Third time's a charm: band to sleeve to bypass.

BACKGROUND: Adjustable gastric bands (AGB) are frequently converted to sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) due to weight recurrence or band complications. Such conversions carry a higher-risk than primary procedures. Some patients undergo two conversions-from AGB to SG, and subsequently from SG to RYGB. This presents a unique situation with limited literature on indications and complication rates associated with these double conversions. METHODS: We examined the 2020-2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use File to evaluate conversions from AGB to SG and then to RYGB. Patient and operative characteristics, along with outcomes, were evaluated. Descriptive statistics were applied. RESULTS: We identified 276 patients who underwent a conversion from AGB to SG and then to RYGB. The primary reason for the second conversion (SG to RYGB) was gastroesophageal reflux disease (GERD) at 55.1%, followed by inadequate weight loss or weight regain (IWL/WR) at 36.9%. The remaining reasons included dysphagia, nausea, vomiting, or others. Patients converted for IWL/WR demonstrated a higher baseline body mass index and prevalence of sleep apnea compared to other cohorts (both p < 0.001). Meanwhile, patients in the "other reasons" group had the highest rate of open surgical approaches (9.1%) and concurrent lysis of adhesions (p = 0.001 and p = 0.022), with correspondingly higher rates of anastomotic leak, reoperations, serious complications, and mortality. CONCLUSIONS: Patients undergoing double conversions (AGB to SG to RYGB) do so primarily for GERD or IWL/WR. Further research is required to better define the optimal primary operation for each patient, aiming to reduce the necessity for multiple conversions.

Does endoscopy at the time of revisional bariatric surgery decrease complication rates? an analysis of the NSQIP database.

BACKGROUND: Endoscopy is performed routinely during bariatric surgery. It is often used for provocative testing and intraluminal inspection during Roux-en-Y gastric bypass (RNYGB) and sleeve gastrectomy (SG). Recent publications would indicate about one-quarter of bariatric cases are performed with concurrent endoscopy, resulting in a slight increase in time but no increase in complications within 30 days compared with cases where no endoscopy is performed. Do these results persist for endoscopy during revisional bariatric surgery (RBS)? METHODS: An analysis of the American College of Surgeons National Surgical Quality Initiative Program (NSQIP) was conducted for the years 2005-2017. Seventeen postoperative outcomes were analyzed in this database. A 1:1 propensity score matching analysis was completed for 13 patient comorbidities and demographics. A McNemar's test for paired categorical variables and a paired t-test for continuous variables were completed, with a significant P value of 0.05. The results were reported as the frequency and percentage for categorical variables and the mean (± standard deviation) for continuous variables. RESULTS: A total of 7249 RBS cases were identified. After propensity score matching for patient comorbidities and demographics 2329 cases remained. Esophagogastroduodenoscopy (EGD) was performed in 375 (16%) of these patients. There were no differences in complication rates between the two groups. CONCLUSIONS: Similar to non-revisional bariatric surgery, there is no difference in 30-day postoperative complications when endoscopy is performed in RBS. Endoscopy is performed in about one-sixth of RBS cases.

Effect of operative times in bariatric surgery on outcomes: a matched analysis of the MBSAQIP database.

BACKGROUND: The implications of operative time (OT) have been studied in different surgical specialties, showing a correlation with higher incidence rates of postoperative complications. However, the impact of OT on bariatric surgery complications is not well elucidated. METHODS: A retrospective review of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database between 2015 and 2019 was performed. A total of 358,382 SG patients and 123,357 RYGB patients were included. The median OT was 68 min (10-720) and 113 min (10-640) for the sleeve gastrectomy (SG) group and the Roux-en-Y gastric bypass group, respectively. The groups were subdivided into two subgroups based on OT in comparison to the median time of each group. The subgroups were compared for surgical complications and outcomes. To reduce selection bias and risk of confounders, we performed a propensity score matching (PSM) for 22 variables. RESULTS: In the PSM-matched cohort, 18,915 SG and 6,495 RYGB patients were included in each subgroup. The SG cohort showed higher rates of Clavien-Dindo Class 1, 2, 3a, 4, and 5 complications as well as higher rates of readmission, reoperation, and reintervention in the longer OT group before matching. After PSM, the subgroup with longer times continued to have higher rates of Clavien-Dindo Class 2 complications and higher rates of readmission and reoperation. Similarly, there were higher rates of all Clavien-Dindo class complications as well as readmission, reoperation, and reintervention in the RYGB group with higher OT. After PSM, there were still higher rates of Clavien-Dindo Class 3a complications as well as readmission and reintervention in the RYGB subgroup with prolonged OT. CONCLUSION: In both SG and RYGB, longer OT was associated with increased rates of complications as well as readmission, reoperation, and reintervention. Surgeons should be cognizant of the increased rates of complications when operative times are longer.

Does bioabsorbable mesh reduce hiatal hernia recurrence rates? A meta-analysis.

INTRODUCTION: The use of bioabsorbable mesh at the hiatus is controversial. Long-term data are scant. We evaluated the world literature and performed a meta-analysis to determine if these meshes were effective in reducing recurrence. METHODS: A literature search was performed using PubMed, MEDLINE, and ClinicalKey. We evaluated articles reporting on both Bio-A™ (polyglycolic acid:trimethylene carbonate-PGA:TMC) and Phasix™ (poly-4-hydroxybutyrate-P4HB) used at the hiatus. The DerSimonian-Laird random effects model was used to estimate the overall pooled treatment effect along with a 95% confidence interval (CI). Similar analysis was conducted to compare the clinical outcomes, i.e., recurrence rate, mean surgical time, mean hospital stays and mean follow-up duration between non-Mesh and Mesh group. The I2 statistic was computed to assess the heterogeneity in effect sizes across the studies. RESULTS: A total of 21 studies (12 mesh studies with 963 subjects and 9 non-mesh studies with 617 subjects) were included to conduct the meta-analysis. There was one article reporting outcomes on P4HB mesh (73 subjects) and 11 on PGA:TMC mesh (890 subjects). The bioabsorbable mesh group had a significantly lower recurrence rate compared to the non-mesh group (8% vs. 18%; 95%CI 0.08-0.17), pooled p-value < 0.0001. Surgery time was shorter in the mesh group compared to the non-mesh group (136.4 min vs. 150 min) but not statistically significant (p = 0.54). There tended to be a more extended follow-up period after surgery in the non-mesh group compared to the mesh group (27 vs. 25.8 months, range 10.8-54 months); but not statistically significant (ES: 27.4; 95%CI 21.6-33.3; p = 0.92). CONCLUSIONS: Hiatal hernia repair with bioabsorbable mesh is more effective at reducing hernia recurrence rate in the mid-term than simple suture cruroplasty. Further studies investigating the long-term outcomes and P4HB mesh are needed.

Best practice approach for redo-surgeries after sleeve gastrectomy, an expert's modified Delphi consensus.

BACKGROUND: Sleeve gastrectomy (SG) is the most common metabolic and bariatric surgical (MBS) procedure worldwide. Despite the desired effect of SG on weight loss and remission of obesity-associated medical problems, there are some concerns regarding the need to do revisional/conversional surgeries after SG. This study aims to make an algorithmic clinical approach based on an expert-modified Delphi consensus regarding redo-surgeries after SG, to give bariatric and metabolic surgeons a guideline that might help for the best clinical decision. METHODS: Forty-six recognized bariatric and metabolic surgeons from 25 different countries participated in this Delphi consensus study in two rounds to develop a consensus on redo-surgeries after SG. An agreement/disagreement ≥ 70.0% on statements was considered to indicate a consensus. RESULTS: Consensus was reached for 62 of 72 statements and experts did not achieve consensus on 10 statements after two rounds of online voting. Most of the experts believed that multi-disciplinary team evaluation should be done in all redo-procedures after SG and there should be at least 12 months of medical and supportive management before performing redo-surgeries after SG for insufficient weight loss, weight regain, and gastroesophageal reflux disease (GERD). Also, experts agreed that in case of symptomatic GERD in the presence of adequate weight loss, medical treatment for at least 1 to 2 years is an acceptable option and agreed that Roux-en Y gastric bypass is an appropriate option in this situation. There was disagreement consensus on efficacy of omentopexy in rotation and efficacy of fundoplication in the presence of a dilated fundus and GERD. CONCLUSION: Redo-surgeries after SG is still an important issue among bariatric and metabolic surgeons. The proper time and procedure selection for redo-surgery need careful considerations. Although multi-disciplinary team evaluation plays a key role to evaluate best options in these situations, an algorithmic clinical approach based on the expert's consensus as a guideline can help for the best clinical decision-making.

Risk of non-hormonal cancer after bariatric surgery: meta-analysis of retrospective observational studies.

BACKGROUND: Obesity is associated with an increased incidence of at least 13 types of cancer. Although bariatric surgery has been associated with a reduced risk of hormonal cancers, data for non-hormonal cancers are scarce. The aim of this study was to evaluate the effect of bariatric surgery on the incidence of non-hormonal cancers. METHODS: Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles between 1984 and 2018, following the PRISMA system. Meta-analysis was conducted using a random-effect model with subgroup analysis by procedure and cancer type. RESULTS: From 2526 studies screened, 15 were included. There were a total of 18 583 477 patients, 947 787 in the bariatric group and 17 635 690 in the control group. In comparison to the non-surgical group, the bariatric group had a lower incidence of cancer (OR .65 (95 per cent c.i. 0.53 to 0.80); P < 0.002). In the subgroup analysis, Roux-en-Y gastric bypass and sleeve gastrectomy were associated with decreased risk of developing cancer, while no difference was observed with adjustable gastric banding. When evaluated by cancer type, liver (OR 0.417 (95 per cent c.i. 0.323 to 0.538)), colorectal (OR 0.64 (95 per cent c.i. 0.49 to 0.84)), kidney and urinary tract cancer (OR 0.77 (95 per cent c.i. 0.72 to 0.83)), oesophageal (OR 0.60 (95 per cent c.i. 0.43 to 0.85)), and lung cancer (OR 0.796 (95 per cent c.i. 0.45 to 0.80)) also presented a lower cancer incidence in the bariatric group. CONCLUSION: Bariatric surgery is related to an almost 50 per cent reduction in the risk of non-hormonal cancers.

Safety of liver biopsy at the time of bariatric surgery: an analysis of the MBSAQIP database.

BACKGROUND: The majority of patients undergoing bariatric surgery have hepatic steatosis. Liver biopsy is not technically difficult to perform at the time of metabolic and bariatric surgery (MBS), but there may be concerns for bleeding complications. The safety of liver biopsy (LBx) at the time of MBS has been studied in single institutional studies but has not been studied on a national level. METHODS: The MBSAQIP database for 2015-2018 was examined. The codes for Roux-en-Y gastric bypass (RYGB) of 43644 and sleeve gastrectomy (SG) 43775 were used along with 47000 (percutaneous liver biopsy), 47001 (percutaneous liver biopsy at time of other procedure), and 47379 (unlisted laparoscopic procedure, liver). Outcomes such as operative time, complications, and length of stay were examined. Propensity-matched analysis was performed to evaluate for adjusted associations. RESULTS: There were 546,532 patients that met our inclusion criteria. Of those, 21,367 (3.9%) underwent LBx. Only 5.5% (8012) of patients undergoing RYGB had a LBx and 3.3% (13,355) of SG patients. Patients who underwent a LBx had a longer operative time before (103 min vs 84 min, p < 0.001) and after propensity matching [regression coefficient (RC): 10.7 (8.87, 12.5)]. There was no increase in length of stay. There was an increased risk in mortality in the unadjusted analysis (prevalence ratio = 1.61, p = 0.02), but when propensity-matched analysis was done, there was no statistically significant difference between the two groups. Concerning bleeding or transfusion, there was no difference in bleeding or rates of transfusion (p= 0.22, p = 0.21). CONCLUSION: Liver biopsy at the time of MBS is safe. It adds operative time, but there is no increase in length of stay, bleeding complications, morbidity, or death.

Is fundoplication necessary after paraesophageal hernia repair? A meta-analysis and systematic review.

INTRODUCTION: Paraesophageal hernias are often asymptomatic, but when symptomatic they should be fixed laparoscopically. A cruroplasty of the diaphragmatic pillars is performed and a fundoplication is usually performed at the time. However, there are times, especially in emergency cases, where it is not always possible to perform a fundoplication. We hypothesized there would be no difference in outcomes whether or not a fundoplication is performed as part of a paraesophageal hernia repair. METHODS: A literature review of available clinical databases was performed using PubMed, Clinical Key and Google Scholar. Our search terms were: "paraesophageal hernia" "paraesophageal hernia repair" "fundoplication" "emergency surgery" "no fundoplication" We excluded studies that were in languages other than English, abstracts and small case series. RESULTS: Our search criteria yielded a total of 22 studies published between 1997 and 2020. There were a total of 8600 subjects enrolled into this study. The overall pooled prevalence of fundoplication were estimated as 69% (95% CI: 59%-78%). In patients who underwent fundoplication, the risk of gastroesophageal reflux disease (GERD) was reduced as compared to patients who did not undergo fundoplication (RR: 0.64, 95% CI: 0.40-1.04, p = 0.069, I2 = 47.2%). A similar trend was also observed in recurrence (RR: 0.53, 95% CI: 0.27-1.03, p = 0.061, I2 = 0.0%) and reoperations (RR: 0.25, 95% CI: 0.02-2.69, p = 0.25, I2 = 56.7%). However, patients who underwent fundoplication had an increased risk of dysphagia (RR: 1.68, 95% CI: 0.59-4.81, p = 0.83, I2 = 42%). CONCLUSIONS: There is a higher rate of recurrence of gastroesophageal reflux disease, recurrence of hernia and reoperation when no fundoplication is performed during a paraesophageal hernia repair but a lower risk of dysphagia, but none of these reached statistical significance.(Comment 1) Paraesophageal hernia repair with fundoplication should be performed, but it is acceptable to not do it in certain situations.

The safety of additional procedures at the time of revisional bariatric surgery.

BACKGROUND: The third most common bariatric operation is revisions of previous bariatric surgeries. Patients may require revisional bariatric surgery for inadequate weight loss or complications. Patients undergoing revisional bariatric surgery may also have other conditions that require surgery. This study evaluates the 30-day postoperative outcomes of patients undergoing revisional bariatric surgery and additional procedures. METHODS: A retrospective review of the 2005-2017 ACS NSQIP database identified 7249 patients who underwent revisional bariatric surgery with 3115 (48%) occurring with additional procedures. A 1:1 propensity score matching analysis was completed for 13 patient demographics and comorbidities. Postoperative variables were then analyzed as available in the NSQIP database. Subgroup analyses were completed for those undergoing paraesophageal hernia repair and abdominal wall hernia repair at the time of revisional bariatric surgery. RESULTS: The most common bariatric surgery that was converted or revised was the AGB (57%) and the most common additional procedure was paraesophageal hernia repair (n = 181, 15%). When additional procedures were completed at the time of revisional bariatric surgery, overall complications (p < 0.001), major systemic complications (p = 0.009) and mortality/major complications (p = 0.018) were all significantly increased. After matching for operative time, only postoperative sepsis remained significant with additional procedures (p = 0.042). In the subgroup analyses on paraesophageal and abdominal wall hernias there were no differences in postoperative complications after matching for operative time. CONCLUSIONS: Additional procedures, including paraesophageal and abdominal wall hernia repairs at the time of revisional bariatric surgery increase postoperative complications. Operative time was longer when additional procedures were performed. Postoperative sepsis was the only complication which remained significant after propensity matching when additional procedures are completed at the time of revisional bariatric surgery.

Trends in bariatric surgery in Texas: an analysis of a statewide administrative database 2013-2017.

BACKGROUND: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) tracks 30-day outcomes of bariatric patients, but only at accredited centers. Presently, these cases are not broken down by state. Administrative databases can be used to answer some of the questions that are not asked by clinical databases and also to validate those databases. We proposed using the inpatient and outpatient administrative databases in Texas to examine both the numbers and trends of bariatric surgery in Texas over a 5-year period. METHODS: The Texas Inpatient Public Use Data File (IPUDF) and the Texas Outpatient Public Data File (OPUDF) were examined for the years 2013-2017. We searched for patients undergoing laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy (SG), laparoscopic Roux-en-Y gastric bypass (LRYGB) and duodenal switch. Robotic assisted cases were also examined. RESULTS: There were 105,199 bariatric cases performed in Texas from 2013 to 2017. There were 173 centers performing bariatric surgery. The most common operation performed was the sleeve gastrectomy at 73,663 case (70% of total). Gastric bypasses were second at 22,890 cases. During this time period, LAGB almost disappeared; dropping from 2090 cases in 2013 to 115 cases in 2017, with removal of 2097 LAGB in the study period in the OPUDF. During this time period, there was a lower growth rate of the number of SG in the IPUDF with a large increase in SG performed with outpatient status, while LRYGB remained relatively stable. CONCLUSION: Rates of bariatric surgery in Texas are increasing slowly. The dominant procedure is the SG with a trend towards being done under outpatient status. LAGB has been essentially phased out. There is an increase in SG being performed under 'outpatient' status.

Small bowel obstructions following the use of barbed suture: a review of the literature and analysis of the MAUDE database.

BACKGROUND: Barbed suture has been adopted across all surgical specialties. One of the infrequent complications seen with the use of barbed suture is small bowel obstructions (SBOs). In this study, we perform a review of the literature and the Manufacturer and User Facility Device Experience Database (MAUDE) to characterize SBOs after the use of barbed sutures in a variety of operative procedures. METHODS: A review of the literature was performed by searching PubMed and Ovid. We used the search terms: "barbed," "suture," "bowel," and "obstructions." For each case report, we examined the initial surgical procedure, type of barbed suture used, the type of complication, the time to complication, the presentation, and the type of operative interventions required. We did the same with the MAUDE database. RESULTS: Our review of the literature revealed 18 different cases of SBO secondary to the use of barbed suture. The four most common procedures, with a total of four cases each, were inguinal hernia procedures, myomectomy, hysterectomy, and pelvic floor reconstructive procedures. The average time of presentation to SBO was found to be 26.3 days post-op (1-196 days). A total of 16 patients (88.9%) presented with abdominal pain. Other common complaints included vomiting (33.3%), abdominal distension (27.8%), oral intolerance (22.2%), and constipation (16.7%). A total of 5 cases were also found to have a possible volvulus on computed tomography (CT), and 2 cases were reported to have strangulation. The MAUDE database had 14 cases reporting on obstruction. CONCLUSIONS: Surgeons should have a high index of suspicion for SBO if a patient presents with obstructive symptoms after a surgery that used barbed suture. This will often present as a mesenteric volvulus on CT. These particular SBOs require operative exploration, with laparoscopy being successful in the majority of cases.

Evaluation of the rate of marginal ulcer formation after bariatric surgery using the MBSAQIP database.

BACKGROUND: Marginal ulcer (MU) formation is a known problem after gastric bypass. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database contains data from all US and Canadian Centers of Excellence including complication rates. We hypothesized that the short-term rate of ulceration is low. METHODS: We queried the MBSAQIP database for the year 2015. We searched patients with primary gastric bypass who developed MU. We then compared preoperative, operative, and postoperative characteristics with patients who did not develop MU. RESULTS: The incidence of MU in the entire cohort of GB patients was 155 of 44,379 (0.35%, 95% CI 0.297%, 0.409%). Among the 155 patients with an ulcer, 88 (57%) patients had only one procedure, 69 had an intervention (therapeutic or diagnostic endoscopy), 16 had readmission, and 3 had reoperation. 65 patients (42%) had two procedures with the majority having both readmissions and endoscopy (n = 59); and two patients (1%) had three procedures. Ulcer formation was most common in the intervention group (11.4%). The occurrence of ulcer formation was associated with unplanned ICU admissions (6.45%), transfusions (5.16%), postoperative UTI (3.87%), sepsis (1.94%), and myocardial infarction (0.65%). Death occurred in 76 patients with no related cases to MUs. The risk of ulcer was associated with increased BMI (OR 1.02, p = 0.01), presence of percutaneous transluminal cardiac catheterization (PTC) (2.17, p = 0.038), histories of DVT (1.72, p = 0.085), and pulmonary embolism (2.84, p = 0.002). CONCLUSIONS: In a nationally reported database, symptomatic MUs rarely occur in the first month. The large majority are diagnosed and treated endoscopically with minimal need for surgical intervention. The risk of anastomotic ulcer was increased with increased BMI, need for PTC, and history of DVT/PE.

From database to practice: the MBSAQIP in the surgical literature.

BACKGROUND: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) has been a game changer for metabolic and bariatric surgery (MBS), with continuous improvements in safety and outcomes throughout the years of its usage. It allows in-depth evaluations of MBS procedures, presenting practitioners and researchers with unparalleled opportunities for quality assessment, research and clinical advancement. OBJECTIVES: To offer an updated overview of MBSAQIP-related publications. SETTING: United States. METHODS: PubMed was queried using keywords "MBSAQIP" and "Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program." Letters to editors, duplicates, commentaries, and retracted articles were excluded. Studies that mentioned MBSAQIP but did not use the data within were also excluded. RESULTS: A total of 400 search items were returned as of August 2023. After exclusions, 289 studies were reviewed. Articles were published in a total of 28 unique journals, the majority of which were featured in Surgery for Obesity and Related Diseases (SOARD), with 114 articles (39.4%). Sixty-one articles were focused on creating predictive models or risk calculators, 58 on investigating the safety of procedures, and 52 on exploring complications. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) were the 2 most commonly discussed procedures, at 80.3% and 80% respectively. Forty-three studies included patients who underwent robotic-assisted MBS. CONCLUSIONS: The MBSAQIP is a valuable resource that has generated a wealth of studies in the literature. It has allowed for intense analysis of clinical issues and fostered a culture of safety and quality improvement. Participating surgeons must pledge commitment to extended follow-up periods to maximize its effectiveness.

Evaluating metabolic and bariatric surgery fellows' attitudes toward their training.

BACKGROUND: The American Society of Metabolic and Bariatric Surgeons (ASMBS) Leadership Academy is conducted at the ASMBS Weekend to prepare surgeons for practice, while in their fellowship. OBJECTIVES: The aim of this analysis is to gather the views of current fellows in training on issues regarding practice patterns and career development. SETTING: Survey at ASMBS Fellows Leadership Academy. METHODS: An online survey was conducted at the last 2 ASMBS Leadership Academy Meetings at the ASMBS Weekend. There were 14 questions. There were 61 respondents. Twenty-three respondents had incomplete surveys and were not included in the final analysis. There were 24 fellows surveyed at the Leadership Academy in November 2022, in San Antonio, TX and 37 in January 2022, in Las Vegas, NV. RESULTS: Fifty-eight percent of attendees were interviewing for employment after their fellowship with 3.64% already employed. Eighteen percent had employment secured upon completion of their fellowship. Of the academic fellows, 29.1% believe that private practice will no longer exist in 2030 and 10.9% of attendees believe that we will have Medicare for all by 2030. Fellows in academic programs ranked their fellowship as either "best decision of my life" or "great" (96.4%) and 3.6% ranked it as "useless (not good/not bad)." Ninety-three percent of attendees said they would do a bariatric fellowship again. Of those that said they would not, all were from a robotic fellowship program. Of those that would do a bariatric fellowship again, 80% stated they would do so at the same institution. CONCLUSIONS: The fellows that attended the ASMBS Leadership Academy overall were very pleased with their fellowship experience, and most would choose to do a MIS/bariatric fellowship again.

Ligamentum Teres Augmentation for Hiatus Hernia Repair After Bariatric Surgery: A Systematic Review and Meta-analysis.

OBJECTIVE: Hiatal hernia (HH) and symptomatic gastroesophageal reflux disease are common complications after metabolic bariatric surgery. This meta-analysis aims to investigate the safety and efficacy of ligamentum teres augmentation (LTA) for HH repair after metabolic and bariatric surgeries (MBS). MATERIALS AND METHODS: CENTRAL, Embase, PubMed, and Scopus were searched for articles from their inception to September 2023 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis system. RESULTS: Five studies met the eligibility criteria, with a total of 165 patients undergoing LTA for HH repair after MBS. The distribution of patients based on surgical procedures included 63% undergoing sleeve gastrectomy, 21% Roux-en-Y gastric bypass, and 16% having one anastomosis gastric bypass. The pooled proportion of reflux symptoms before LTA was 77% (95% CI: 0.580-0.960; I2 = 89%, n = 106). A pooled proportion of overall postoperative symptoms was 25.6% (95% CI: 0.190-0.321; I2 = 0%, n = 44), consisting of reflux at 14.5% (95% CI: 0.078-0.212; I2 = 0%, n = 15). The pooled proportion of unsuccessful LTA outcomes was 12.5% (95% CI: 0.075-0.175; I2 = 0%, n = 21). CONCLUSION: Our meta-analysis demonstrated that LTA appears to be a safe and efficacious procedure in the management of HH after MBS.

Comparative analysis of sleeve conversions of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2020 Database.

BACKGROUND: Although the sleeve gastrectomy (SG) is the dominant bariatric procedure, studies have shown conversion rates of up to 30%. These conversions are generally for weight regain (WR), insufficient weight loss (IWL) or gastroesophageal reflux disease (GERD). Before 2020, details on why conversions were being performed were not collected in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use Data File (PUF). Now, the indication for sleeve conversion is noted in the PUF, allowing identification and reporting sleeve conversion reasons. OBJECTIVE: We aimed to examine the reasons for SG conversions nationwide. SETTING: The 2020 MBSAQIP PUF. METHODS: The 2020 MBSAQIP PUF was examined to determine the reasons why SG were converted to other operations. The data field of "Revision/Conversion Final Indication" was used along with "Procedure type." Primary bariatric operations were excluded. Descriptive statistics were applied. Different reasons for conversion and operations were compared by preoperative characteristics and operative outcomes. RESULTS: There were 103,782 primary SG reported in the 2020 PUF. There were 7181 SG that were converted to other operations. The most common conversion (86.2%) was to Roux-en-Y gastric bypass (RYGB). The main reason for SG conversion was GERD at 48.4%, followed by WR/IWL (41.9%). Biliopancreatic diversion with duodenal switch and single-anastomosis duodenoileal bypass with sleeve patients differed significantly from RYGB patients in specific preoperative characteristics and operative outcomes. CONCLUSION: The most common procedure SG is converted to is the RYGB. GERD was the most common reason for SG conversion, followed by WR/IWL.

MBSAQIP database: are the data reliable?

BACKGROUND: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database collects data from all accredited centers in the US. A prior study showed data quality issues limiting use of up to 20% of the 2015 database. OBJECTIVES: To evaluate the completeness and data quality (internal validity, accuracy, and consistency) of the MBSAQIP database between 2015 and 2019. SETTING: United States. METHODS: All subsets of data from the MBSAQIP Participant User Data File (PUDF) were compiled into one main file. Completeness, internal validity, accuracy, and consistency were evaluated. Completeness was determined via missing values. Internal validity was assessed using the percentage of patients with a body mass index (BMI) < 30 kg/m2 who underwent primary bariatric surgery. Accuracy was evaluated using reported versus calculated BMI. Consistency was assessed using the percentage of patients with a gain of >5 or a loss of >20 units of BMI change in 30 days. Effects across years were assessed using a chi-squared test. RESULTS: Missing data for age, BMI, and ASA was consistently low (<2.5%) with no significant difference across years. Only .02% of patients who underwent a primary bariatric procedure had a reported BMI <30 kg/m2. The mean difference between reported versus calculated BMI was -.02 units. A maximum of .33% of patients gained >5 units of BMI, and a maximum of .85% of patients lost > 20 units of BMI in early follow-up. CONCLUSIONS: While the MBSAQIP is a database with acceptable data quality and minimal changes from 2015-2019, ongoing efforts are needed to improve data.

Evaluation of Long-Term Nutrition Outcomes After Duodenal Switch: A Systematic Review and Meta-Analysis.

BACKGROUND: Biliopancreatic diversion with duodenal switch (BPD-DS) is the most effective and durable metabolic and bariatric surgery to achieve a target weight loss. However, many surgeons are hesitant to adopt BPD-DS due to a lack of training, technical complexity, and long-term nutrition deficiencies. This meta-analysis aimed to investigate long-term nutrition outcomes after primary BPD-DS in the management of obesity. METHODS: Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles from their inception to February 2023 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) system. The review was registered prospectively with PROSPERO (CRD42023391316). RESULTS: From 834 studies screened, 8 studies met the eligibility criteria, with a total of 3443 patients with obesity undergoing primary BPD-DS. At long-term follow-up (≥5 years), 25.4% of patients had vitamin A deficiency (95% CI: -.012, .520, I2 = 94%), and 57.3% had vitamin D deficiency (95% CI: .059, 1.086, I2 = 86%). Calcium deficiency was observed in 125 patients (22.2%, 95% CI: .061, .383, I2 = 97%), and 69.7% had an abnormal parathyroid hormone level (95% CI: .548, .847, I2 = 78%). Ferritin level was abnormal in 30 patients (29.0%, 95% CI: .099, .481, I2 = 79%). CONCLUSIONS: Despite displaying comparable nutrition-related outcomes to mid-term follow-up, our study demonstrated that BPD-DS could result in a high level of long-term nutrition deficiency after BPD-DS for selected patients. However, further randomized controlled studies with standardized supplementation regimens and improvement in compliance are necessary to evaluate and prevent long-term nutritional deficiencies after BPD-DS.