Revision/Conversion Surgeries After One Anastomosis Gastric Bypass-An Experts' Modified Delphi Consensus.

PURPOSE: There is a lack of evidence for treatment of some conditions including complication management, suboptimal initial weight loss, recurrent weight gain, or worsening of a significant obesity complication after one anastomosis gastric bypass (OAGB). This study was designed to respond to the existing lack of agreement and to provide a valuable resource for clinicians by employing an expert-modified Delphi consensus method. METHODS: Forty-eight recognized bariatric surgeons from 28 countries participated in the modified Delphi consensus to vote on 64 statements in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was regarded to indicate a consensus. RESULTS: A consensus was achieved for 46 statements. For recurrent weight gain or worsening of a significant obesity complication after OAGB, more than 85% of experts reached a consensus that elongation of the biliopancreatic limb (BPL) is an acceptable option and the total bowel length measurement is mandatory during BPL elongation to preserve at least 300-400 cm of common channel limb length to avoid nutritional deficiencies. Also, more than 85% of experts reached a consensus on conversion to Roux-en-Y gastric bypass (RYGB) with or without pouch downsizing as an acceptable option for the treatment of persistent bile reflux after OAGB and recommend detecting and repairing any size of hiatal hernia during conversion to RYGB. CONCLUSION: While the experts reached a consensus on several aspects regarding revision/conversion surgeries after OAGB, there are still lingering areas of disagreement. This highlights the importance of conducting further studies in the future to address these unresolved issues.

Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus.

Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

IFSO Consensus on Definitions and Clinical Practice Guidelines for Obesity Management-an International Delphi Study.

INTRODUCTION: This survey of international experts in obesity management was conducted to achieve consensus on standardized definitions and to identify areas of consensus and non-consensus in metabolic bariatric surgery (MBS) to assist in an algorithm of clinical practice guidelines for the management of obesity. METHODS: A three-round Delphi survey with 136 statements was conducted by 43 experts in obesity management comprising 26 bariatric surgeons, 4 endoscopists, 8 endocrinologists, 2 nutritionists, 2 counsellors, an internist, and a pediatrician spanning six continents over a 2-day meeting in Hamburg, Germany. To reduce bias, voting was unanimous, and the statements were neither favorable nor unfavorable to the issue voted or evenly balanced between favorable and unfavorable. Consensus was defined as ≥ 70% inter-voter agreement. RESULTS: Consensus was reached on all 15 essential definitional and reporting statements, including initial suboptimal clinical response, baseline weight, recurrent weight gain, conversion, and revision surgery. Consensus was reached on 95/121 statements on the type of surgical procedures favoring Roux-en-Y gastric bypass, sleeve gastrectomy, and endoscopic sleeve gastroplasty. Moderate consensus was reached for sleeve gastrectomy single-anastomosis duodenoileostomy and none on the role of intra-gastric balloons. Consensus was reached for MBS in patients > 65 and < 18 years old, with a BMI > 50 kg/m2, and with various obesity-related complications such as type 2 diabetes, liver, and kidney disease. CONCLUSIONS: In this survey of 43 multi-disciplinary experts, consensus was reached on standardized definitions and reporting standards applicable to the whole medical community. An algorithm for treating patients with obesity was explored utilizing a thoughtful multimodal approach.

First National Consensus on the Safe Practice of Medical Tourism for Bariatric Surgery in Mexico.

BACKGROUND: Medical tourism is increasing every year, especially in fields such as bariatric surgery. Global concerns rely on the fact of its safety, mainly because of a lack of standardization, unknown number of cases, and the type of specialists performing such procedures. Mexico continues to be among the top countries receiving patients from abroad, but there is no national consensus, guidelines, or recommendations about the practice in such fields. METHODS: A group of 32 bariatric surgeons with an accumulated experience of 25,196 procedures in the medical tourism modality were gathered to perform a national consensus in bariatric surgery tourism. The Delphi methodology was used for this project, with a total of 52 items applied. A consensus was reached when the experts' position was ≥ 70% for each statement. The items included pre- and postoperative phases, patient selection, follow-up, and ethical and legal considerations. RESULTS: Of the 52 statements, 40 (76.9%) reached a consensus of ≥ 70%; 36 in favor, 5 against, and 11 with indeterminate responses. CONCLUSIONS: Although more than two-thirds of the statements related to high standard practice reached a consensus, weak points in the medical tourism modality were identified. This first consensus serves to establish the basis of safe practices, eventually reach national guidelines, and define the top standards of care when performing bariatric surgery tourism.

Best practice approach for redo-surgeries after sleeve gastrectomy, an expert's modified Delphi consensus.

BACKGROUND: Sleeve gastrectomy (SG) is the most common metabolic and bariatric surgical (MBS) procedure worldwide. Despite the desired effect of SG on weight loss and remission of obesity-associated medical problems, there are some concerns regarding the need to do revisional/conversional surgeries after SG. This study aims to make an algorithmic clinical approach based on an expert-modified Delphi consensus regarding redo-surgeries after SG, to give bariatric and metabolic surgeons a guideline that might help for the best clinical decision. METHODS: Forty-six recognized bariatric and metabolic surgeons from 25 different countries participated in this Delphi consensus study in two rounds to develop a consensus on redo-surgeries after SG. An agreement/disagreement ≥ 70.0% on statements was considered to indicate a consensus. RESULTS: Consensus was reached for 62 of 72 statements and experts did not achieve consensus on 10 statements after two rounds of online voting. Most of the experts believed that multi-disciplinary team evaluation should be done in all redo-procedures after SG and there should be at least 12 months of medical and supportive management before performing redo-surgeries after SG for insufficient weight loss, weight regain, and gastroesophageal reflux disease (GERD). Also, experts agreed that in case of symptomatic GERD in the presence of adequate weight loss, medical treatment for at least 1 to 2 years is an acceptable option and agreed that Roux-en Y gastric bypass is an appropriate option in this situation. There was disagreement consensus on efficacy of omentopexy in rotation and efficacy of fundoplication in the presence of a dilated fundus and GERD. CONCLUSION: Redo-surgeries after SG is still an important issue among bariatric and metabolic surgeons. The proper time and procedure selection for redo-surgery need careful considerations. Although multi-disciplinary team evaluation plays a key role to evaluate best options in these situations, an algorithmic clinical approach based on the expert's consensus as a guideline can help for the best clinical decision-making.

The first modified Delphi consensus statement on sleeve gastrectomy.

INTRODUCTION: Sleeve gastrectomy (SG) is the commonest bariatric procedure worldwide. Yet there is significant variation in practice concerning its various aspects. This paper report results from the first modified Delphi consensus-building exercise on SG. METHODS: We established a committee of 54 globally recognized opinion makers in this field. The committee agreed to vote on several statements concerning SG. An agreement or disagreement amongst ≥ 70.0% experts was construed as a consensus. RESULTS: The committee achieved a consensus of agreement (n = 71) or disagreement (n = 7) for 78 out of 97 proposed statements after two rounds of voting. The committee agreed with 96.3% consensus that the characterization of SG as a purely restrictive procedure was inaccurate and there was 88.7% consensus that SG was not a suitable standalone, primary, surgical weight loss option for patients with Barrett's esophagus (BE) without dysplasia. There was an overwhelming consensus of 92.5% that the sleeve should be fashioned over an orogastric tube of 36-40 Fr and a 90.7% consensus that surgeons should stay at least 1 cm away from the angle of His. Remarkably, the committee agreed with 81.1% consensus that SG patients should undergo a screening endoscopy every 5 years after surgery to screen for BE. CONCLUSION: A multinational team of experts achieved consensus on several aspects of SG. The findings of this exercise should help improve the outcomes of SG, the commonest bariatric procedure worldwide, and guide future research on this topic.

A Global Survey by the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) on Perceptions of Bariatric Medical Tourism (BMT) by Health Professionals: Guidelines from IFSO for BMT.

BACKGROUND: Bariatric medical tourism (BMT) is a rapidly expanding industry, with over 650 million people with obesity worldwide and total number rising by over 300% between 2003 and 2014. The overall health tourism industry is worth over $400 billion/year. METHODS: International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) conducted a global survey to analyze the details of BMT and the perceptions of bariatric health care professionals (HCP) regarding BMT. RESULTS: A total of 383 bariatric HCP's with experience of 272,548 procedures responded from 65 countries. Seventy-three percent of respondents had managed BMT patients, whilst low cost of surgery was felt to be the driving factor in 77% of cases. The USA contributed the most patients travelling for BMT with 11.6%. Twenty-four percent of respondents stated that they had no access to adequate notes regarding the patient's operation, whilst 12% felt BMT is associated with a higher mortality. Only 49% of respondents felt that IFSO guidelines were followed by the operating surgeon. Sleeve gastrectomy was the commonly offered surgery and an overall mean operation cost was $8716. Nearly 64% of respondents felt BMT needed better coordination between practitioners, whilst almost 85% of respondents supported the idea of a forum to facilitate safe BMT worldwide. CONCLUSION: This IFSO survey has outlined the current BMT trends worldwide and highlighted areas of concern in the care of such patients. It has expanded our knowledge and should be used as a starting point to establish international forums to aid collaboration.

COVID-19: IFSO LAC Recommendations for the Resumption of Elective Bariatric Surgery.

BACKGROUND: COVID-19 pandemic varies greatly and has different dynamics in every country, city, and hospital in Latin America. Obesity increases the risk of SARS-CoV-2 infection, and it is one of the independent risk factors for the most severe cases of COVID-19. Currently, the most effective treatment against obesity available is bariatric and metabolic surgery (BMS), which further resolves or improves other independent risk factors like diabetes and hypertension. OBJECTIVE: Provide recommendations for the resumption of elective BMS during COVID-19 pandemic. METHOD: This document was created by the IFSO-LAC Executive Board and a task force. Based on data collected from a survey distributed to all IFSO-LAC members that obtained 540 responses, current evidence available, and consensus reached by other scientific societies. RESULTS: The resumption of elective BMS must be a priority maybe similar to oncological surgery, when hospitals reach phase I or II, treating obesity patients in a NON-COVID area, avoiding inadvertent intrahospital contagion from healthcare provider, patients, and relatives. Same BMS indication and types of procedures as before the pandemic. Discard the presence of SARS-CoV-2 within 72 h prior to surgery. Continues laparoscopic approach. The entire team use N95 mask. Minimum hospital stays. Implement remote visits for the follow-up. CONCLUSION: Resumption of elective BMS is crucial because it is not only a weight loss operation but also resolves or improves comorbidities and appears to be an immune restorative procedure of obese patients in the medium term, offering them the same probability of contracting COVID-19 as the regular population.

Hepaticoyeyunostomía en Y de Roux con asa de Barker modificada y su abordaje e instrumentación endoscópica: experiencia en una Unidad de Cirugía General durante 11 años / Roux-en-Y hepaticojejunostomy with Barker's modified limb and its access and endoscopic instrumentation: 11 years experience in a General Surgery Unit

La hepaticoyeyunostomía en Y de Roux con Asa de Baker modificada es una derivación bilioentérica que posee una Asa de yeyuno subcutánea que sirve para poderinstrumentar endoscópicamente el árbol biliar las veces que sea necesario. El presente trabajo presenta la experiencia de la 4a. Unidad de Cirugía del Hospital General San Juan de Dios de Guatemala en los últimos 11 años. Material y Métodos: De enero de 1992 a enero de 2003 se han efectuado 191 derivaciones bilio-entéricas, 24 coledocoduodenostomías L-L y 167 hepatico-yeyunostomía en Y de Roux con Asa de Barker Modificada a 154 mujeres y 37 hombres, entre las edades de 18 a 69 años. Resultados: Se han operado 93 pacientes por lesiones iatrogénicas al árbol biliar, 62 pacientes por obstrucción litiásica biliar, 7 por quistes del colédoco, 25 por cáncer y 4 por pseudoquistes de páncreas. De los 167 casos con hepaticoyeyunostomía en Y de Roux con Asa de Barker modificada 5 pacientes (3.03 por ciento) presentaron colangitis a repetición, todos aquellos pacientes post-iatrogenia. De éstos 5 casos 2 se resolvieron con tratamiento médico y a 3 se les efectuó instrumentación endoscópica del árbol biliar. Un caso no se pudo instrumentar por estrechez puntiforme se reintervino a ésta paciente y se le efectuó una nueva derivación. Las otras dos pacientes fueron instrumentadas, dilatadas y se colocaron endoprótesis biliares 10 Fr. temporal, a una de estas pacientes hubo necesidad de instrumentarla dos veces, resolviéndose la estrechez en los dos casos. Conclusión: La hepaticoyeyunostomía en Y de Roux con Asa de Barker Modificada es una derivación bilioentérica que permite el acceso permanente al árbol biliar pudiendo ser instrumentado endoscópicamente las veces que sea necesario

Fundoplicatura de Nissen videolaparoscópica: experiencia de 104 casos / Laparoscopic Nissen fundoplication: experience in 104 cases

Introducción: Con el desarrollo de la Cirugía Laparoscópica la Enfermedad por Reflujo Gastroesofágico (ERGE) puede ser tratada de una manera invasiva, ofreciendo al paciente una recuperación rápida y definitiva a tan molesto problema. La Fundoplicatura de Nissen Video-laparoscópica es actualmente el procedimiento quirúrgico más frecuentemente realizado para el control del RGE. El objetivo del presente trabajo es presentar la experiencia del autor con ésta técnica en 104 casos. Material y Métodos: De diciembre de 1995 a octubre de 2002 el autor, ha efectuado fundoplicatura de Nissen por vía laparoscópica en 104 pacientes, 59 hombres y 45 mujeres, entre las edades de 9 a 71 años, todos con RGE crónico y con un mínimo de tratamiento médico de 18 meses cada uno. El protocolo pre-operatorio incluye: Historia de RGE crónico, Video-endoscopía superior más biopsias por gastroenterólogo, exámenes de laboratorio de rutina. La técnica quirúrgica es la descrita por Peters, DeMeester y Hinder en 1992. No se liberaron los vasos cortos en los primeros 25 casos, en los 79 restantes sí. Resultados: Se ha tenido un seguimiento en 102 casos, 2 pacientes se han ido a vivir al extranjero y ya no hay comunicación, se ha logrado controlar el RGE en los 102 casos. No hubo conversaciones a cirugía abierta, no hubo mortalidad. 1 paciente presentó disfagia postoperatoria al mes de operado la cual se resolvió con dos dilataciones esofágicas, 1 paciente presentó disfagia postoperativa al mes de operado la cual se resolvió con dos dilataciones esofágicas, 1 paciente presentó disfagia al 7o. día postoperatorio, misma que se resolvió con tratamiento médico. Conclusión: La Fundoplicatura de Nissen Video-laparoscópica controla de manera permanente la Enfermedad por reflujo gastroesofágico

Banda gástrica ajustable para el control de la obesidad mórbida: experiencia del grupo bariátrico en Guatemala / Adjustable gastric banding for morbid obesity control: experience of the bariatric group in Guatemala

Introducción: El sistema de Banda Gástrica Ajustable consiste en la colocación por vía laparoscópica de un dispositivo de silicón en la parte más alta del estómago, creando un reservorio gástrico de 30 cc, obteniendo un cambio definitivo en los hábitos alimenticios del paciente por medio de una saciedad temprana con disminución de peso progresiva, recibiendo un aporte calórico de no más de 800 calorías diarias. 3Cirujanos Endoscópicos (Grupo Bariátrico) con amplia experiencia en cirugía del hiato esofágico se unieron para formar un equipo multidisciplinario para la evaluación y tratamiento del paciente obeso. Material y Métodos: De noviembre de 1999 a octubre de 2002 se colocaron 187 bandas gástricas ajustables, 134 Suecas (OBTECH) y 53 Lap-ban (BIOENTERICS). Resultados: Se han operado 28 hombres y 159 mujeres, entre las edades de 13 a 66 ños, consiguiendo una disminución del sobrepeso de manera satisfactoria en el 96.79 por ciento de los pacientes, el 3.21 por ciento restante (6 casos) no presentó una adecuada evolución por morbilidad y problemas en el metabolismo. No hubo mortalidad. 2 bandas fueron retiradas, una por infección severa y otra por un deslizamiento anterior temprano más necrosis gástrica. Conclusión: La colocación de la banda gástrica ajustable es una alternativa definitiva y confiable para el control de la obesidad en Guatemala

Cistadenoma mucinoso del páncreas: diagnóstico y manejo quirúrgico de un caso / Pancreatic mucinous cystadenoma: diagnosis and surgical management of one case

Se presenta el caso de una paciente de 66 años que consultó por cuadro de dolor a nivel epigástrico, sensación de llenura, fiebre e ictericia de una semana de evolución. Fue estudiada en imagenología y con una colangiopancreatografía-endoscópica-retrógrada que evidenciaron la presencia de una ectasia ductal mucinosa compatible con un cistadenoma mucinoso del páncreas. Se operó a la paciente resencando el 95 del páncreas, confirmándose histológicamente la presencia de un cistadenoma mucinoso sin evidencia de malignidad, el quiste iba desde la cabeza hasta la cola del páncreas. La paciente se encuentra en buenas condiciones generales 21 meses después de la resección y sin diabetes

Divertículo de Meckel: diagnóstico laparoscópico-tratamiento video-asistido: reporte de un caso / Meckel's diverticulum: laparoscopic diagnosis and video assisted treatment: report a case

El divertículo de Meckel es la anomalía congénita más común del intestino, con una incidencia del l al 3/100. Se reporta el caso de un joven de 22 años de edad, quien consultó por dolor en la fosa ilíaca derecha. Los resultados de laboratorio y rayos X orientaban hacia un cuadro de apendicitis aguda; se efectuó laparoscopía diagnóstica y el hallazgo operatorio fue un divertículo de Meckel inflamado; se efectuó resección extracorpórea del divertículo y anastomosis termino-terminal en dos planos. Se hace una revisión de la literatura sobre el divertículo de Meckel y sus complicaciones, así como su diagnóstico y tratamiento video-asistido