Patient Perspectives on Adherence with Micronutrient Supplementation After Bariatric Surgery.

BACKGROUND: Adherence to post-bariatric surgery nutritional supplements can be poor and is associated with higher micronutrient deficiency rates. There is currently no available study specifically seeking patients' perspectives on the reasons behind poor adherence and how to address it. METHODS: Bariatric surgery patients living in the UK were invited to take part in an anonymous survey on SurveyMonkey®. RESULTS: A total of 529 patients (92.61% females, mean age 47.7 years) took part. Most of these patients had undergone either a Roux-en-Y gastric bypass (63.0%) or sleeve gastrectomy (24.0%). Most of the patients were in full-time (49.0%, n = 260/529) or part-time (15.7%, n = 83/529) employment. Approximately 54.0% (n = 287/529) of the respondents reported having trouble taking all their supplements. Males were significantly more likely to report complete compliance. The most important reported reason for poor compliance was difficulty in remembering (45.6%), followed by too many tablets (16.4%), side effects (14.3%), cost (11.5%), non-prescribing by GP (10.8%), bad taste (10.1%), and not feeling the need to take (9.4%). Patients suggested reducing the number of tablets (41.8%), patient education (25.7%), GP education (24.0%), reducing the cost (18.5%), and more information from a healthcare provider (12.5%) or a pharmacist (5.2%) to improve the compliance. CONCLUSIONS: This study is the first attempt to understand patient perspectives on poor adherence to post-bariatric surgery nutritional recommendation. Patients offered a number of explanations and also provided with suggestions on how to improve it.

Impact of biliopancreatic limb length on severe protein-calorie malnutrition requiring revisional surgery after one anastomosis (mini) gastric bypass.

BACKGROUND: One anastomosis (mini) gastric bypass (OAGB) is believed to be more malabsorptive than Roux-en-Y gastric bypass. A number of patients undergoing this procedure suffer from severe protein-calorie malnutrition requiring revisional surgery. The purpose of this study was to find the magnitude of severe protein-calorie malnutrition requiring revisional surgery after OAGB and any potential relationship with biliopancreatic limb (BPL) length. METHODS: A questionnaire-based survey was carried out on the surgeons performing OAGB. Data were further corroborated with the published scientific literature. RESULTS: A total of 118 surgeons from thirty countries reported experience with 47,364 OAGB procedures. Overall, 0.37% (138/36,952) of patients needed revisional surgery for malnutrition. The highest percentage of 0.51% (120/23,277) was recorded with formulae using >200 cm of BPL for some patients, and lowest rate of 0% was seen with 150 cm BPL. These data were corroborated by published scientific literature, which has a record of 50 (0.56%) patients needing surgical revision for severe malnutrition after OAGB. CONCLUSIONS: A very small number of OAGB patients need surgical correction for severe protein-calorie malnutrition. Highest rates of 0.6% were seen in the hands of surgeons using BPL length of >250 cm for some of their patients, and the lowest rate of 0% was seen with BPL of 150 cm. Future studies are needed to examine the efficacy of a standardised BPL length of 150 cm with OAGB.

Perioperative Practices Concerning One Anastomosis (Mini) Gastric Bypass: A Survey of 210 Surgeons.

BACKGROUND: There is currently little evidence available on the perioperative practices concerning one anastomosis/mini gastric bypass (OAGB/MGB) and no published consensus amongst experts. Even the published papers are not clear on these aspects. The purpose of this study was to understand various perioperative practices concerning OAGB/MGB. METHODS: Bariatric surgeons from around the world were invited to participate in a questionnaire-based survey. Only surgeons performing this procedure were included. RESULTS: Two hundred and ten surgeons from 39 countries with a cumulative experience of 68,442 procedures took the survey. Surgeons described a large number of absolute (n = 55) and relative contraindications (n = 59) to this procedure in their practice. Approximately 71.0% (n = 148/208), 70.0% (n = 147/208) and 65.0% (n = 137/209), respectively, routinely perform a preoperative endoscopy, screening for Helicobacter pylori and ultrasound scan of the abdomen. A minority (35.0%, n = 74/208) of the surgeons used a constant bilio-pancreatic limb (BPL) length for all the patients with remaining preferring to tailor the limb length to the patient and approximately half (49.0%, n = 101/206) routinely approximate diaphragmatic crura in patients with hiatus hernia. Some 48.5% (n = 101/208) and 40.0% (n = 53/205) surgeons, respectively, do not recommend routine iron and calcium supplementation. CONCLUSION: This survey is the first attempt to understand a range of perioperative practices with OAGB/MGB. The findings will help in identifying areas for future research and allow consensus building amongst experts with preparation of guidelines for future practice.

Bariatric Surgery in Septuagenarians: a Comparison with <60 Year Olds.

INTRODUCTION: There is reluctance amongst many healthcare professionals to offer bariatric surgery to septuagenarians. There is only one study in the scientific literature specifically describing any experience with this group of patients and none that compares the outcomes in this group with younger patients. METHODS: We retrospectively examined our prospective database to identify all those who were >70 years old at the time of bariatric surgery. This group was then compared with a matched (for sex, body mass index, surgical procedure, and time of surgery) cohort of younger (<60 year old) patients. Information was obtained from our database, case notes, hospital electronic records, by interviewing team members, and from general practitioners. RESULTS: A total of 10 septuagenarians were compared with 10 younger patients (mean age 41 years). There were one early complication and 1 late complication in the over 70 group as opposed to no early complication and 2 late complications in the younger group. There was no mortality or early reoperation in either group. Excess weight loss of 50.4, 67.4, and 74.0% in the >70 age group at 6, 12, and 24 months, respectively, was no different to 51.3, 70.8, and 73.9% in <60 year olds. The effect on the co-morbidity resolution was similar in the two groups. CONCLUSION: In carefully selected septuagenarians, bariatric surgery can be performed with safety and efficacy comparable to those <60 years old.

Understanding Objections to One Anastomosis (Mini) Gastric Bypass: A Survey of 417 Surgeons Not Performing this Procedure.

BACKGROUND: Despite published experience with thousands of patients, the uptake of One Anastomosis/Mini Gastric Bypass (OAGB/MGB) has been less than enthusiastic and many surgeons still harbour objections to this procedure. The purpose of this study was to understand these objections scientifically. METHODS: Bariatric surgeons from around the world were invited to participate in a questionnaire-based survey on SurveyMonkey®. Surgeons already performing this procedure were excluded. RESULTS: Four hundred seventeen bariatric surgeons (from 42 countries) not currently performing OAGB/MGB took the survey. There were 211/414 (50.97%) and 188/414 (45.41%) respondents who expressed concerns that it will lead to an increased risk of gastric and oesophageal cancers respectively. A total of 62/416 (14.9%) and 201/413 (n = 48.6%) surgeons respectively felt that OAGB/MGB was associated with a higher early (30-day) and late complication rate compared to the RYGB. Moreover, 7.8% (n = 32/411) and 16.26% (n = 67/412) of the respondents were concerned that OAGB/MGB carried a higher early (30-day) and late mortality, respectively, in comparison with the RYGB. There were 79/410 (19.27%) and 88/413 (21.3%) respondents who were concerned that OAGB/MGB was not an effective procedure for weight loss and co-morbidity resolution, respectively. A total of 258/411 (62.77%) respondents reported that OAGB/MGB was not approved by their national society as a mainstream bariatric procedure; 51.0% of these surgeons would start performing this procedure if it was. CONCLUSIONS: Surgeons not performing OAGB/MGB cite a number of concerns for not performing this operation. This survey is the first scientific attempt to understand these objections scientifically.

Management of super-super obese patients: comparison between one anastomosis (mini) gastric bypass and Roux-en-Y gastric bypass.

BACKGROUND: Gastric bypass can be technically challenging in super-super obese patients. Both Roux-en-Y gastric bypass (RYGB) and one anastomosis (mini) gastric bypass (OAGB/MGB) have been described in these patients, but direct comparisons are lacking. The purpose of this study was to compare the early outcomes with these two procedures in patients with body mass index (BMI) of ≥60 kg/m2 in our unit. METHODS: We identified all super-super obese patients who underwent either OAGB/MGB or RYGB from our prospectively maintained database. Information was also obtained from the case notes and from hospital computerized records. We obtained data regarding patient demographics, operative details, complications, and weight loss, in both groups, and compared them using standard statistical methods. RESULTS: This study compares our results with 19 OAGB/MGB and 47 RYGB super-super obese patients performed in our unit between October 2012 and June 2015. OAGB/MGB group patients had a significantly higher weight and body mass index. There was no mortality or major complication in either group. There were two late complications in the OAGB/MGB group compared to six in the RYGB group. One patient in the OAGB/MGB group needed conversion to RYGB for persistent reflux symptoms. OAGB/MGB patients achieved a significantly higher EWL of 70.4% at 2 years compared to 57.1% in the RYGB group. The difference between TWL of 44.4 and 33.4%, respectively, was also significant at 2 years. TWL of 43.0 and 29.3%, respectively, in OAGB/MGB and RYGB groups at 18 months was also significantly different, but the difference in EWL at 18 months did not reach significance. CONCLUSION: One anastomosis (mini) gastric bypass yields superior weight loss at 18 and 24 months in comparison with Roux-en-Y gastric bypass in patients with BMI of ≥60 kg/m2. Findings need confirmation in larger randomized studies.

Monitoring of Liver Function Tests after Roux-en-Y Gastric Bypass: An Examination of Evidence Base.

There is no consensus on the monitoring of liver function tests after Roux-en-Y gastric bypass (RYGB). Since the main objective of such monitoring would be to diagnose early those who will eventually develop liver failure after RYGB, we performed a systematic review on this topic. An extensive search of literature revealed only 10 such cases in 6 published articles. It would hence appear that liver failure is a rare problem after RYGB. Routine lifelong monitoring of liver function tests is therefore unnecessary for otherwise asymptomatic individuals. Such monitoring should hence be reserved for high-risk groups, such as patients with liver cirrhosis, those undergoing extended limb/distal RYGB, patients with new illnesses, those abusing alcohol, those on hepatotoxic drugs and those presenting with a surgical complication.

Management of Super-super Obese Patients: Comparison Between Mini (One Anastomosis) Gastric Bypass and Sleeve Gastrectomy.

Management of super-super obese patients poses a particular challenge for bariatric surgeons. Many staged algorithms exist for these patients. Essentially all of these involve a lower-risk procedure like sleeve gastrectomy first before a definitive second-stage procedure like gastric bypass or duodenal switch. This study compares our results with 19 mini (one anastomosis) gastric bypass and 56 sleeve gastrectomy in super-super obese patients. Sleeve gastrectomy patients were significantly older. There was no mortality or major complication in either group. There was no minor complication in mini (one anastomosis) gastric bypass group compared to two in the sleeve gastrectomy group. Mini (one anastomsosis) gastric bypass patients experienced significantly higher weight loss compared to sleeve gastrectomy patients at 6 months, 1 year, and 2 years after surgery.

Small Bowel Limb Lengths and Roux-en-Y Gastric Bypass: a Systematic Review.

There is currently no consensus on the combined length of small bowel that should be bypassed as biliopancreatic or alimentary limb for optimum results with Roux-en-Y gastric bypass. A number of different limb lengths exist, and there is significant variation in practice amongst surgeons. Inevitably, this means that some patients have too much small bowel bypassed and end up with malnutrition and others end up with a less effective operation. Lack of standardisation poses further problems with interpretation and comparison of scientific literature. This systematic review concludes that a range of 100-200 cm for combined length of biliopancreatic or alimentary limb gives optimum results with Roux-en-Y gastric bypass in most patients.

Routine Liver Biopsy During Bariatric Surgery: an Analysis of Evidence Base.

Non-alcoholic fatty liver disease and non-alcoholic steato-hepatitis are common in patients undergoing bariatric surgery. Non-alcoholic steato-hepatitis can progress to cirrhosis of the liver and hepatocellular carcinoma. Non-invasive methods of diagnosing non-alcoholic steato-hepatitis are not as accurate as liver biopsy, and bariatric surgery presents a unique opportunity to carry out a simultaneous liver biopsy. Routine liver biopsy can help early and accurate diagnosis of obesity-associated liver conditions. This has led some surgeons to argue for routine liver biopsy at the time of bariatric surgery. However, most bariatric surgeons remain unconvinced and liver biopsy is currently not routine practice with bariatric surgery. This review examines published scientific literature to ascertain the usefulness of routine liver biopsy at the time of bariatric surgery.

Bariatric Surgery in Type 1 Diabetes Mellitus: A Systematic Review.

Bariatric surgery is recognised as an effective treatment strategy for obese patients with type 2 diabetes mellitus. An increasing number of patients with type 1 diabetes mellitus also suffer with obesity and obesity-associated comorbidities but the role of bariatric and metabolic surgery in this group of patients is unclear. This systematic review investigates published English language scientific literature to understand the results of bariatric surgery in obese patients with type 1 diabetes mellitus. We found that these patients can experience significant weight loss and comorbidity resolution with bariatric surgery. Though most patients also see a decline in total insulin requirement, glycaemic control remains difficult. Most of the patients reported in literature have undergone gastric bypass but data is insufficient to recommend any particular procedure.

Preoperative Interventions for Patients Being Considered for Bariatric Surgery: Separating the Fact from Fiction.

Preoperative interventions aimed at patients referred for bariatric surgery continue to divide funders, commissioners, and practitioners alike. A number of preoperative interventions and variables have been used to influence patient selection. Many of these are believed to lead to better postoperative outcomes by helping target a limited resource (bariatric surgery) at those most likely to benefit. Inevitably, this leads to competition amongst patients and some being denied benefits of surgery. There is a risk that these strategies for resource allocation may actually deprive the most vulnerable and those most in need. This review examines evidence and justification behind popular preoperative interventions for patients being considered for bariatric surgery patients in the light of published English language scientific literature.

Revisional Roux-en-Y Gastric Bypass and Sleeve Gastrectomy: a Systematic Review of Comparative Outcomes with Respective Primary Procedures.

Though primary bariatric surgery is now firmly established as the first-line treatment for morbid obesity, this is not the case with revisional bariatric surgery. Despite proven benefits and patient demand, revisional bariatric surgery continues to attract controversy. Even though it is widely believed to be riskier and less effective than primary bariatric surgery, there is currently no systematic review in literature addressing this point. This review aims to establish outcomes after revisional bariatric surgery in comparison with those after primary bariatric surgery. Since Roux-en-Y gastric bypass or sleeve gastrectomy is currently the commonest anatomy achieved after revisional bariatric surgery, this review focuses on the outcome of revisional Roux-en-Y gastric bypass and revisional sleeve gastrectomy in comparison with respective primary procedures.

A retrospective comparison of early results of conversion of failed gastric banding to sleeve gastrectomy or gastric bypass.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is associated with high long-term failure rates requiring conversion to alternative procedures. Operative conversion to laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric (LRYGB) bypass is associated with higher complication rates than primary procedures. OBJECTIVES: To compare results for converting failed LAGB to LSG versus LRYGB. SETTING: University Hospital, United Kingdom, National Health Service. METHODS: All patients undergoing conversion of LAGB to LRYGB and LSG from July 2006 to September 2012 were included. A retrospective analysis of our prospectively maintained database was performed to identify differences in death rates, complication rates, length of hospital stay, and weight loss. Within this study LRYGB was the preferred choice for conversion and LSG was only considered in the presence of significant intraabdominal adhesions, because of patient choice, or in patients with contraindications to LRYGB. RESULTS: Eighty-nine patients with failed LAGB underwent conversional surgery within this period. Of these, 64 patients underwent conversion to LRYGB and 25 underwent conversion to LSG. There was no statistical difference in percentage of excess weight loss at 1 or 2 years after conversional surgery to LSG or LRYGB. Conversion to LRYGB was carried out as a single procedure in 51/64 (80%) compared with 10/25 (40%) for conversion to LSG (P = .003). One postoperative complication occurred requiring reoperation after conversion to LRYGB. CONCLUSION: There was no difference in complication rates, hospital stay, and early weight loss when converting failed LAGB to LRYGB or LSG. Both procedures are appropriate for conversion from LAGB, although a staged approach is often needed, especially for LSG.

Simultaneous sleeve gastrectomy and hiatus hernia repair: a systematic review.

Sleeve gastrectomy can exacerbate gastro-oesophageal reflux disease in some patients and cause de novo reflux in others. Some surgeons believe Roux-en-Y gastric bypass is the best bariatric surgical procedure for obese patients with hiatus hernia. Others believe that even patients with hiatus hernia can also be safely offered sleeve gastrectomy if combined with a simultaneous hiatus hernia repair. Still, others will offer these patients sleeve gastrectomy without any attempt to diagnose or repair hiatus hernia repair. The effectiveness of concurrent hiatal hernia repair in reducing the incidence of postoperative reflux after sleeve gastrectomy is unclear. This review systematically investigates the results and techniques of simultaneous sleeve gastrectomy and hiatus hernia repair for the treatment of obesity in accordance with PRISMA guidelines.

Primary banded Roux-en-Y gastric bypass: a systematic review.

Primary banding of Roux-en-Y gastric bypass remains controversial. Though there are surgeons who believe it should be the standard practice as it results in superior weight loss and prevents weight regain in the long term, there are others who are concerned about the risk of food intolerance and complications related to band. This review investigates published English language literature systematically to find out the advantages and disadvantages of primary banding of a Roux-en-Y gastric bypass.