Prognostic factors of weight loss after sleeve gastrectomy: Multi centre study in Spain and Portugal. / Factores predictivos de pérdida ponderal tras la gastrectomía vertical. Estudio multicéntrico hispano-portugués.

INTRODUCTION: Sleeve gastrectomy (SG) has become a technique in its own right although a selective or global indication remains controversial. The weight loss data at 5 years are heterogeneous. The aim of the study is to identify possible prognostic factors of insufficient weight loss after SG. METHODS: A SG retrospective multicenter study of more than one year follow-up was performed. Failure is considered if EWL>50%. Univariate and multivariate study of Cox regression were performed to identify prognostic factors of failure of weight loss at 1, 2 and 3 years of follow up. RESULTS: A total of 1,565 patients treated in 29 hospitals are included. PSP per year: 70.58±24.7; 3 years 69.39±29.2; 5 years 68.46±23.1. Patients with EWL<50 (considered failure): 17.1% in the first year, 20.1% at 3 years, 20.8% at 5 years. Variables with influence on the weight loss failure in univariate analysis were: BMI>50kg/m2, age>50years, DM2, hypertension, OSA, heart disease, multiple comorbidities, distance to pylorus> 4cm, bougie>40F, treatment with antiplatelet agents. The reinforcement of the suture improved results. In multivariate study DM2 and BMI are independent factors of failure. CONCLUSION: The SG associates a satisfactory weight loss in 79% of patients in the first 5 years; however, some variables such as BMI>50, age>50, the presence of several comorbidities, more than 5cm section of the pylorus or bougie>40F can increase the risk of weight loss failure.

Effectiveness and efficiency of a special program to reduce the bariatric surgery waiting list at a tertiary hospital. / Eficacia y eficiencia de un programa especial para la disminución de la lista de espera de cirugía bariátrica en un hospital terciario.

INTRODUCTION: Bariatric surgery is one of the most common surgical practices in Spain. However, this procedure currently has longest delay on surgical waiting lists (SWL). We have developed a special surgical program that aims to reduce this waiting list and to assess the economic and clinical repercussions in a high-volume bariatric surgery unit. METHODS: A three-month prospective study was carried out comparing outcomes, results and perioperative resources consumed for 45 patients who underwent bariatric surgery. The patients were divided into 2 groups: patients who underwent the standard procedure in the operating room, and patients treated in the special program. Epidemiological, healthcare and economic factors were taken into account. RESULTS: Two homogeneous groups of patients were operated on, successfully reducing the SWL. Morbidity was similar in both groups and the average cost of the surgeries performed was €5,331.40; in the standard group, the cost was €5,372.50±€798.10, and the cost of the special program group was €5,290.30±€685.10, with no significant differences. CONCLUSIONS: In hospitals with a high volume of bariatric surgery, it is feasible to incorporate special surgical programs that are able to reduce surgical waiting lists, while maintaining quality criteria and without incurring a greater expense to the healthcare system.

Intraoperative Scintigraphy With Portable Gamma Camera for the Localization of Interaortocaval Paraganglioma.

ABSTRACT: A 15-year-old adolescent girl diagnosed of interaortocaval paraganglioma with a positive 123I-MIGB SPECT/CT and 1 unsuccessful prior surgery was operated on with the assistance of a handheld gamma camera. Once the lesion was located and removed, 2 images were taken, one of the surgical field (without 123I-MIGB uptake) and another of the tumor ex vivo (with high 123I-MIGB uptake), confirming that the lesion had been satisfactorily excised. This case highlights the use of a portable gamma camera as a useful tool to locate this rare tumor, with a SPECT/CT positive for 123I-MIGB and a difficult anatomical location suspected.

Clinical symptoms are correlated with gastrojejunal anastomosis complications only during the first year after laparoscopic Roux-en-Y gastric bypass.

INTRODUCTION: Introduction: after laparoscopic Roux-en-Y gastric bypass (LRYGBP) many patients complain of epigastric pain or food intolerance, leading to the performance of upper gastrointestinal (UGI) endoscopy. Objective: this study aims to assess which symptomatology as reported by LRYGBP patients during follow-up suggested correlation with pathological findings of endoscopy, and which factors might play a role, taking the timing of symptom presentation into account. Materials and methods: a retrospective cohort study was performed identifying LRYGBP patients presenting with food intolerance and/or epigastric pain who had undergone endoscopy. Primary outcomes were endoscopy findings, their association with patient characteristics, and timing of symptom presentation. Results: of the 514 patients complaining of epigastric pain and/or food intolerance, 81 (15.6 %) underwent endoscopy. A gastrojejunostomy complication was found in 58 % of cases. All patients who complained about food intolerance and epigastric pain presented pathological findings. The only preoperative factor associated with a gastrojejunostomy complication was being a smoker (p = 0.021). Time between surgery and endoscopy was also a predictive factor for endoscopic pathological findings (p = 0.007); in cases of epigastric pain, symptom onset during the first year (median: 10 months) was related to increased risk of gastrojejunal complications (p < 0.05). Conclusions: endoscopies performed within one year of surgery were significantly more likely to reveal pathological findings than endoscopies performed after the first postoperative year, especially in patients experiencing epigastric pain.

INTRODUCCIÓN: Introducción: tras un baipás gástrico laparoscópico en "Y de Roux" muchos pacientes refieren dolor epigástrico o intolerancia alimenticia, lo que motiva la realización de una endoscopia digestiva alta. Objetivos: el objetivo de este estudio es intentar establecer una relación entre la sintomatología referida por los pacientes sometidos a baipás gástrico con los hallazgos endoscópicos patológicos y conocer qué factores pueden estar implicados, considerando el momento de presentación. Material y métodos: estudio retrospectivo de cohortes, identificando a los pacientes sometidos a baipás gástrico laparoscópico que presentan dolor epigástrico o intolerancia alimenticia durante el seguimiento y a los que se realizó una endoscopia digestiva alta. El objetivo primario es relacionar los hallazgos endoscópicos con la sintomatología y el momento de aparición. Resultados: de los 514 pacientes que presentaban dolor epigástrico o intolerancia alimenticia, 81 (15,6 %) fueron sometidos a endoscopia digestiva alta. En un 58 % de los casos se encontraron complicaciones relacionadas con la gastroyeyunostomía. En todos los pacientes que presentaban simultáneamente dolor e intolerancia aparecieron hallazgos endoscópicos patológicos. El único factor preoperatorio relacionado con las complicaciones fue el hábito tabáquico (p = 0,021). El tiempo entre la cirugía y la realización de la endoscopia también fue un factor significativamente relacionado con los hallazgos endoscópicos (p = 0,007). En los casos de dolor epigástrico durante el primer año (media: 10 meses) existía un incremento del riesgo de aparición de complicaciones de la gastroyeyunostomía (p < 0,05). Conclusiones: las endoscopias realizadas durante el primer año postoperatorio tenían más probabilidades de presentar hallazgos patológicos, sobre todo en los pacientes afectos de dolor epigástrico.

Shortening of the Common Channel as a Rescue Surgery After Gastric Bypass Failure.

BACKGROUND: After Roux-en-Y gastric bypass (RYGB), up to 30% failures in weight loss have been reported. Among multiple solutions available, we report our experience with shortening of the common channel (SCC) by performing a limb distalization of the alimentary or the biliopancreatic limb. SETTINGS: University Hospital. METHODS: We reviewed data from 23 patients that underwent limb distalization between 2001 and 2019 due to inadequate weight loss after an initial RYGB in our center. All patients who failed to achieve an excess weight loss reduction of > 50% or maintained a body mass index (BMI) above 35 kg/m2 were included. Multiple variables were analyzed during the follow-up at five time points: initial, after RYGB, before SCC, after SCC, and current. RESULTS: The mean BMI prior to the RYGB was 51.8 kg/m2, after RYGB was 37.6 kg/m2, before SCC was 43.6 kg/m2, after SCC was 36.1 kg/m2, and the final BMI was 36.3 kg/m2. No morbidity was seen after SCC. Long-term associated nutritional deficiencies were only identified in 3 patients which had iron deficiency and 1 patient with vitamin D deficiency. Patients with associated comorbidities significantly improved or were withdrawn from medications after the RYGB, with minor variations after SCC. CONCLUSIONS: Limb distalization with SCC is a safe and effective technique for patients who failed to achieve an adequate weight loss after RYGB. There is a slight increase in excess of weight loss after the SCC compared with RYGB. In addition, no further weight regain was documented.

Roux-en-Y Gastric Bypass as an Effective Bariatric Revisional Surgery after Restrictive Procedures.

INTRODUCTION: Revisional surgery must be considered when insufficient weight loss is attained or weight is subsequently regained. This study aimed to investigate the value of Roux-en-Y gastric bypass (RYGB) as a revisional procedure after restrictive surgery. MATERIALS AND METHODS: An observational, retrospective study including patients initially operated on for morbid obesity with restrictive techniques (vertical-banded gastroplasty [VBG], adjustable gastric band [AGB], and sleeve gastrectomy) and reoperated with RYGB in our centre between December 1994 and January 2019. Demographic and anthropometric data, associated comorbidities (diabetes mellitus type II, arterial hypertension, dyslipidaemia, and chronic obstructive pulmonary disease) and surgery-related data (approach, complications, and hospital stay) were evaluated at 5 different time points: initial (prior to first intervention), after the first surgical intervention, before the second intervention (gastric bypass), after the gastric bypass, and at present. RESULTS: A total of 63 patients were included. VBG was the most frequent initial procedure (n = 33). The mean age was 39 ± 9.52 years, and the average initial weight was 143.53 ± 28.6 kg. Weight loss was achieved in all groups, with a median excess weight loss of 58% after the first surgery and 40.3% after gastric bypass. In terms of weight loss, the best results after the second surgery were obtained when the first surgery was AGB, with statistically significant differences. CONCLUSIONS: RYGB is effective as a conversion procedure after a previous restrictive surgery, obtaining a significant reduction in weight and BMI. It has an acceptable morbidity rate and is more effective after an AGB.

Analysis of mid-term weight loss after Roux-en-Y gastric bypass and sleeve gastrectomy: Proposed percentile charts for total weight loss percentages to be used in daily clinical practice. / Análisis de la pérdida ponderal a medio plazo después del bypass gastroyeyunal en Y de Roux y de la gastrectomía vertical: propuesta de gráficos de percentiles del porcentaje de peso total perdido para su uso en la práctica clínica diaria.

INTRODUCTION: The aim of this study is to analyze weight evolution after the main bariatric surgical techniques (Roux-en-Y gastric bypass [RYGB] and sleeve gastrectomy [SG]) performed at a representative sample of Spanish hospitals in order to develop percentile charts for the percentage of total weight loss during the first 3 years after surgery. METHODS: A retrospective longitudinal cohort study was conducted based on the data provided by 9 Spanish hospitals. Weight data were analyzed both in % total weight loss and % excess weight lost corresponding to the RYGB (n=1,887) and SG (n=1,210). RESULTS: RYGB continues to be the most frequently performed technique in our sample. In both surgical techniques, maximum weight loss occurred 18 months after surgery. Both techniques followed the same weight evolution, although the % total weight loss values were lower in the case of the SG after 36 months (29.3±10 vs. 33.6±10). Age and gender are decisive in the weight results (better in younger patients for both techniques and better in women for RYGB). CONCLUSIONS: Percentile charts of % total weight loss after bariatric surgery represent a very useful tool and an important advance in the quality of patient management.

Revisional bariatric surgery due to failure of the initial technique: 25 years of experience in a specialized Unit of Obesity Surgery in Spain. / Cirugía bariátrica de conversión por fallo de la técnica inicial: 25 años de experiencia en una Unidad especializada de Cirugía de la Obesidad en España.

OBJECTIVES: To evaluate the effectiveness of conversion surgery in a bariatric surgery unit with 25years of experience. METHOD: Retrospective observational study of patients with typeII obesity or higher who were reoperated by means of conversion surgery due to weight regain, residual body mass index (BMI)>35kg/m2 or <50% of excess weight loss. The demographic and anthropometric data, comorbidities and perioperative data were analyzed in 5 periods of time: initial, post-surgery1, pre-surgery2, post-surgery2 and current. RESULTS: A total of 112 patients were included, with a mean age of 40.2years, who initially underwent vertical banded gastroplasty (VBG) (32.1%), gastric banding (GB) (23.2%), Roux-en-Y gastric bypass (RYGB) (21.4%) and sleeve gastrectomy (SG) (23.2%). The conversion techniques, with a median time between the two surgeries of 70months, included: RYGB, SG, one-anastomosis gastric bypass (OAGB), shortening of the common loop (SCL) and biliopancreatic diversion (BPD). There was a reduction of the initial weight from 144.2±30.3 to 101.5±21.8kg after surgery-1; from 115.6±24.0 to 91.5±19.0kg after surgery-2. The weight at present is 94.7±16.4kg, with a median follow-up of 27.5months. Similar results were seen with the BMI. The improvement of comorbidities mainly occurred after the first intervention. CONCLUSIONS: Conversion surgery causes a weight reduction that does not exceed the loss achieved after the first surgery; however, it does manage to stabilize weight over time. The perioperative morbidity rate is acceptable and would justify its application, despite the limited impact on comorbidities.

Mild acute biliary pancreatitis vs cholelithiasis: are there differences in the rate of choledocholithiasis?

The rate of choledocholithiasis at the time of elective surgery after mild acute biliary pancreatitis is still unclear because it decreases rapidly after the onset. The aims of this study are as follows: (1) To investigate whether the incidence of choledocholithiasis in mild biliary pancreatitis is higher than in patients with symptomatic cholelithiasis. (2) To evaluate the usefulness of intraoperative cholangiography in the diagnosis of unsuspected choledocholithiasis in mild pancreatitis. Prospective study including 130 patients undergoing laparoscopic surgery and classified into two groups: mild biliary pancreatitis (n = 44) and symptomatic cholelithiasis (n = 86). Choledocholithiasis was evaluated by endoscopic cholangiopancreatography, magnetic resonance, and intraoperative cholangiography. Preoperatively, choledocholithiasis was identified in five patients with symptomatic cholelithiasis and two with biliary pancreatitis (5.81 vs 4.54%; p = 0.472). In 117 cases (90%), intraoperative cholangiography was successfully performed, identifying unsuspected choledocholithiasis in five patients of the colelithiasis group and in three in the group of pancreatitis (5.81 vs 6.81%; p = 0.492). The total number of patients with choledocholithiasis in the whole series was 15 (11.5%); 11.6% in colelithiasis group vs 11.4% in biliary pancreatitis group; p = 0.605. The rate of choledocholithiasis was not significantly different between the groups of patients with mild acute biliary pancreatitis and symptomatic cholelithiasis. Intraoperative cholangiography identified unsuspected choledocholithiasis in 6.81% of patients with mild acute biliary pancreatitis.

One-Stage vs Two-Stage Laparoscopic Roux-en-Y Gastric Bypass in Obese Patients with Body Mass Index >55 Kg/m2; 5-YEAR FOLLOW UP.

BACKGROUND: Surgical strategies in patients with BMI > 55 kg/m2 are not well established. OBJECTIVES: The objective of this study is to compare the long term results and complications of 1- vs. 2-stage laparoscopic "Roux-en-Y″ gastric bypass (LRYGB) for patients with BMI > 55 kg/m2. METHODS: Retrospective review of the complications and outcomes, between January 2007 and January 2010, for patients with a BMI > 55 kg/m2 who underwent directly a LRYGB (1-stage) or a LRYGB as a 2nd stage of a laparoscopic sleeve gastrectomy (LSG). RESULTS: Twenty-four patients were enrolled (no patient was lost during the 5-year follow-up). In the 1-stage LRYGB group, two patients had grade II complications according to Clavien-Dindo classification. In the 2-stage LRYGB group, complications of the first and the second surgery were summed. There were no differences between the two groups despite being heterogenous (more men with a higher BMI in the 2-stage group). There was a statistically significant difference in the final BMI in 1-stage LRYGB group compared to the 2-stage LRYGB group (34.46 ± 6.29 vs. 40.40 ± 3.47; p = 0.01, respectively) and in percentage of excess of BMI loss (%EBMIL; 69.80 ± 19.96 vs. 54.54 ± 13.93; p = 0.04, respectively). CONCLUSIONS: In patients with a BMI > 55 kg/m2, both 1- and 2-stage LRYGB give good long-term results. If feasible, a 1-stage LRYGB obtains a better percentage of excess of BMI loss but if not possible, the strategy of initially performing a laparoscopic sleeve gastrectomy followed by a LRYGB is safe and there were no differences in complications.

Prognostic Factors for Morbimortality in Sleeve Gastrectomy. The Importance of the Learning Curve. A Spanish-Portuguese Multicenter Study.

BACKGROUND: Complications in sleeve gastrectomy (SG) can cast a shadow over the technique's good results and compromise its safety. The aim of this study is to identify risk factors for complications, and especially those that can potentially be modified to improve safety. METHODS: A retrospective multicenter cohort study was carried out, involving the participation of 29 hospitals. Data was collected on demographic variables, associated comorbidities, technical modifications, the surgeon's experience, and postoperative morbimortality. A multivariate logistic regression analysis was carried out on risk factors (RFs) for the complications of leak/fistula, hemoperitoneum, pneumonia, pulmonary embolism, and death. RESULTS: The following data were collected for 2882 patients: age, 43.85 ± 11.6. 32.9 % male; BMI 47.22 ± 8.79; 46.2 % hypertensive; 29.2 % diabetes2; 18.2 % smokers; bougie calibre ≥40 F 11.1 %; complications 11.7 % (2.8 % leaks, 2.7 % hemoperitoneum, 1.1 % pneumonia, 0.2 % pulmonary embolism); and death 0.6 %. RFs for complications were as follows: surgeon's experience < 20 patients, OR 1.72 (1.32-2.25); experience > 100 patients, OR 0.78 (0.69-0.87); DM2, OR1.48(1.12-1.95); probe > 40 F, OR 0.613 (0.429-0.876). Leak RFs were the following: smoking, OR1.93 (1.1-3.41); surgeon's experience < 20 patients, OR 2.4 (1.46-4.16); experience of 20-50 patients, OR 2.5 (1.3-4.86); experience >100 patients, OR 0.265 (0.11-0.63); distance to pylorus > 4 cm, OR 0.510 (0.29-0.91). RFs for death were as follows: smoking, OR 8.64 (2.63-28.34); DM2, OR 3.25 (1.1-9.99); distance to pylorus < 5 cm, OR 6.62 (1.63-27.02). CONCLUSIONS: The safety of SG may be compromised by nonmodifiable factors such as age >65, patient comorbidities (DM2, hypertension), and prior treatment with anticoagulants, as well as by modifiable factors such as smoking, bougie size <40 F, distance to the pylorus <4 cm, and the surgeon's experience (<50-100 cases).