Comparing the Efficacy and Safety of Roux-en-Y Gastric Bypass with One-Anastomosis Gastric Bypass with a Biliopancreatic Limb of 200 or 160 cm: 1-Year Results of the Tehran Obesity Treatment Study (TOTS).

PURPOSE: One-anastomosis gastric bypass (OAGB) has raised concerns about nutritional complications possibly attributed to the biliopancreatic limb (BPL) length. We aimed to assess the results of a conservative approach of OAGB compared with the original OAGB and Roux-en-Y gastric bypass (RYGB) in a 1-year follow-up study. MATERIALS AND METHODS: This retrospective study was conducted based on prospectively maintained data in a cohort of patients who underwent either RYGB with a Roux limb of a 150 cm and a BPL of 50 cm (n = 145), OAGB with a 200-cm BPL (n = 272), or OAGB with a 160-cm BPL (n = 383), from March 2013 to 2017 at three university hospitals by a single surgical team. RESULTS: Groups were comparable regarding age and sex. Mean preoperative body mass indexes of the RYGB, OAGB-160, and OAGB-200 groups were 44.5 ± 5.8, 45.6 ± 6.3, and 46.7 ± 6.4 kg/m2, respectively. One-year follow-up rates were 83.4%, 85.3%, and 82.5% for the RYGB, OAGB-200, and OAGB-160 groups, respectively. One-year percent total weight loss values were 33.8 ± 6.7 after OAGB-160 and 35.3 ± 6.9 after OAGB-200 (P = 0.056), which were significantly greater compared with 30.9 ± 8.9 after RYGB (P < 0.001). All groups were comparable regarding remission of type 2 diabetes mellitus, hypertension, dyslipidemia, and fatty liver. Mean operative time was longer with RYGB than with either OAGB techniques. Groups were comparable for postoperative complications except for the incidence of protein-calorie malnutrition (PCM), occurring in 11 patients (4.7%) after OAGB-200, 7 of whom required revisional surgery, in one patient (0.3%) after OAGB-160 who responded to parenteral alimentation, but in no patients after RYGB. CONCLUSION: After 1 year, OAGB with a 160-cm BPL was as effective as OAGB with a 200-cm BPL and RYGB, but safer than OAGB-200. This approach also avoided the need for revisional surgery following postoperative malnutrition.

Longitudinal Comparison of the Effect of Gastric Bypass to Sleeve Gastrectomy on Liver Function in a Bariatric Cohort: Tehran Obesity Treatment Study (TOTS).

BACKGROUND: Patients with morbid obesity commonly have fatty liver disease and elevated liver enzymes. While surgery effectively induces weight loss, bariatric techniques may differ regarding liver function improvement. OBJECTIVES: To evaluate and compare the trends of liver function recovery after gastric bypass surgery (GB) with sleeve gastrectomy (SG). SETTING: University hospitals, Iran. METHODS: Adult bariatric candidates without a history of alcohol consumption or other etiologies of liver disease who underwent SG (n = 682) or GB (n = 355) were included. Trends of weight loss parameters and alanine transaminase (ALT), aspartate transaminase (AST), and alkaline phosphatase (ALP) at 0, 6 (in 90.4%), 12 (in 83.5%), and 24 months (in 67.1%) were compared using generalized estimating equations method. RESULTS: Overall, 1037 patients with mean age of 38.4 ± 11.2 and mean body mass index of 44.9 ± 6.2 kg/m2 were analyzed. Seventy-eight percent of patients had fatty liver by ultrasound. Both GB and SG patients lost significant weight, with GB patients having a higher percentage of excess weight loss at 24 months (80.1% vs. 75.9%, Pbetween-group = .008). SG patients showed more favorable trends in liver chemistries with significantly lower ALT at 12 months and AST and ALP levels at 6 and 12 months. However, the two groups were comparable at 24 months. Significantly more GB patients developed high ALT at 6 and high AST at 6 and 12 months. Undergoing GB was associated with smaller 0-12-month changes in ALT, AST, and ALP. CONCLUSIONS: Bariatric surgery resulted in improvement in liver function parameters, with SG showing advantages over GB in the first postoperative year.

Biopsy-proven progressive fatty liver disease nine months post mini-gastric bypass surgery: A case study.

INTRODUCTION: Mini-gastric bypass (MGB) is a popular bariatric procedure. Its effect on non-alcoholic fatty liver disease (NAFLD), however, has not yet been comprehensively studied. PRESENTATION OF CASE: A 57 year-old non-alcoholic female with a body mass index of 42.8kg/m2 underwent MGB without any incident. A concurrent liver biopsy showed an NAFLD activity score (NAS) of 2/8 without fibrosis. She presented at postoperative month eight with edema, vague abdominal pain, nausea, and vomiting and was hospitalized. Her BMI had dropped to 25.7kg/m2. Her blood workup revealed mild anemia, mildly elevated liver enzymes, and hypoalbuminemia (2.5g/dL). Liver ultrasound revealed grade-2 fatty liver. She received parenteral nutrition and intensive nutrient supplementation. Nevertheless, with regard to unsuccessful supportive measures and rising liver enzymes, revisional surgery -gastrogastrostomy- was performed. Her liver biopsy demonstrated a NAS of 7/8 at the time of revisional surgery. Her postoperative course was uneventful and she was discharged after one week. DISCUSSION: Bariatric surgery has shown favorable results regarding improvement of NAFLD in morbid obesity. This beneficial effect has been linked to the amount of weight loss. However, case reports have shown deteriorating liver function and NAFLD even after significant weight loss. They all have in common significant weight loss in a relatively short period of time. There may also be a connection between specific bariatric surgery procedures and this phenomenon. CONCLUSION: Future studies comparing the effect of various bariatric procedures, including MGB, are necessary to help clinicians decide the optimal procedure for patients with this liver condition.

Severe fatal protein malnutrition and liver failure in a morbidly obese patient after mini-gastric bypass surgery: Case report.

INTRODUCTION: Mini-gastric bypass (MGB) is a bariatric surgical technique popular in many centers due to shorter duration, easier technique, and excellent weight loss results. However, it may be associated with postoperative malnutrition. This case describes the clinical course and unfortunate outcome of a morbidly obese patient who underwent MGB and developed malnutrition in the first postoperative year. PRESENTATION OF CASE: A 37 year-old female patient with a BMI of 44kg/m2 successfully underwent MGB surgery in June 2015 and was discharged uneventfully. She presented with lower extremity edema and generalized weakness 8 months later, with a blood albumin level of 3.1g/dL, compared to a normal preoperative value. She was admitted and received a high-protein diet, and her clinical condition improved. Three months after her discharge, she was readmitted with the same complaints, as well as pancytopenia. She was also hypocupremic. After unsuccessful intensive supportive measures, she finally underwent revisional gastrogastrostomy. However, she developed signs and symptoms of profound liver failure postoperatively (albumin 1.8g/dL; total bilirubin 7.5mg/dL; prothrombin time 34s) and pancytopenia persisted. All resuscitative measures were unsuccessful and she expired in July 2016. DISCUSSION: Multiple factors can contribute to postoperative malnutrition and liver dysfunction after MGB, including the presence of baseline liver disease, inadequate diet supplementation, leaving a too-short common small intestinal channel, and ethnic variations in small bowel length. These factors should also be considered when deciding to perform corrective surgery. CONCLUSION: Careful, individualized treatment and follow-up plans may help to prevent such catastrophic consequences.

Comparison of the Effect of Gastric Bypass and Sleeve Gastrectomy on Metabolic Syndrome and its Components in a Cohort: Tehran Obesity Treatment Study (TOTS).

INTRODUCTION: Metabolic syndrome (MetS) is a prevalent counterpart of morbid obesity. With the surgical technique of sleeve gastrectomy (SG) gaining widespread acceptance for weight loss in morbid obese patients, we aimed to undertake a study to compare its effectiveness to gastric bypass (GB) for metabolic control in these patients. METHODS: A total of 425 patients from a prospectively collected database of morbid obese subjects between 18 and 65 years of age undergoing a primary bariatric procedure from March 2013 to September 2015 were included. Statistical analysis was performed using general estimation equation and propensity scores, and odds ratios were calculated. RESULTS: Three hundred nineteen patients underwent SG and 106 underwent GB. Mean age of the patients was 37.8 ± 11.7, and mean body mass index (BMI) was 44.3 ± 5.9 kg/m2. MetS was present in 61.4% of patients and diabetes mellitus in 48.6%. MetS prevalence decreased from 60 and 64% in the SG and GB groups to 16 and 10% at 12 months, respectively. These improvements were consistent throughout the study period in both groups, with no significant difference between the two groups (for all variables: P trend < .001, P interaction > .05). After propensity score-adjusted analysis, neither surgical technique showed superiority over the other regarding metabolic improvement (OR for MetS resolution: 0.81, 95% CI: 0.49-1.34). CONCLUSIONS: In this short-term study with 1-year follow-up, SG showed similar results to GB in terms of weight loss, MetS resolution, and glycemic control in a large Middle Eastern cohort. Long-term studies are needed to further investigate the effectiveness of SG in this regard.

Novel jejunoduodenostomy technique for prevention of duodenal stump blowout following gastrectomy.

INTRODUCTION: Many patients undergo gastrectomy every year with a risk of duodenal stump blowout. We compared the conventional surgical techniques with a new and simple method of reconstruction to prevent this complication. METHODS: We reviewed the medical records of all the patients who underwent gastrectomy from 2002 to 2013 (total or partial distal gastrectomies with Billroth II, Roux-en-Y, and our new technique of reconstruction) in Shohada Tajrish University hospital, Tehran, Iran. RESULTS: A total of 179 patients were eligible for the study: 101 had undergone the new technique (study group) and 78 had undergone the conventional methods (control group). There were three cases of duodenal stump blowout, all in the control group (4 %, P<0.05). One was fatal (1 %). The post-operative hospital stay was significantly shorter in the study group (8.93 vs. 11.51 days, P<0.05). DISCUSSION: Our results show that this new technique can effectively prevent duodenal stump blowout. Other advantages of this technique include the maintenance of physiological passage of food and a safe route for future diagnostic and therapeutic endoscopic interventions. CONCLUSIONS: We present a simple technique that eliminates the risk of duodenal stump blowout. Randomized controlled trials are necessary to confirm our findings.