kg and 35.1?±?3.5 kg/m², respectively. The average time from LSG to the first live birth was 32.0?±?19.1 months. Mean BMI decreased significantly after LSG, from 35.1?±?3.5 to 24.9?±?2.3 kg/m² at conception. The mean percentage of excess body mass index loss was 85.8?±?16.7 % at conception and 42.7?±?25.1 % at delivery. Gained weight during pregnancy was 15.1?±?5.2 kg. The mean gestational age and birth weight were 39.0?±?1.6 weeks and 3,229.0?±?505.9 g. In two cases (15.4 %), cesarean section was performed. No cases of pregnancy-induced hypertension and diabetes developed. Major congenital anomalies and neonatal deaths were not recorded. Larger study with longer follow-up is needed to evaluate the effect of LSG in pregnancies. However, these findings show that LSG seems to be a safe option for morbidly obese women in their reproductive period.     

腹腔镜袖状胃切除术

患者女性，30岁，BMI36.6，诊断代谢综合征。患者平卧"大"字位，头高左侧高30°，主刀右侧站位。距幽门2 cm开始紧贴胃壁游离胃大弯，充分游离胃底，显露左侧膈肌脚及食道左侧，经口置入36 F减重胃管，沿胃管距幽门4 cm开始进行袖状胃裁剪，根据胃壁厚度应用不同钉脚高度的切割闭合钉，连续全层缝合加固胃切缘，并将胃切缘复位固定于大网膜及胰腺背膜，经主操作孔取出切除的胃组织，清理腹腔，放置引流管，缝合戳卡孔。     

Transumbilical Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy is a procedure for the management of morbid obesity, which usually implies the placement of multiple trocars. It is now possible to perform procedures through smaller incisions, known as “invisible” or single port surgery. We describe the case of a transumbilical sleeve gastrectomy completed totally laparoscopically through a single port using a multichannel device.     

Comparison of the Outcomes of Single Anastomosis Duodeno-Ileostomy with Sleeve Gastrectomy (SADI-S), Single Anastomosis Sleeve Ileal (SASI) Bypass with Sleeve Gastrectomy,and Sleeve Gastrectomy Using a Rodent Model with Diabetes

Obesity Surgery - Single anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S) is a powerful form of bariatric surgery; however, it has a high risk of malnutrition. Single anastomosis...     

Laparoscopic Ileal Interposition with Diverted Sleeve Gastrectomy Versus Laparoscopic Transit Bipartition with Sleeve Gastrectomy for Better Glycemic Outcomes in T2DM Patients

Background

Metabolic procedures provide better outcomes for obese patients with type 2 diabetes mellitus. Our aim was to compare the glycemic regulation in patients that have undergone the laparoscopic ileal interposition with diverted sleeve gastrectomy (II-DSG), laparoscopic transit bipartition with sleeve gastrectomy (TB-SG), and laparoscopic sleeve gastrectomy (LSG) throughout a 12-month follow-up period retrospectively.

Methods

This study considered patients with T2DM who underwent metabolic procedures. The postoperative changes in the glucose, C-peptide, HbA1c, HOMA-IR, insulin, cholesterol, body mass index, and total weight loss (TWL) were compared retrospectively. The intended outcome was to reach a long lasting fasting blood glucose (FBG) <126 mg/dl. A multivariate regression analysis was applied to define the predictive markers in glucose regulation.

Results

Present study consisted of 83 patients with a mean age of 47.25 ± 6.58 years, mean preoperative BMI of 37.36 ± 2.71 kg/m², and mean outcomes in the HbA1C and FBG of 9.05 ± 1.33% and 237 ± 15 mg/dl, respectively. There were similar correlations in BMI and total weight loss (TWL). At 12-month follow up period, compared to LSG group, TB-SG and II-DSG groups have higher remission proportions (35.3, 67.9, 54.7, respectively, p < 0.05) with similar TWL% (22.35, 27.14, 23.16%) outcomes. The II-DSG and TB-SG results drew closer together toward the end of this study interval unlike the LSG group.

Conclusion

Our results showed that II-DSG and TB-SG ensured significant regression rates during the follow-up period. Since the TB-SG achieved these outcomes by finite anastomoses and intervening segments, it was considered to be a superior procedure compared to II-DSG and LSG procedures.

     

Indications and Short-Term Outcomes of Revisional Surgery After Failed or Complicated Sleeve Gastrectomy

Background

Sleeve gastrectomy (SG) is an upcoming primary treatment modality for morbid obesity. The aim of this study was to report the indications for and the outcomes of revisional surgery after SG.

Methods

Four hundred sixteen individuals underwent a SG between August 2006 and July 2010 with a minimum follow-up of 12?months. The patients that needed revision were identified from our prospective registry. Patients were subdivided in a first group undergoing revision as part of a two-step procedure, a second group with failure of a secondary SG, and a third group with failure of a primary SG.

Results

Twenty-three patients (5.5?%) had an unplanned revision. Fourteen (3.4?%) had a two-step procedure because of super obesity. A significant additional weight loss was achieved after revision; no complications occurred in this group. Five patients with failure of a secondary SG had no significant additional weight loss after revision. Reflux disease was cured. Eighteen patients in the third group showed significant additional weight loss and remission of diabetes and hypertension. Both reflux disease and dysphagia did not heal in all affected patients after revision. The early complication rate in the whole cohort was 23.4?%; staple line leakage was 5.4?%, and bleeding was 8.1?%. Revision-related mortality was 0?%.

Conclusion

In a large series of sleeve gastrectomies, the unplanned revision rate was 5.5?%. Revision of a sleeve gastrectomy is feasible in patients that do not achieve sufficient weight loss and in those patients developing complications after the initial sleeve gastrectomy.     

Sleeve Gastrectomy Model in Wistar Rats

BACKGROUND: Sleeve gastrectomy (SG) has been used for the surgical treatment of morbid obesity, as a first step or as a definitive treatment. The objective of this pilot study was to establish an animal model for SG in Wistar rats. METHODS: 12 male Wistar rats were operated on. 8 of them underwent a SG, with a hand-sewn invaginating suture, and 4 underwent a laparotomy and stomach manipulation (control group). Sterilized materials, prophylactic antibiotics and nutritional supplementation were used. The animals' weight was checked on the operation day and on a weekly basis, for 7 weeks. RESULTS: The experimental SG model was possible due to careful procedures in the pre- and postoperative period. The average weight loss in the sleeve gastrectomy group was 49.6 g (43 to 60 g) until the 4th week, whereas in the control group average weight loss was 15 g (10 to 25 g) but the weight loss was achieved in the 1st week. After the 7th week, there was weight gain in both groups. However, in the SG group, this gain was significantly lower than in the control group. CONCLUSION: It has been possible to obtain a SG experimental model. The effects of this SG appear to be beneficial in weight loss. Biochemical and molecular mechanisms may also be investigated based on this model.     

Behavioral Outcomes Following Laparoscopic Sleeve Gastrectomy Performed After Failed Laparoscopic Adjustable Gastric Banding

A healthy diet and good eating behaviors are essential components of long-term success in weight maintenance after bariatric surgery. Although rates of revised bariatric surgery have increased, data on subsequent behavioral outcomes are sparse. The aim of our study was to investigate behavioral outcomes following revised laparoscopic sleeve gastrectomy (R-LSG) that was indicated for failed laparoscopic adjustable gastric banding and compare with outcomes following primary laparoscopic sleeve gastrectomy (P-LSG). Twelve patients who underwent R-LSG and 25 patients who underwent P-LSG between 2007 and 2009 in our medical center completed a questionnaire that assessed weight loss, eating behaviors, physical activity, food tolerance, and satisfaction. The average time elapsed since the operation was 18 months for both groups. In the R-LSG group, more patients reported non-normative eating patterns and less healthy food selection than in the P-LSG group. Food tolerance and satisfaction were also lower after R-LSG. Engagement in regular physical activity increased from 0 to 16.7 % in the R-LSG group and from 8 to 33 % in the P-LSG group. After R-LSG, 58 % reported eating at scheduled times, compared with 85 % after P-LSG. Levels of healthy food selection, food tolerance, normative eating patterns, and physical activity were lower in the R-LSG group than in the P-LSG group. This study highlights the need to develop pre- and post-surgery treatment that would promote better behavioral outcomes in the growing number of individuals undergoing repeat bariatric surgery.     

Technical Controversies in Laparoscopic Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy is a recently developed technique for treating morbid obesity. Since it is a simple procedure, many bariatric surgeons have adopted it in recent years with good results. However, there is still no standard procedure across different surgical teams. We will discuss the more controversial aspects of the surgical technique: the size of the bougie, the beginning of the distal section, the section shape at the gastroesophageal junction, the necessity and manner of reinforcing the staple line, and the routine use of intraoperative leak testing.