Fully ambulatory robotic single anastomosis duodeno-ileal bypass (SADI): 40 consecutive patients in a single tertiary bariatric center.

BACKGROUND: Single Anastomosis Duodeno-Ileal bypass (SADI) is becoming a key option as a revision procedure after laparoscopic sleeve gastrectomy (LSG). However, its safety as an ambulatory procedure (length of stay < 12 h) has not been widely described. METHODS: A prospective bariatric study of 40 patients undergoing SADI robotic surgery after LSG with same day discharge (SDD), was undertaken in April 2021. Strict inclusion and exclusion criteria were applied and the enhanced recovery after bariatric surgery protocol was followed. Anesthesia and robotic procedures were standardized. Early follow-up (30 days) analyzed postoperative (PO) outcomes. RESULTS: Forty patients (37 F/3 M, mean age: 40.3yo), with a mean pre-operative BMI = 40.5 kg/m2 were operated. Median time after LSG was 54 months (21-146). Preoperative comorbidities included: hypertension (n = 3), obstructive sleep apnea (n = 2) and type 2 diabetes (n = 1). Mean total operative time was 128 min (100-180) (mean robotic time: 66 min (42-85)), including patient setup. All patients were discharged home at least 6 h after surgery. There were four minor complications (10%) and two major complications (5%) in the first 30 days postoperative (one intrabdominal abscess PO day-20 (radiological drainage and antibiotic therapy) and one peritonitis due to duodenal leak PO day-1 (treated surgically)). There were six emergency department visits (15%), readmission rate was 5% (n = 2) and reintervention rate was 2.5% (n = 1) There was no mortality and no unplanned overnight hospitalization. CONCLUSIONS: Robotic SADI can be safe for SDD, with appropriate patient selection, in a high-volume center.

Assessment of guidelines for bariatric and metabolic surgery: a systematic review and evaluation using appraisal of guidelines for research and evaluation II (AGREE II).

BACKGROUND: In recent years, multiple guidelines on bariatric and metabolic surgery were published, however, their quality remains unknown, leaving providers with uncertainty when using them to make perioperative decisions. This study aims to evaluate the quality of existing guidelines for perioperative bariatric surgery care. METHODS: A comprehensive search of MEDLINE and EMBASE were conducted from January 2010 to October 2022 for bariatric clinical practice guidelines. Guideline evaluation was carried out using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) framework. RESULTS: The initial search yielded 1483 citations, of which, 26 were included in final analysis. The overall median domain scores for guidelines were: (1) scope and purpose: 87.5% (IQR: 57-94%), (2) stakeholder involvement: 49% (IQR: 40-64%), (3) rigor of development: 42.5% (IQR: 22-68%), (4) clarity of presentation: 85% (IQR: 81-90%), (5) applicability: 6% (IQR: 3-16%), (6) editorial independence: 50% (IQR: 48-67%), (7) overall impressions: 48% (IQR: 33-67%). Only six guidelines achieved an overall score >70%. CONCLUSIONS: Bariatric surgery guidelines effectively outlined their aim and presented recommendations. However, many did not adequately seek patient input, state search criteria, use evidence rating tools, and consider resource implications. Future guidelines should reference the AGREE II framework in study design.

Single Anastomosis Duodeno-Ileal bypass (SADI-S) as Primary or Two-Stage Surgery: Mid-Term Outcomes of a Single Canadian Bariatric Center.

PURPOSE: Compare primary single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) and two-stage SADI after sleeve gastrectomy (SG) in terms of weight loss, reduction/remission of comorbidities, and morbidity. METHODS: Retrospective study including 179 patients treated laparoscopically between 2016 and 2020. A 50Fr bougie was used for the SG in the primary SADI-S (group 1) and 36/40Fr for the two-stage procedure (group 2). The duodeno-ileal anastomosis was performed at 250 cm from the ileocecal valve and at least 2 cm after the pylorus. RESULTS: Mean age was 44.1 years old, and there were 148 women and 31 men. There were 67 (37.4%) patients in group 1 and 112 (62.6%) in group 2, with 67% completing the 4-year follow-up. Mean preoperative body mass index (BMI) was 51.1 kg/m2 and 44.6 kg/m2 for groups 1 and 2, respectively. Preoperative comorbidities were obstructive sleep apnea, hypertension, type 2 diabetes, and dyslipidemia in 103 (57.5%), 93 (52%), 65 (36.3%), and 58 (32.4%) of cases. At 4 years postoperatively, excess weight loss (EWL) was 67.5% in group 1 and 67% in group 2 (p = 0.1005). Both groups had good comorbidity remission rates. Early postoperative morbidity rate was 10.4% in group 1 and 3.6% in group 2. In group1, there were mostly postoperative intra-abdominal hematomas managed conservatively (n = 4). Two revisional surgeries were needed for duodeno-ileal anastomosis leaks. Postoperative gastroesophageal reflux disease (GERD), daily diarrhea, vitamin, and protein levels were similar in both groups. CONCLUSION: Both types of strategies are efficient at short and mid-term outcomes. Preoperative criteria will inform surgeon decision between a primary and a two-stage strategy.

Long-term follow-up of a cohort with post sleeve gastrectomy leaks: results of endoscopic treatment and salvage surgery.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is the most performed bariatric procedure worldwide. The most challenging postoperative complication is gastric leak. The objectives of this study are to examine the efficacy and morbidity of different therapeutic strategies addressing leakage, and the long-term outcomes of a cohort of LSG leaks. METHODS: A retrospective review of patients treated for LSG leaks between September 2014 and January 2023 at our high-volume bariatric surgery center was performed. RESULTS: The charts of 37 patients (29 women and 8 men) were reviewed, with a mean age of 43 years and a median follow-up of 24 months. The mean preoperative body mass index was 45.1 kg/m2. Overall, 30/37 (81%) patients were successfully treated with endoscopic management, and 7/37 (19%) ultimately underwent salvage surgery. If the leak was diagnosed earlier than 6 weeks, endoscopic treatment had a 97% success rate. The median number of endoscopic procedures was 2 per patient, and included internal pigtails, stents, septoplasty, endoluminal vacuum therapy and over-the-scope clips. Complications included stent-related ulcers (10), esophageal stenosis requiring endoscopic dilatations (4), stent migrations (2) and kinking requiring repositioning (1), and internal pigtail migration (3). Revisional surgery consisted of proximal gastrectomy and Roux-en-Y esophago-jejunal anastomosis, Roux-en-Y fistulo-jejunostomy or classic Roux-en-Y gastric bypass proximal to the gastric stricture. In 62% of the cases, the axis/caliber of the LSG was abnormal. Beyond 4 attempts, endoscopy was unsuccessful. The success rate of endoscopic management dropped to 25% when treatment was initiated more than 45 days after the index surgery. CONCLUSIONS: Purely endoscopic management was successful in 81% of cases; with 97% success rate if diagnosis earlier than 6 weeks. After four failed endoscopic procedures, a surgical approach should be considered. Delayed diagnosis appears to be a significant risk factor for failure of endoscopic treatment.

Understanding the impact of radical changes in diet and the gut microbiota on brain function and structure: rationale and design of the EMBRACE study.

BACKGROUND: Bariatric surgery leads to profound changes in gut microbiota and dietary patterns, both of which may interact to impact gut-brain communication. Though cognitive function improves postsurgery, there is a large variability in outcomes. How bariatric surgery-induced modifications in the gut microbiota and dietary patterns influence the variability in cognitive function is still unclear. OBJECTIVES: To elucidate the associations between bariatric surgery-induced changes in dietary and gut microbiota patterns with cognition and brain structure. SETTING: University hospital. METHODS: A total of 120 adult patients (≥30 years) scheduled to undergo a primary bariatric surgery along with 60 age-, sex-, and body mass index-matched patients on the surgery waitlist will undergo assessments 3-months presurgery and 6- and 12-month postsurgery (or an equivalent time for the waitlist group). Additionally, 60 age-and sex-matched nonbariatric surgery eligible individuals will complete the presurgical assessments only. Evaluations will include sociodemographic and health behavior questionnaires, physiological assessments (anthropometrics, blood-, urine-, and fecal-based measures), neuropsychological cognitive tests, and structural magnetic resonance imaging. Cluster analyses of the dietary and gut microbiota changes will define the various dietary patterns and microbiota profiles, then using repeated measures mixed models, their associations with global cognitive and structural brain alterations will be explored. RESULTS: The coordinating study site (Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de-Montréal, QC, Canada), provided the primary ethical approval (Research Ethics Board#: MP-32-2022-2412). CONCLUSIONS: The insights generated from this study can be used to develop individually-targeted neurodegenerative disease prevention strategies, as well as providing critical mechanistic information.

Five-year outcomes after surgery for class 1 obesity: a retrospective analysis of a Canadian bariatric centre's experience.

BACKGROUND: There is a paucity of literature exploring the role of bariatric surgery in class 1 obesity. We evaluated the 5-year outcomes after bariatric surgery in patients with class 1 obesity, assessing weight loss, resolution/reduction of obesity-related comorbidities, morbidity and mortality. METHODS: We performed a single-centre retrospective analysis of patients who underwent bariatric surgery (laparoscopic sleeve gastrectomy [LSG] or laparoscopic Roux-en-Y gastric bypass [LRYGB)]) for class 1 obesity (body mass index [BMI] 30.0-34.9) between January 2012 and February 2019. RESULTS: Thirty-seven patients (35 [95%] female, mean age 44.5 yr [standard error (SE) 11.3 yr], mean preoperative BMI 33.1) were included, of whom 32 underwent LSG and 5 underwent LRYGB. Thirty-five patients were followed for 5 years post-operatively, achieving a mean BMI of 25.6 (SE 1.2) and excess weight loss of 89.4% (SE 15.1%). Remission of hypertension was achieved in 5 of 12 patients (42%), and remission of dyslipidemia was achieved in 7 of 11 patients (64%). Of the 11 patients with diabetes, 7 underwent LSG and 4, LRYGB. At 5 years postoperatively, the mean glycosylated hemoglobin concentration was 6.3%. Four patients in the LSG group developed de novo reflux, 1 patient required conversion to LRYGB, and 1 patient with sleeve stenosis required endoscopic dilatation. There were no deaths in either patient group. CONCLUSION: At our centre, bariatric surgery for class 1 obesity was safe and had long-term efficacy, with remission or reduction of related comorbidities. Prospective controlled trials are required to confirm these results.

Percutaneous Transgastric Duodenal Stenting and Gastrostomy Repair Using a Vascular Closure Device: Proof of Concept in a Porcine Model.

Introduction. Gastroduodenal stenting is efficacious and safe in both benign and malignant foregut diseases. Transgastric duodenal stenting has been described and however requires a gastrostomy tube to remain in situ for 4 to 6 weeks post-procedure which can lead to complications. We present a technique for immediate gastric repair using a suture-mediated vascular closure device, without the need for a gastrostomy tube in porcine models. Methods. Percutaneous access into the stomach was achieved using fluoroscopy. Two or 3 Perclose Proglide devices were pre-deployed. The tract was dilated and a wire advanced into the distal duodenum. A 15.5 cm covered enteric stent was delivered through the gastrostomy, deployed and position confirmed. The gastrostomy was closed using Perclose Proglide sutures. Necropsy leak pressure measurement was performed to assess integrity of gastrostomy closure in the porcine models. Results. Two (n = 8) or 3 (n = 2) Perclose Proglide devices were deployed in ten porcine models, with 1 misfire (4.5%). Percutaneous transgastric access and stent delivery was successful in all porcine models. Mean leak pressure in the animals with adequately deployed devices was 219 mmHg (range 172 mmHg-270 mmHg). Conclusion. This study demonstrates percutaneous transgastric duodenal stenting with immediate gastric repair using suture-mediated vascular closure devices is a feasible procedure.

Successful surgical weight loss with laparoscopic sleeve gastrectomy for morbid obesity prior to kidney transplantation.

Morbid obesity in kidney transplant (KT) candidates is associated with increased complications and graft failure. Multiple series have demonstrated rapid and significant weight loss after laparoscopic sleeve gastrectomy (LSG) in this population. Long-term and post-transplant weight evolutions are still largely unknown. A retrospective review was performed in eighty patients with end-stage kidney disease (ESKD) who underwent LSG in preparation for KT. From a median initial BMI of 43.7 kg/m2 , the median change at 1-year was -10.0 kg/m2 . Successful surgical weight loss (achieving a BMI < 35 kg/m2 or an excess body weight loss >50%) was attained in 76.3% and was associated with male gender, predialysis status, lower obesity class and lack of coronary artery disease. Thirty-one patients subsequently received a KT with a median delay of 16.7 months. Weight regain (increase in BMI of 5 kg/m2 postnadir) and recurrent obesity (weight regain + BMI > 35) remain a concern, occurring post-KT in 35.7% and 17.9%, respectively. Early LSG should be considered for morbidly obese patients with ESKD for improved weight loss outcomes. Early KT after LSG does not appear to affect short-term surgical weight loss. Candidates with a BMI of up to 45 kg/m2 can have a reasonable expectation to achieve the limit within 1 year.

Behavioral weight management interventions in metabolic and bariatric surgery: A systematic review and meta-analysis investigating optimal delivery timing.

Metabolic and bariatric surgery (MBS) yields unprecedented clinical outcomes, though variability is high in weight change and health benefits. Behavioral weight management (BWM) interventions may optimize MBS outcomes. However, there is a lack of an evidence base to inform their use in practice, particularly regarding optimal delivery timing. This paper evaluated the efficacy of BWM conducted pre- versus post- versus pre- and post-MBS. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and included pre- and/or post-operative BWM interventions in adults reporting anthropometric and/or body composition data. Thirty-six studies (2,919 participants) were included. Post-operative BWM yielded greater decreases in weight (standardized mean difference [SMD] = -0.41; 95% confidence interval [CI]: -0.766 to -0.049, p < 0.05; I2 = 93.5%) and body mass index (SMD = -0.60; 95% CI: -0.913 to -0.289, p < 0.001; I2 = 87.8%) relative to comparators. There was no effect of BWM delivered pre- or joint pre- and post-operatively. The risk of selection and performance bias was generally high. Delivering BWM after MBS appears to confer the most benefits on weight, though there was high variability in study characteristics and risk of bias across trials. This provides insight into the type of support that should be considered post-operatively.

A reliable, reproducible flow cytometry protocol for immune cell quantification in human adipose tissue.

The ability to accurately identify and quantify immune cell populations within adipose tissue is important in understanding the role of immune cells in metabolic disease risk. Flow cytometry is the gold standard method for immune cell quantification. However, quantification of immune cells from adipose tissue presents a number of challenges because of the complexities of working with an oily substance and the rapid deterioration of immune cell viability before analysis can be performed. Here we present a highly reproducible flow cytometry protocol for the quantification of immune cells in human adipose tissue, which overcomes these issues.

Customized bariatric stents for sleeve gastrectomy leak: are they superior to conventional esophageal stents? A systematic review and proportion meta-analysis.

OBJECTIVE: Recently, there has been a burgeoning interest in the utilization of customized bariatric stents (CBS) for management of sleeve gastrectomy leak (SGL). We aimed to conduct a proportion meta-analysis to evaluate the cumulative efficacy and safety of these new stents and to compare them with the conventional esophageal stents (CES). METHODS: A systematic literature search of the PubMed, Cochrane Library, Scopus, Web of Science and Google Scholar databases was conducted through May 1, 2020. Primary outcomes were technical and clinical success and post-procedure adverse events of CBS and CES. Secondary outcomes were number of stents and endoscopic sessions per patient, and time to leak closure. A proportion meta-analysis was performed on outcomes using a random-effects model, and the weighted pooled rates (WPRs) or mean difference with 95% confidence interval (CI) were calculated. RESULTS: The WPR with 95% CI of technical success, clinical success, and stent migration for CBS were 99% (93-100%) I2 = 34%, 82% (69-93%) I2 = 58%, and 32% (17-49%), I2 = 69%, respectively. For CES, the WPR (95% CI) for technical success, clinical success, and stent migration were 100% (97-100%) I2 = 19%, 93% (85-98%) I2 = 30%, and 15% (7-25%), I2 = 41%, respectively. Adverse events other than migration were very low with both types of stents. On proportionate difference, CBS had lower clinical success (11%) and higher migration rate (17%) in comparison to CES. In successfully treated patients, CBS was associated with lower mean number of stents and endoscopic sessions, and shorter time to leak closure compared to CES. The overall quality of evidence was very low. CONCLUSIONS: In treatment of SGL, there is very low level evidence that CES are superior to CBS in terms of clinical success and migration rate, though may require more stent insertions and endoscopic procedures. The evidence however remains very uncertain. Perhaps relevant to some types of stents, CBS are promising; however design modification is strongly recommended to improve outcomes.

Case Report: Endoscopic Removal of an Eroded Gastric Band Causing Small Bowel Obstruction upon Migration into the Proximal Jejunum.

BACKGROUND: Adjustable gastric banding (AGB) is on the decline due to its relatively modest amount of expected weight loss, coupled with high rates of revision and complications such as band erosion. Management of eroded gastric bands can be challenging especially when complete intra-gastric erosion is followed by distal migration causing small bowel obstruction. METHODS: We present an endoscopic option of using a pediatric colonoscope to remove an eroded AGB causing jejunal obstruction. RESULT: Endoscopic removal of an eroded ABG causing bowel obstruction was successful. CONCLUSION: Endoscopy remains a safe and relatively non-invasive approach to deal with such complications.

Decreasing complication rates for one-stage conversion band to laparoscopic sleeve gastrectomy: A retrospective cohort study.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) revision surgery is often necessary because of its high failure rate. The objective of this study was to demonstrate that better patient selection, when converting a failed LAGB to a laparoscopic sleeve gastrectomy (LSG) as a one-stage revision procedure, is safe, feasible and improves the complication rate. PATIENTS AND METHODS: A retrospective chart review was performed on patients who underwent a one-stage conversion of failed gastric banding to a LSG. Collected data included age, sex, body mass index (BMI), intraoperative complications, length of stay and post-operative complications. The results were compared to a previous study of 90 cases of LSG as a revision procedure for failed LAGB. RESULTS: There were 75 patients in the current study, 61 women and 14 men, aged 25-67 (average: 46), with a mean BMI of 45 kg/m2 (32-66). Seventy patients (93.3%) were operated for insufficient weight loss and 5 patients (6.7%) for intolerance to the band. In our previous study, 35 patients (39%) were operated for slippage, erosion or obstruction and 14 (15.6%) had post-operative complications as opposed to only 4 patients (5.3%) in this series (P = 0.0359). Gastric leak also improved to 1.3% compared to 5.5% previously. Average hospitalisation time was 2.5 days (1-40). CONCLUSIONS: Rigorous patient selection, without band complications such as slippage, erosion or obstruction, allows for a significantly lower rate of operative complications for a one-stage conversion of failed gastric banding to a LSG.

Efficiency of Laparoscopic One-Step Revision of Failed Adjusted Gastric Banding to Gastric Sleeve: a Retrospective Review of 101 Consecutive Patients.

BACKGROUND: Until recently, laparoscopic adjustable gastric banding (LAGB) was one of the most commonly performed bariatric surgeries worldwide. Today, its high rate of complications and failure rates up to 70% requires revisional surgery. The one-stage conversion from LAGB to laparoscopic sleeve gastrectomy (LSG) has been shown to be safe, although there are some concerns on efficacy and long-term weight loss. OBJECTIVES: To demonstrate that one-step revision of LAGB to another restrictive procedure, such as LSG, might have efficient long-term outcomes. METHODS: The charts from 133 revisional LSGs for failed or complicated LAGB were retrospectively reviewed for the period between January 2010 and August 2017. Thirty-two patients were excluded for loss to follow-up. Demographics, complications, and percentage of excess weight loss (%EWL) were determined. RESULTS: One hundred one patients were included (85 women and 16 men), with a mean age of 48.5 years, and a mean body mass index of 47.1 kg/m2. During the follow-up, 15 patients (15%) underwent a second revisional surgery for weight loss failure (8 Roux-en-Y gastric bypass (RYGBP), 3 biliopancreatic diversion, 3 single anastomosis duodenal-ileal bypass, 1 revisional LSG). Ten patients (10%) had long-term complications (8 severe reflux and 2 stenosis) during this period and underwent a second revisional surgery (10 RYGBP). The remaining 76 had a mean follow-up of 4.3 years and a mean %EWL of 53.2%. CONCLUSION: Single-stage conversion to LSG is a safe and appropriate solution for failed or complicated LAGB with good long-term weight loss.

Laparoscopic Sleeve Gastrectomy: A Radiological Guide to Common Postsurgical Failure.

Laparoscopic sleeve gastrectomy is one of the most common bariatric procedures worldwide. It has recently gained in popularity because of a low complication rate, satisfactory resolution of comorbidities, and excellent weight loss outcome. This article reviews the surgical technique, expected postsurgical imaging appearance, and imaging findings of common complications after laparoscopic sleeve gastrectomy. Understanding of the surgical technique of laparoscopic sleeve gastrectomy and of the normal postsurgical anatomy allows accurate interpretation of imaging findings in cases of insufficient weight loss, weight regain, and postsurgical complications.

Laparoscopic revision of Billroth II with Braun anastomosis into Roux-en-Y anatomy in a patient with intestinal malrotation.

INTRODUCTION: Various reconstructions of the gastro-intestinal tract have been described in the past after distal gastrectomy. Among these, a Billroth II (BII) anastomosis can be performed with the addition of the Omega entero-enterostomy that may theoretically reduce the alkaline reflux. Given the significant complications associated with this procedure such as biliary reflux, marginal ulceration, and afferent loop syndrome, a revision into a Roux-en-Y anatomy is generally recommended. METHODS AND PROCEDURES: A 73-year-old healthy male was referred to our foregut surgery service for treatment of severe biliary gastritis. The patient previously underwent an open distal gastrectomy with a BII reconstruction followed by a Braun-type entero-enterostomy 6 months later. His main complaint was worsening daily biliary reflux with constant regurgitations, which were non-responsive to medical treatment. The preoperative endoscopy confirmed the diagnosis of severe biliary gastritis secondary to alkaline reflux. The distance between the gastro-jejunostomy and the Braun anastomosis was also measured with a pediatric colonoscope and the length of the efferent limb was estimated to be 80 cm. RESULTS: Identification of the afferent and efferent limb was complicated by the patient's incomplete intestinal malrotation with the angle of Treitz being present in the right hypochondrium. Intra-operative gastroscopy enabled visualization of the jejuno-jejunostomy and ensured correct interpretation of the anatomy. Subsequently, resection of the afferent limb completed the revision into a Roux-en-Y anatomy. The patient recovered well after the surgery and was discharged home on post-operative day 2. At 6 months follow-up, the patient's reflux symptoms have completely disappeared. CONCLUSION: BII reconstruction with or without Braun entero-enterostomy is a classic historical option following distal gastrectomy. Surgical revision of a BII into a Roux-en-Y anatomy is a good solution for severe biliary reflux and other long-term complications. Intra-operative endoscopy is a great adjunct to laparoscopic exploration in case of complex surgical procedures.