[Twenty-five years of duodenal switch. How to switch to the duodenal switch]. / Veinticinco años de cruce duodenal. Cómo cambiar al cruce.

INTRODUCTION: Background: the duodenal switch (DS) is a procedure that combines a vertical gastrectomy (VG) plus a biliopancreatic diversion (BPD). Objectives: to report our experience in 950 consecutive DS patients with morbid obesity (MO) performed from 1994 to 2011, with 27 years of follow-up. Environment: mix of teaching and private institution in a regional hospital in Spain. Methods: retrospective review of 950 consecutive morbidly obese patients treated with DS surgery. Results: five hundred and eighteen open DS (ODS) and 432 laparoscopic DS (LDS) were performed. Operative mortality was 0.84% (1.38% in ODS and 0.38% in LDS); 4.84% had one leak, two had liver failure (0.2%) and malnutrition was present in 3.1%. At five years, the body mass index (BMI) percentage of lost overweight (%EWL) was 80% and the percentage of expected BMI loss was more than 100%. Conclusions: the DS is the most aggressive bariatric technique but with the best long-term weight loss. Operative complications and long-term follow-up guidelines are described.

INTRODUCCIÓN: Antecedentes: el cruce duodenal (CD) es un procedimiento que combina una gastrectomía vertical (GV) más una derivación biliopancreática (DBP). Objetivos: informar de nuestra experiencia en 950 CD consecutivos en pacientes con obesidad mórbida (OM) realizados de 1994 a 2011 y con 27 años de seguimiento. Entorno: mezcla de enseñanza e institución privada en un hospital comarcal de España. Métodos: revisión retrospectiva de 950 pacientes consecutivos con obesidad mórbida tratados con cirugía de CD. Resultados: se realizaron 518 CD abiertos (CDA) y 432 CD laparoscópicos (CDL). La mortalidad operatoria fue del 0,84% (1,38% en CDA y 0,38% en CDL). El 4,84% tuvo una fuga, dos tuvieron insuficiencia hepática (0,2%) y la desnutrición estuvo presente en el 3,1%. A los cinco años, el porcentaje de sobrepeso perdido (PSP) de índice de masa corporal (IMC) fue del 80% y el porcentaje de pérdida esperada de IMC fue más del 100%. Conclusiones: el CD es la técnica bariátrica más agresiva pero con mejor pérdida de peso a largo plazo. Se describen las complicaciones operatorias y pautas de seguimiento a largo plazo.

Four decades of bariatric surgery in a community hospital of Spain.

INTRODUCTION: Bariatric surgical practice changes in the community setting may be under-reported. We present the developments in a Spanish bariatric surgical practice in the community setting of Alcoy from its origin in 1977 through the present. METHODS: Bariatric surgical techniques employed in a country community setting over the course of nearly four decades were reviewed retrospectively and qualitatively. RESULTS: Surgeons and medical professionals from Alcoy, Spain were involved in the evolution of bariatric surgery patient management and surgical technique from 1977s through 2017. During the last 40 years, 1,475 patients were treated in our clinics. Spanish bariatric surgeons contributed to advances in gastric bypass in the 1970s, vertical banded gastroplasty in the 1980s, bilio-pancreatic diversion/duodenal switch in the 1990s, and innovations associated with laparoscopy from the 1990s onward. Outcomes and approaches to prevention and treatment of bariatric surgical complications are reviewed from a community perspective. Contributions to the bariatric surgical nomenclature and weight-loss reporting are noted. CONCLUSIONS: The practice of bariatric surgery in the community setting must be updated continuously, as in any human and surgical endeavor. Medical professionals in community bariatric practices should contribute their experiences to the field through all avenues of scientific interaction and publication.

Stapling the bougie in sleeve gastrectomy: video.

Laparoscopic sleeve gastrectomy has become the most popular bariatric surgical operation. Based on the lesser curvature, the sleeve is created with endo-staplers, which separate the lesser curvature longitudinally and vertically from the rest of the stomach, including the greater curvature. The use of a bougie (a medical instrument used in an esophageal dilation) helps to calibrate the diameter of the sleeve. Intraoperative bougie stapling is a serious complication that should be prevented; when it happens, correction is mandatory. We present 3 cases with a video.

Sleeve-forming gastrectomy is the right terminology.

Gastric sleeve is the final result when a vertical or sleeve-forming gastrectomy is performed. There is controversy about the nomination of the procedure to make a lesser curvature gastric sleeve (LCS) since the term sleeve gastrectomy, used commonly, is grammatically a misnomer. Lexicon incorrectness should not be accepted scientifically for any nomination. The Spanish Royal Academy of Medicine and seven leaders of the International Federation for the Surgery of Obesity (IFSO) were consulted. Four past IFSO presidents, four chief editors of the Obesity Surgery journal and two presidents of national associations all agree that the sleeve gastrectomy term is a misnomer and sleeve-forming gastrectomy is proposed as the correct term.

Laparoscopic gastric sleeve, subtotal antrectomy and omentoplasty.

Sleeve-forming gastrectomy (SFG) is the operation to make a gastric sleeve (GS). The video presents the subtotal removal of the antrum and the use of sliding self-locking stitch and Aberdeen knots as suture reinforcement with omentoplasty of the GS staple line with the aim of decreasing bleeding and leaks.

Liver failure and transplantation after duodenal switch.

Liver failure (LF) and liver transplant (LT) are rare after a biliopancreatic diversion/duodenal switch procedure for obesity, but occasionally it may happen. Two clinical cases are presented. One patient, 18 years ago, had LF, but a liver donor could not be found, and the patient died. The second patient, 2 years ago, received a successful LT and is now well and asymptomatic. Careful follow-up, medical management and surgical intervention may prevent the occurrence of LF. Transplantation and bowel reversal may be necessary.

[Beginnings of bariatric and metabolic surgery in Spain]. / Inicios de la cirugía bariátrica y metabólica en España.

When bariatric and metabolic surgery initially began in Spain, it was a subject of debate, due to not knowing exactly who were the first surgeons to perform it. A study has revealed the authors of the first interventions.

[Recommendations for the peri-operative management of bariatric surgery patients: results of a national survey]. / Recomendaciones para el manejo perioperatorio de los pacientes de cirugía bariátrica: resultados de una encuesta nacional.

To standardise possible peri-operative bariatric surgery protocols, a survey was prepared to be filled in by members of the Spanish Society for Obesity (Sociedad Española de Cirugía de la Obesidad) (SECO), and to approve it at the XII National Congress. A total of 47 members of SECO from 14 autonomous communities responded, and it unanimously approved by the Congress. As highly recommended peri-operative procedures, were proposed: full laboratory analysis (98%) with an endocrine study (90%), ECG (96%), chest x-ray (98%), an oesophageal-gastric imaging test (endoscopy or gastro-duodenal transit study (98%), antibiotic prophylaxis (92%) and use of low molecular weight heparins pre-operatively (96%), and for 2 weeks (83%). Pre-surgical, abdominal ultrasound (86%), spirometry (80%), diet (88%) and psychological study (76%), and during surgery, use of elastic stockings (76%), leak tests (92%) and drainages (90%), were established as advisable procedures.

Weight loss reporting: predicted body mass index after bariatric surgery.

BMI and %EBMIL are the most accurate methods for comparing results of patients after bariatric surgery. %EBMIL is based on BMI 25 as a constant end-point for all patients, but BMI 25 is easily achieved by patients with BMI < 50, whereas it is not so feasible for patients with BMI > 50. We were prompted to obtain by statistical methods a mathematical formula able to calculate the final BMI (FBMI) 3 years after the operation, dependent on the initial or preoperative BMI (IBMI) of a multicenter group of morbid obese patients operated with different bariatric techniques. We also obtained a specific formula for each bariatric procedure of this group of patients. We propose the name Predicted BMI for the value obtained with these formulas and its application in the %EBMIL instead of the constant value of BMI 25. We have analyzed the IBMI and FBMI of a multicenter group of 7,410 patients, subjected to different bariatric procedures with a minimum follow-up of 36 months. Statistical methods with a linear regression model have been used to obtain the two types (global and specific) of Predicted BMI. We first obtained a general formula of PBMI = IBMI x 0.4 + 11.75 for the total population of patients, and a second specific formula for each bariatric technique: PBMI = IBMI x 0.43 + 13.25 + technique_correction_adjustment. Predicted BMI and its application to the %EBMIL may result in a more rational comparison of results of bariatric patients, bariatric techniques, and groups of bariatric surgeons. Predicted BMI may advance the BMI that each patient would probably achieve after surgery.

Dilated upper sleeve can be associated with severe postoperative gastroesophageal dysmotility and reflux.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is an effective bariatric procedure, and it can be done as an isolated LSG or in conjunction with biliopancreatic diversion bypass/duodenal switch (laparoscopic duodenal switch; LDS). Gastroesophageal reflux after LSG has been described, but the mechanism is unknown and the treatment in the severest cases has not been discussed. We describe a cohort of patients who have underwent an LSG or LDS, and have suffered from a severe postoperative gastroesophageal motility disorder and/or reflux, report on their treatment, and discuss possible underlying mechanisms. METHODS: Seven hundred and six patients underwent an LSG by two of the authors (AK, AB). Sixty nine patients underwent laparoscopic sleeve gastrectomy in Hadassah Medical Center, Jerusalem, Israel (January, 2006 and December 2008; 55 isolated LSG, 14 with LDS), and 637 (212 isolated LSG, 425 LDS) in Clinica San Jorge and Alcoy Hospital in Alcoy, Spain, (January 2002 and November 2008). RESULTS: Of them, eight patients who has suffered from a gastroesophageal dysmotility and reflux disease postoperatively and needed a specific treatment besides regular proton pump inhibitors (PPIs) were identified (1.1%). CONCLUSION: A combination of dilated upper part of the sleeve with a relative narrowing of the midstomach, without complete obstruction, was common to all eight patients who suffered from a severe gastroesophageal dysmotility and reflux. The sleeve volume, the bougie size, and the starting point of the antral resection do not seem to have an effect in this complication. Operative treatment was needed in only one case out of eight; in the rest of the patients, medical modalities were successful. More knowledge is required to understand the underlying mechanisms.

[Expected body mass index after bariatric surgery]. / Indice de masa corporal esperable tras cirugía bariátrica.

INTRODUCTION: The body mass index (BMI) is the most practical method to measure and compare obesity between individuals. The Percentage of Excess BMI Loss (PEBMIL) is used to present results in operated patients and is based on the premise that a BMI-25 is the final aim, on being the upper limit in normal subjects. It is possible to achieve a BMI-25 in morbid obese (MO) patients with initial low BMIs (<50) but it is rare in overweight (OW) patients with a BMI>50. Expected BMI (EBMI) would be that which should be reached by all subjects depending on their initial BMI. OBJECTIVE: The objective of this study is to search for, using statistical methods, a formula based on clinical evidence that can identify the EBMI depending on the initial BMI. PATIENTS AND METHOD: We analysed the initial and final BMI in a group of 135 MO patients, operated on using the duodenal switch procedure and with a follow up of over 3 years. A linear regression method has been used to obtain a formula that could calculate the EBMI of each patient operated on. RESULTS: We obtained an algorithm in which EBMI=Initial BMIx0.33+14. If we apply the individualised EBMI instead of the BMI-25, the median PEBMIL was 99.48 (range: 76.75-110.46). CONCLUSION: This result suggests that the application of an individual EBMI is a more reliable estimate of the success or failure of bariatric operations.

Short- and mid-term outcomes of sleeve gastrectomy for morbid obesity: the experience of the Spanish National Registry.

BACKGROUND: Reports on laparoscopic sleeve gastrectomy (LSG) communicate very good short-term results on very high-risk morbid obese patients. However, mid- and long-term results are still unknown. A National Registry has been created in Spain to achieve information on the outcomes of this bariatric procedure. METHODS: Data were obtained from 17 centers and collected in a database. Technical issues, preoperative comorbid conditions, hospital stay, early and late complications, and short- and mid-term weight loss were analyzed. RESULTS: Five hundred forty patients were included; 76% were women. Mean BMI was 48.1 +/- 10. Mean age was 44.1 +/- 11.8. Morbidity rate was 5.2% and mortality rate 0.36%. Complications presented more frequently in superobese patients (OR, 2.8 (1.18-6.65)), male (OR, 2.98 (1.26-7.0)), and patients >55 years old (OR, 2.8 (1.14-6.8)). Staple-line reinforcement was related to a lower complication rate (3.7 vs 8.8%; p = 0.039). Mean hospital stay was 4.8 +/- 8.2 days. Mean follow-up was 16.5 +/- 10.6 months (1-73). Mean percent excess BMI loss (EBL) at 3 months was 38.8 +/- 22, 55.6 +/- 8 at 6 months, 68.1 +/- 28 at 12 months, and 72.4 +/- 31 at 24 months. %EBL was superior in patients with lower initial BMI and lower age. Bougie caliber was an inverse predictive factor of %EBL at 12 and 24 months (RR, 23.3 (11.4-35.2)). DM is remitted in 81% of the patients and HTA improved in 63.2% of them. A second-stage surgery was performed in 18 patients (3.2%). CONCLUSIONS: LSG provides good short- and mid-term results with a low morbid-mortality rate. Better results are obtained in younger patients with lowest BMI. Staple-line reinforcement and a thinner bougie are recommended to improve outcome.