Long-Term Outcomes of Patients with Staple Line Leaks Following Sleeve Gastrectomy.

PURPOSE: The long-term outcomes of patients with staple line leaks (SLL) after SG are under-reported. The purpose of this study is to evaluate the long-term outcomes of patients with SLL after SG. MATERIALS AND METHODS: A retrospective analysis of a maintained patient registry of patients undergoing SG between January 2012 and December 2020 in a single bariatric center was analyzed and included patients with SLL. Outcomes were compared to a group without SLL. RESULTS: During this period, 1985 patients underwent SG of which 61 patients (3.1%) developed leak. 26 patients (1.3%) had overt SLL and the rest had organ space infection around the staple line. The mean age and body mass index (BMI) were 39.8 ± 11.3 and 41.5 ± 4.7, respectively. 7 patients (11.4%) underwent concomitant surgery and 12 patients (19.7%) had intraoperative complications. Leak was complicated by Clavien-Dindo ≥ 3 in 31 patients (50.8%). Reoperation rate was 27.8% (n = 17). ≥ 2 interventions were required in 26% of patients (n = 16). Two patients died during hospitalization due to septic complications. Long-term follow-up of median 121 months was available in 78% of the cohort (n = 48). The median total weight loss and BMI were 27% and 30.1 kg/m2, respectively. Weight loss outcomes were higher in comparison to patients without SLL. Seven patients (14.6%) underwent SG revision. All associated medical problems improved during follow-up except for gastroesophageal reflux which was found in 50% of cohort. CONCLUSION: Long-term outcomes of SG patients with SLL are satisfactory in terms of weight loss, resolution of comorbidities, and requirement for surgical revision.

Revision of restrictive bariatric procedures in elderly patients: results at a 5-year follow-up.

Revisional Bariatric Surgery (RBS) is increasing in popularity. Elderly patients (> 65 years old) are sometimes referred for RBS evaluation. The aim of this study is to evaluate outcomes of elderly patients undergoing RBS. A retrospective analysis of a cohort from a single-tertiary bariatric center. All elderly patients undergoing RBS after restrictive procedures between 2012 and 2022 were included. Thirty Nine patients undergoing RBS were included in the comparative analysis - 23 patients (57.5%) after adjustable gastric banding (s/p LAGB) and 16 patients (40%) after Sleeve Gastrectomy (s/p SG). The mean age and body mass index (BMI) of patients were comparable (67.2 ± 2.8 years and 38.3 ± 7.4, respectively). There was no difference in associated medical problems except reflux which was higher in s/p SG (68% vs. 13%; p < 0.001). The mean time interval between surgeries was 8.7 ± 5.1 years. The surgeries included One anastomosis gastric bypass (n = 22), SG (n = 8) and Roux-en-y gastric bypass (n = 9). Early major complication rates were comparable (4.3% and 12.5%; p = 0.36), and readmission rate was higher in patients s/p SG (p = 0.03). Ninety percent of patients were available to a follow-up of 59.8 months. The mean BMI and total weight loss was 29.2 and 20.3%, respectively with no difference between groups. The rate of patients with associated medical problems at last follow-up was significantly reduced. Five patients (12.5%) underwent revisional surgery due to complications during follow-up. In conclusion, RBS in the elderly is associated with a reasonable complication rate and is effective in terms of weight loss and improvement of associated medical problems in a 5-year follow-up.

Primary versus Revisional One Anastomosis Gastric Bypass: Outcomes of Patients with at Least 8-Year Follow-Up.

INTRODUCTION: One anastomosis gastric bypass (OAGB) prevalence is increasing worldwide and shows good mid- to long-term results. Data on long-term outcomes of revisional OAGB (rOAGB) is limited. This study's objective was to evaluate the long-term outcomes of patients undergoing primary OAGB (pOAGB) and rOAGB. METHODS: A retrospective analysis of a prospectively maintained patient registry at a single-tertiary center. Patients undergoing OAGB from January 2015 to May 2016 were included and grouped into pOAGB and rOAGB. RESULTS: There were 424 patients, of which 363 underwent pOAGB, and 61 underwent rOAGB. Baseline characteristics were insignificantly different between groups except for the type 2 diabetes (T2D) rate which was higher in pOAGB (26% vs. 11.5%, p = 0.01). The mean follow-up time was 98.5 ± 3.9 months, and long-term follow-up data were available for 52.5% of patients. The mean total weight loss (TWL) was higher in the pOAGB group (31.3 ± 14 vs. 24.1 ± 17.6, p = 0.006); however, TWL was comparable when relating to the weight at primary surgery for rOAGB. The rate of T2D and hypertension resolution was 79% and 72.7% with no difference between groups. Thirteen patients (5.9%) underwent OAGB revision during follow-up, with no difference between groups. Two deaths occurred during follow-up, both non-related to OAGB. CONCLUSION: OAGB is effective as a primary and as a revisional procedure for severe obesity with good long-term results in terms of weight loss and resolution of associated diseases. In addition, the revisional surgery rates and chronic complications are acceptable. Further large prospective studies are required to clarify these data.

Technical Considerations in One Anastomosis Gastric Bypass-the Israeli Society of Metabolic and Bariatric Surgery Experience.

BACKGROUND: One anastomosis gastric bypass (OAGB) is gaining popularity worldwide due to its safety and effectiveness. OAGB is the most commonly performed metabolic bariatric surgery (MBS) in Israel. Israel is the only country where OAGB is the most prevalent MBS. Our aim is to address OAGB technical aspects using a national survey completed by members of the Israeli Society of Metabolic and Bariatric Surgery (ISMBS). MATERIALS AND METHODS: An online-survey composed of a 17-item-based questionnaire was sent to ISMBS members. All responses were collected and analyzed. RESULTS: A total of 47/64 (73.4%) ISMBS members participated in the survey. Most surgeons (74.5%) had > 10 years of MBS experience, and most (61.7%) performed > 100 MBS/year. The majority (78.7%) perform OAGB as their most common procedure. Most surgeons fashion a 10-15-cm pouch and use a 36-Fr bougie, (57.4% and 38.3%). Regarding bowel length measurement, 70% use visual estimation and 10.6% routinely measure total small bowel length (TSBL). The most common reasons for creating a longer biliopancreatic limb (BPL) were high body mass index (BMI) and revisional surgery (83.3% and 66%, respectively). In a primary procedure of a patient with a BMI = 40, most (76.6%) would create a 150-200-cm BPL. In patients with a BMI > 50 or revisional cases, most (70.2% and 68.0%) would create a 175-225-cm BPL. CONCLUSION: OAGB is the most prevalent MBS performed in Israel. This survey showed common preferences and variations among ISMBS members. Further studies are needed in order to standardize and build a consensus on OAGB technique.

Long Term Effects of Metabolic and Bariatric Surgery on Idiopathic Intracranial Hypertension.

BACKGROUND: Idiopathic Intracranial Hypertension (IIH) is a rare disorder, linked to severe obesity. The study aimed to evaluate long-term effects of metabolic and bariatric surgery (MBS) on IIH outcomes. METHODS: Retrospective study of patients with IIH and severe obesity who underwent MBS. Data were retrieved from prospectively maintained databases of two bariatric surgeons. RESULTS: Thirteen patients were included, of them 12 women. Median age was 36 (interquartile range;IQR 21,47) years and body mass index (BMI) was 40.4 (IQR 37.8,41.8) kg/m2. All patients had visual disturbances,12/13 had headaches, and 6/13 had tinnitus. The mean opening pressure on lumbar puncture was 45 cmH2O, and 11/13 patients had papilledema. Medications for IIH were consumed by 11/13 patients, and 2/13 patients had prior surgical intervention for IIH. MBS types included sleeve gastrectomy (n=7), adjustable gastric banding (n=2), roux-en-y gastric bypass (n=2), one anastomosis gastric bypass (n=1), duodenal switch (n=1). At a median follow-up of 10 years (IQR 8,13), the median BMI and total weight loss were 29.7 kg/m2 and 27%, respectively. Remission of symptoms was achieved in 9/13 patients. CONCLUSIONS: MBS results in significant and sustainable weight loss, with subsequent resolution or improvement of IIH. It may be considered as a preventive measure for IIH in patients with severe obesity.

Ten-Year Results of Laparoscopic Sleeve Gastrectomy: a Retrospectively Designed Study of a Single Tertiary Center.

PURPOSE: Laparoscopic sleeve gastrectomy (SG) is the most popular bariatric surgery. Nonetheless, only a few studies have reported its long-term outcomes. This study aimed to evaluate changes in weight and body mass index (BMI) parameters, resolution of comorbidities, and frequency of re-operations in a follow-up period of at least 10 years. MATERIALS AND METHODS: Data was available from 180 patients' records who underwent SG between 2008 and 2011 in the Tel Aviv Sourasky Medical Center. Eighty patients agreed to partake in a follow-up assessment that was completed via a phone call questionnaire and hospital computed registry. RESULTS: Patients' mean preoperative BMI was 43.86 ± 6.36 kg/m2 which was significantly higher when compared to mean nadir BMI and last follow-up BMI (29.44 ± 7.12 and 36.34 ± 9.7; p < 0.001). Mean percentage of excess weight loss (%EWL) at 10 years was 42.65 ± 36.02% and mean percentage of total weight loss was 19.33 ± 16.73%. Twenty-eight patients (35%) maintained at least 50% EWL. Twenty-seven (33.75%) patients underwent at least one surgical procedure following SG. Eleven patients (13.75%) underwent a conversion to Roux-en-Y gastric bypass and six patients (7.5%) underwent conversion to one anastomosis gastric bypass. Resolution of type 2 diabetes (T2D), hypertension, and hypercholesterolemia occurred in 47%, 43.7%, and 48.4%, respectively. De-novo cases of gastroesophageal reflux (GERD) were present in 40%. CONCLUSION: SG shows high long-term failure rates. One of every three patients will undergo another surgical procedure within a 10-year period.

Revisional Surgery of One Anastomosis Gastric Bypass for Severe Protein-Energy Malnutrition.

BACKGROUND: One anastomosis gastric bypass (OAGB) is safe and effective. Its strong malabsorptive component might cause severe protein-energy malnutrition (PEM), necessitating revisional surgery. We aimed to evaluate the safety and outcomes of OAGB revision for severe PEM. METHODS: This was a single-center retrospective analysis of OAGB patients undergoing revision for severe PEM (2015-2021). Perioperative data and outcomes were retrieved. RESULTS: Ten patients underwent revision for severe PEM. Our center's incidence is 0.63% (9/1425 OAGB). All patients were symptomatic. Median (interquartile range) EWL and lowest albumin were 103.7% (range 57.6, 114) and 24 g/dL (range 19, 27), respectively, and 8/10 patients had significant micronutrient deficiencies. Before revision, nutritional optimization was undertaken. Median OAGB to revision interval was 18.4 months (range 15.7, 27.8). Median BPL length was 200 cm (range 177, 227). Reversal (n = 5), BPL shortening (n = 3), and conversion to Roux-en-Y gastric bypass (RYGB) (n = 2) were performed. One patient had anastomotic leak after BPL shortening. No death occurred. Median BMI and albumin increased from 22.4 kg/m2 (range 20.6, 30.3) and 35.5 g/dL (range 29.2, 41), respectively, at revision to 27.5 (range 22.2, 32.4) kg/m2 and 39.5 g/dL (range 37.2, 41.7), respectively, at follow-up (median 25.4 months, range 3.1, 45). Complete resolution occurs after conversion to RYGB or reversal to normal anatomy, but not after BPL shortening. CONCLUSIONS: Revisional surgery of OAGB for severe PEM is feasible and safe after nutritional optimization. Our results suggest that the type of revision may be an important factor for PEM resolution. Comparative studies are needed to define the role of each revisional option.

Anastomotic Ulcer Perforation Following One Anastomosis Gastric Bypass.

PERFORATED ANASTOMOTIC ULCER AFTER ONE ANASTOMOSIS GASTRIC BYPASS: BACKGROUND: One anastomosis gastric bypass (OAGB) is a common bariatric metabolic surgery. Anastomotic ulcer (AU) perforation is a delayed complication, liable to cause sepsis and death. We present a cohort of twelve patients who underwent emergent surgery due to AU perforation. MATERIALS AND METHODS: A retrospective analysis of a single center database of patients operated for AU perforation after OAGB (January 2015 to December 2021). Data retrieved included perioperative characteristics and postoperative outcomes. RESULTS: The incidence of AU perforation among 1425 OAGB patients is 0.7%. AU perforation occurred after OAGB at a median time interval of 13 months (interquartile range (IQR) 5, 23). Eight patients had at least one risk factor for AU perforation. All patients presented with acute abdominal pain. Pneumoperitoneum was evident in ten patients on imaging studies. Surgery was laparoscopic in eleven patients, with one conversion to laparotomy. Operative findings were AU perforation, with a median perforation size of 5 mm (IQR 1.1, 18.7). Laparoscopic omentopexy ± primary AU repair, open omentopexy ± primary AU repair, and laparoscopic conversion to Roux-en-Y gastric bypass were performed (n = 9, 2, 1 patients, respectively). Median length of stay was 7.5 days (IQR 5, 11.5). No major complications occurred. All patients are doing well at a median follow-up of 11.5 months (IQR 2.2, 19.2). Four out of seven smoking patients still smoke. CONCLUSION: AU perforation after OAGB mandates a high index of suspicion, prompt diagnosis, and surgical treatment. Laparoscopic omentopexy ± primary AU repair is feasible in most cases, safe, and confers good outcomes.

Endoscopic Management of Sleeve Stenosis.

PURPOSE: Sleeve gastrectomy is one of the most popular bariatric procedures performed. A complication of this surgery is sleeve stenosis, causing significant morbidity and the need for corrective intervention. Endoscopic treatment using pneumatic dilation has evolved as an effective, and minimally invasive, technique to successfully treat this complication. Here we report our experience with endoscopic management of sleeve stenosis at a tertiary bariatric center. MATERIAL AND METHODS: We identified all patients that underwent endoscopic management of sleeve stenosis at a tertiary bariatric center from 2010. We reviewed patient demographics, operative data, interval to endoscopic treatment, and outcomes of pneumatic dilations. RESULTS: Sixty seven patients underwent 130 endoscopic dilations. The majority of these patients were female (71%), and at the time of sleeve gastrectomy average age was 43.3 years (range 18-68 years) and average BMI was 41.5 kg/m2 (range 31-63 kg/m2). The time interval to first endoscopic procedure was 7.2 months (range 0.75-53 months), with an average of 2 procedures per patient. During the follow-up period, the success rate of endoscopic dilatation was 76.1%, while the remaining 16 patients underwent conversion to gastric bypass. Two patients underwent emergency conversion to gastric bypass for sleeve perforation during the procedure (1.5%). There was a modest weight gain of 3 kg (4.2% total body weight) after sleeve dilatation. CONCLUSIONS: Endoscopic management of sleeve stenosis is safe and effective, with a success rate of over 75%. During endoscopic management, there was a 1.5% risk of sleeve perforation requiring emergency surgery. Mild weight regain occurred following endoscopic sleeve dilation.

Bariatric Surgery Affects Plasma Levels of Alanine Aminotransferase Independent of Weight Loss: A Registry-Based Study.

Patients that undergo bariatric surgery experience weight loss and a reduction in the plasma levels of the hepatic enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST). We used the Israeli national bariatric registry, which includes demographic, clinical, and biochemical data on 19,403 patients, of which 1335 patients had two-year follow-up data on ALT, AST, A1C, and BMI, to test the dependence of the reduction in the levels of ALT and AST on weight loss. The data were analyzed using regression models, retrospective matching, and time course analyses. Changes in liver enzymes did not correlate with change in BMI, and linear regression models did not demonstrate that the change in ALT and AST values were dependent on pre-operative levels of BMI or the extent of weight loss. ALT and AST levels were reduced two years after surgery compared with a cohort of retrospectively matched patients for ethnicity, sex, age, BMI, and A1C. Finally, patients who regained weight displayed a reduction in levels of liver enzymes. Our results suggest that bariatric surgery affects AST and ALT levels via weight loss dependent and independent mechanisms. Mechanistic studies that will identify the nature of this effect and the clinical relevance of ALT and AST levels to the post-bariatric liver function are warranted.

Sleeve Gastrectomy Is Associated with a Greater Reduction in Plasma Liver Enzymes Than Bypass Surgeries-A Registry-Based Two-Year Follow-Up Analysis.

Bariatric surgeries may lead to an improvement in metabolic fatty liver disease, and a reduction in the levels of the hepatic enzyme Alanine Aminotransferase (ALT). We compared the effects of Sleeve Gastrectomy (SG), Roux en Y Gastric Bypass (RYGB) and One Anastomosis Gastric Bypass (OAGB) on the levels of ALT by analysis of two-year follow-up data from 4980 patients in the Israeli Bariatric Registry that included laboratory tests and demographic information. Pre-operative characteristics of patients, and particularly levels of liver enzymes, were similar across surgery types. Regression modeling and retrospective matching showed that SG was superior to RYGB and OAGB in reducing ALT levels, and in reducing the fraction of patients with abnormally high ALT levels. Two-year post-surgery, an increase in ALT levels from normal to abnormal levels was observed in 5% of SG patients, and in 18% and 23% of RYGB and OAGB patients. In conclusion, SG leads to a greater reduction in ALT levels compared with bypass surgeries and a lower incidence of post-surgical elevation of ALT levels. Further studies are required to identify the cause for the rise in liver enzymes, and to determine whether ALT levels correlate with liver pathology especially following bariatric surgery.

Sleeve Gastrectomy Failure-Revision to Laparoscopic One-Anastomosis Gastric Bypass or Roux-n-Y Gastric Bypass: a Multicenter Study.

INTRODUCTION: Laparoscopic sleeve gastrectomy (LSG) is the most popular bariatric procedure performed worldwide. However, many patients undergo secondary surgery due to either weight-related and complication-related reasons or both. Conversional options vary with one-anastomosis gastric bypass (OAGB) and Roux-n-Y gastric bypass (RYGB) being the most common. The aim of the study was to assess the safety and efficacy of converting failed LSG to either OAGB or RYGB, and compare weight-related results and post-conversion complications. METHODS: Retrospective review of hospital records of patients who underwent conversion from LSG to either RYGB or OAGB due to insufficient weight loss or weight regain in 7 bariatric centers between 2013 and 2019. Data retrieved included demographics, anthropometrics, comorbidities, indication for conversion, conversion type, complications, and weight loss. RESULTS: During the study period, 396 patients were included in the study. Eighty-four (21%) patients were lost to follow-up. RYGB and OAGB were performed in 119 and 144 patients, respectively. Mean age and body mass index (BMI) at revision were 44.2 years (range 19-72) and 40.6 ± 5.9 kg/m2 (range 35-71), respectively. Of these, 191 (73%) were female. Percent total body weight loss (%TWL) was 16% ± 1% for the RYGB group vs. 23% ± 12% for the OAGB group (p = 0.0007) at a median follow-up of 29 months (range 7-78 months) following conversion. Gastroesophageal reflux disease (GERD) was significantly higher 1 year following conversion to OAGB vs. RYGB occurring in 25 (17.4%) and 9 (7.6%) patients, respectively (p = 0.018). CONCLUSIONS: Conversion of LSG to OAGB, compared to RYGB, results in increased weight loss but a higher rate of GERD and potential nutritional deficiencies.

Roux-en-Y Gastric Bypass Versus One Anastomosis Gastric Bypass as a Preferred Revisional Bariatric Surgery After a Failed Silastic Ring Vertical Gastroplasty.

BACKGROUND: Over the years, the silastic ring vertical gastroplasty (SRVG) has shown poor long-term outcomes with both weight regain and complications. Therefore, most bariatric surgeons have been presented with the need to perform a successful and safe conversion procedure. Yet the preferred and recommended conversion surgery regarding weight loss, comorbidity improvement, and postoperative complications remains under debate. OBJECTIVE: The aim of this study is to compare the outcomes of conversion from SRVG with either Roux-en-Y gastric bypass (RYGBP) or one anastomosis gastric bypass (OAGB). MATERIALS AND METHODS: A retrospective study was conducted from our bariatric surgery units' database. We reviewed the files of patients who underwent either a RYGBP or OAGB after a previous SRVG. Demographics, obesity-related comorbidities, BMI before and after the procedure, postoperative complications, and length of hospital stay were analyzed. RESULTS: Between May 2008 and August 2018, fifty-four patients underwent conversion from a failed SRVG. Twenty-one patients underwent conversion to OAGB (39%), and thirty-three patients underwent conversion to RYGBP (61%). Major complications were reported in 9.5% of the OAGB group and 15.1% of the RYGBP group. At a mean follow-up of 28 months, the OAGB group achieved a 78.5% excess BMI loss compared with 57.6% in the RYGBP group (p = 0.137). One patient (4.7%) of the OGBP group and 5 (15.1%) of the RYGBP group needed reoperations due to complications (p = 0.224). CONCLUSION: The OGBP is gaining popularity and evidence as an effective and safe procedure. Here we show the successful utilization of the OGBP, when compared with RYGBP, as a revisional procedure after SRVG.

One Anastomosis Gastric Bypass as a Revisional Procedure After Failed Laparoscopic Adjustable Gastric Banding.

BACKGROUND: Recent data demonstrates that laparoscopic adjustable gastric banding (LAGB) is found to be associated with high rates of weight loss failure and long-term complications. Therefore, the search for the optimal revisional bariatric procedure is ongoing. OBJECTIVE: We aim to assess the safety and efficacy of converting a failed LAGB to laparoscopic one anastomosis gastric bypass (OAGB) as a revisional procedure. SETTING: Large, metropolitan, tertiary, university hospital. METHODS: Retrospective review of patients who underwent OAGB after LAGB.Demographics, comorbidities, BMI before and after the procedure, complications, and length of stay were documented. RESULTS: Fifty-seven patients underwent OAGB after LAGB. For 41 patients, the band was removed, and an OAGB was performed in a single procedure (71.9%), and 96.5% of the cases were completed laparoscopically. Postoperative complications occurred in 9 patients (15.7%), including one mortality. Average BMI decreased from 42.8 ± 7.0 to 31.3 ± 5.2 kg/m2 at least 1 year after surgery, representing a mean %EWL of 64.5%. There was no statistical difference in complication rates between the 1-stage and 2-stage approach. CONCLUSIONS: Conversion of a failed LAGB to OAGB is effective but carries higher complication rates. Randomized controlled studies comparing different procedures are necessary to further clarify the optimal revisional bariatric operation.

Sleeve Gastrectomy in the Elderly.

BACKGROUND: Even though risks are higher and long-term results may be less favorable, the elderly obese can still benefit from bariatric surgery. Whether the higher surgical risk is worth the benefits is yet to be determined. MATERIALS AND METHODS: We reviewed our database and identified all patients aged 65 or older who underwent sleeve gastrectomy between May 2010 and November 2015. We documented patient demographics, obesity-related comorbidities, body mass index (BMI) before and after the procedure, percent excess weight loss, comorbidity improvement or resolution, length of follow-up, postoperative complications, re-operations, and length of hospital stay. We compared our study group to a control group of sleeve gastrectomy patients under the age of 65. RESULTS: Sixty-six patients (mean age 67.6 ± 2.6 years) underwent laparoscopic sleeve gastrectomy. Patients achieved an average of 53.5% excess BMI loss (EBMIL) after 21 months of follow-up. EBMIL was inferior to that achieved by the control group (EBMIL 77.3%, p < 0.0001). Elderly patients showed significant improvement or resolution in all obesity-related comorbidities. Complication and re-operation rates were similar between the 2 groups. CONCLUSION: In an elderly population, laparoscopic sleeve gastrectomy is safe and effective, yet weight loss outcomes are more modest when compared to a younger surgical population. Carefully selected elderly patients can benefit from bariatric surgery.

Lipid-Associated Macrophages Control Metabolic Homeostasis in a Trem2-Dependent Manner.

Immune cells residing in white adipose tissue have been highlighted as important factors contributing to the pathogenesis of metabolic diseases, but the molecular regulators that drive adipose tissue immune cell remodeling during obesity remain largely unknown. Using index and transcriptional single-cell sorting, we comprehensively map all adipose tissue immune populations in both mice and humans during obesity. We describe a novel and conserved Trem2+ lipid-associated macrophage (LAM) subset and identify markers, spatial localization, origin, and functional pathways associated with these cells. Genetic ablation of Trem2 in mice globally inhibits the downstream molecular LAM program, leading to adipocyte hypertrophy as well as systemic hypercholesterolemia, body fat accumulation, and glucose intolerance. These findings identify Trem2 signaling as a major pathway by which macrophages respond to loss of tissue-level lipid homeostasis, highlighting Trem2 as a key sensor of metabolic pathologies across multiple tissues and a potential therapeutic target in metabolic diseases.

Gastric Bypass as a Third Bariatric Procedure-Our Experience with 42 Cases.

BACKGROUND: It is not uncommon to encounter patients seeking a third, fourth, or even fifth bariatric procedure. With higher expected complication rates and questionable patient benefit, the indication for multiple revisions is still in doubt. To evaluate the perioperative and post-operative outcomes of patients undergoing gastric bypass after two previous bariatric surgeries or more. METHODS: We identified all patients that underwent gastric bypass following at least 2 previous bariatric surgeries. We looked at patient demographics, previous bariatric surgeries, pre-operative body mass index (BMI) and obesity-related co-morbidities, perioperative complications, length of stay (LOS), re-admissions and re-operations, percentage of excess weight loss, and resolution or improvement in comorbidities. RESULTS: Forty-two patients met the inclusion criteria, the majority being females (31, 73.8%). Average age was 45.6 years (range 27-62), average weight and BMI was 116 kg (range 75-175 kg) and 41.1 kg/m2 (range 25.6-58.7 kg/m2), respectively. Thirty-two patients had two previous bariatric surgeries (73.8%), and 10 patients had 3 former bariatric surgeries (23.8%), and for one patient, this was the fifth bariatric procedure (2.4%). Mean LOS was 10 days (range 2-56 days). Eight patients (19%) needed re-admission and 5 (11.9%) needed re-operation. At a median follow up of 48 months (range 7-99 months), the average BMI was 34.5 kg/m2 (range 23.7-55.1 kg/m2) reflecting an excess BMI loss of 43.3%. CONCLUSIONS: Gastric bypass as a third or more bariatric procedure is effective yet associated with high complication rates, re-admissions, and re-operations.

Anti-factor Xa levels in patients undergoing laparoscopic sleeve gastrectomy: 2 different dosing regimens of enoxaparin.

BACKGROUND: Morbidly obese patients undergoing bariatric surgery are at risk for developing venous thromboembolic events. Data regarding the appropriate dosing strategy in this special population is limited. OBJECTIVE: To evaluate 2 different dosing regimens of enoxaparin in a prospective cohort of patients undergoing laparoscopic sleeve gastrectomy. SETTING: University hospital, Israel METHODS: The study cohort consisted of 54 patients divided into 2 groups. Group I received 40 mg enoxaparin every 24 hours, and group II received 60 mg enoxaparin every 24 hours. Anti-factor Xa (FXa) levels from each patient were obtained 3 to 4 hours after administration of the third dose of enoxaparin. Levels between .2 and 0.5 U/mL were considered appropriate. Five additional patients were selected as controls. RESULTS: There were 31 patients in group I and 23 patients in group II. There was a statistically significant difference between anti-FXa levels achieved in each group: .247 U/mL in group I (range, .15-.39) versus .346 U/mL (range, .24-.8) in group II. Both groups achieved mean anti-FXa levels in the range designated appropriate with a high proportion of patients achieving appropriate levels (group I: 80.6%; group II: 91.3%). Univariate analyses found that total weight and sex were significantly correlated with anti-FXa levels. However, a multivariate analysis including enoxaparin dose found that only enoxaparin dose remained significantly correlated with anti-FXa levels. CONCLUSION: In the absence of sufficient data regarding clinical efficacy and safety of different dosing regimens both dosing regimens studied are reasonable choices for venous thromboembolic events prophylaxis after bariatric surgery.

Laparoscopic bariatric surgery for those with body mass index of 70-125 kg/m2.

BACKGROUND: Data on laparoscopic bariatric surgery in the extremely obese are limited. Technical difficulties, in addition to the patients' severe weight-related co-morbidities, can compromise the safety of bariatric surgery in these patients. Our objectives were to assess the safety and feasibility of laparoscopic bariatric surgery in extremely obese patients and to compare the outcomes of different surgical approaches at a bariatric surgery center of excellence in an academic medical center. METHODS: We reviewed our prospectively collected database and identified all patients with a body mass index (BMI) of ≥ 70 kg/m(2) who had undergone bariatric surgery. The data on patient demographics, baseline characteristics, and outcomes of bariatric surgery were retrieved. RESULTS: A total of 49 patients with a mean BMI of 80.7 kg/m(2) (range 70-125) underwent 61 bariatric procedures. Of the 49 patients, 26 underwent sleeve gastrectomy, 11 gastric bypass, and 12 underwent a 2-stage procedure (sleeve gastrectomy followed by gastric bypass). At a mean follow-up of 17.4 months, the average BMI had decreased to 60.9 kg/m(2) (36% excess weight loss). Overall, the patients who underwent a 2-stage procedure achieved greater percentage of excess weight loss (54.5%) than did those who underwent either single-stage sleeve gastrectomy or gastric bypass (25.4%, P = .002 and 43.8%, P = .519, respectively). Of the 61 cases, 60 (98.4%) were completed laparoscopically. The early complication rate was 16.4% overall; most were minor complications. The late complication rate was 14.8%. A single late mortality occurred in this series. CONCLUSION: Laparoscopic bariatric surgery can be performed safely on patients with a BMI of ≥ 70 kg/m(2). A staged approach might offer better weight loss results.