Bariatric surgery and the diseased kidney: a 5-year assessment of safety and postoperative renal outcomes.

BACKGROUND: Obesity and its related medical conditions are well-established contributors to the development of chronic kidney disease (CKD). Metabolic and bariatric surgery (MBS), including procedures such as sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), is a potential intervention for these individuals. However, the heightened risk of postoperative complications casts doubts on the suitability of MBS in this population. Our aim is to evaluate the long-term safety, anthropometric and renal outcomes of MBS in patients with CKD. METHODS: A retrospective review of patients who underwent primary laparoscopic MBS with a BMI ≥ 35 kg/m2 and a preoperative diagnosis of stage 2 to 5 CKD. Criteria for CKD diagnosis and staging were based on estimated glomerular filtration rate measurements in accordance with established guidelines. Anthropometric and renal outcomes were measured at 3-, 6-, 12-, 24- and 60-months postoperatively. RESULTS: A total of 302 patients (177 SG, 125 RYGB) were included. RYGB was preferred for patients with stage 3 CKD, while SG was more common in stages 4 and 5. At 5-year follow-up, percentage of total weight loss was higher in the RYGB cohort compared to SG (25.1% vs. 18.6%, p = 0.036). Despite SG patients having more advanced CKD, the incidence of late complications was significantly higher following RYGB, with 11 incidents (8.8%), compared to the SG cohort with only 4 cases (2.3%) (p = 0.014). In those with preoperative CKD stage 3, 76 patients (43.2%) improved to stage 2, with another 9 patients (5.1%) improving further to stage 1. Of all patients, 63 (20.8%) eventually received a successful renal transplant. CONCLUSIONS: MBS is an effective strategy for sustained weight loss in patients with CKD with acceptable complications rates. RYGB leads to a higher percentage of overall weight loss, albeit with an elevated likelihood of late surgical complications. Future studies are needed to determine the safety of MBS in this demographic.

Micronutrient status 2 years after bariatric surgery: a prospective nutritional assessment.

Background: Among commonly performed bariatric surgeries, biliopancreatic diversion with duodenal switch (BPD-DS) provides greater weight loss than Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG), with sustained metabolic improvements. However, the risk of long-term nutritional deficiencies due to the hypoabsorptive component of BPD-DS hinders its widespread use. Objective: The aim of the study was to examine nutritional status over 2 years after BPD-DS, RYGB or SG. Methods: Patients were recruited in the REMISSION trial (NCT02390973), a single-center, prospective study. Out of 215 patients, 73, 48 and 94, respectively, underwent BPD-DS, RYGB or SG. Weight loss, micronutrient serum levels (including iron, calcium, parathormone, vitamins A, B12 and D), and nutritional supplementation were assessed over 2 years. Patients were supplemented according to the type of surgery and individual micronutrient level evolution. Results: At baseline, BPD-DS patients were younger than SG patients (p = 0.0051) and RYGB patients had lower body mass index (p < 0.001). Groups had similar micronutrient levels before surgery, with vitamin D insufficiency as the most prevalent nutritional problem (SG: 38.3%, RYGB: 39.9%, BPD-DS: 54.8%, p = 0.08). BPD-DS patients showed lower levels of iron, calcium and vitamin A than SG patients at 24 months. Groups had similar levels of vitamin D at 24 months. Prevalence of vitamin D, calcium, iron, vitamin A and vitamin B12 deficiency was similar among groups at 24 months. Rates of vitamin D insufficiency and iron deficiency were lower at 24 months than at baseline. Micronutrient intake was consistent with recommendations in groups post-surgery, but most BPD-DS patients took vitamin A and vitamin D supplement doses above initial recommendations. Conclusion: With appropriate medical and nutritional management, all surgeries led to similar rates of vitamin D, calcium, iron, vitamin A and vitamin B12 deficiencies at 24 months. However, initial vitamin A and vitamin D supplementation recommendations for BPD-DS patients should be revised upwards.

Leptin receptor deficiency impedes metabolic surgery related-weight loss through inhibition of energy expenditure in db/db mice.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) surgery is an effective metabolic surgery against diabetes and obesity. Clinical evidence indicates that patients with severe obesity have a poor curative effect in losing weight if they suffer from leptin or its receptor deficiency, but the underlying mechanism remains elusive. Here, we investigated the effect of leptin receptor deficiency on metabolic dysfunction in db/db mice treated by RYGB surgery. METHODS: The db/db mice and their heterozygote control db/m mice were subjected to RYGB or sham surgery. Body weight, blood glucose, food intake and glucose tolerance were evaluated. Micro-PET/CT and histological analysis were performed to examine the glucose uptake of tissues and the fat changes in mice. The key factors in glucose and fatty acid metabolism were detected by western blot analysis. RESULTS: Compared with the sham group, the db/db mice in the RYGB group showed more significant weight regain after surgical recovery and improvement in hyperinsulinemia and glucose tolerance. However, the total body fat and multiple organ lipid deposition of RYGB-treated db/db mice was increased. The underlying mechanism studies suggested that the activation of AMPK regulated GLUT4 to increase glucose uptake, but AMPK could not promote fatty acid oxidation through the JAK2/STAT3 pathway under leptin receptor deficiency in db/db mice. CONCLUSION: We conclude that leptin receptor deficiency impedes the AMPK activation-mediated fat catabolism but does not affect AMPK-related glucose utilization after metabolic surgery in db/db mice. This result helps select surgical indications for patients with obesity and diabetes.

Trends in bariatric surgery training: bariatric operations performed by Fellowship Council trainees from 2012 to 2019.

BACKGROUND: The American Society for Metabolic and Bariatric Surgery (ASMBS) Fellowship Certificate was created to ensure satisfactory training and requires a minimum number of anastomotic cases. With laparoscopic sleeve gastrectomy becoming the most common bariatric procedure in the United States, this may present a challenge for fellows to obtain adequate numbers for ASMBS certification. OBJECTIVES: To investigate bariatric fellowship trends from 2012 to 2019, the types, numbers, and approaches of surgical procedures performed by fellows were examined. SETTING: Academic training centers in the United States. METHODS: Data were obtained from Fellowship Council records of all cases performed by fellows in ASMBS-accredited bariatric surgery training programs between 2012 and 2019. A retrospective analysis using standard descriptive statistical methods was performed to investigate trends in total case volume and cases per fellow for common bariatric procedures. RESULTS: From 2012 to 2019, sleeve gastrectomy cases performed by all Fellowship Council fellows nearly doubled from 6,514 to 12,398, compared with a slight increase for gastric bypass, from 8,486 to 9,204. Looking specifically at bariatric fellowships, the mean number of gastric bypass cases per fellow dropped over time, from 91.1 cases (SD = 46.8) in 2012-2013 to 52.6 (SD = 62.1) in 2018-2019. Mean sleeve gastrectomy cases per fellow increased from 54.7 (SD = 31.5) in 2012-2013 to a peak of 98.6 (SD = 64.3) in 2015-2016. Robotic gastric bypasses also increased from 4% of all cases performed in 2012-2013 to 13.3% in 2018-2019. CONCLUSIONS: Bariatric fellowship training has seen a decrease in gastric bypasses, an increase in sleeve gastrectomies, and an increase in robotic surgery completed by each fellow from 2012 to 2019.

Robot-assisted vs laparoscopic bariatric procedures in super-obese patients: clinical and economic outcomes.

The increased operative time and costs represent the main limitations of robotic technology application to bariatric surgery. Robotic platforms may help the surgeon to overcome the technical difficulties in super-obese (SO, BMI ≥ 50 kg/m2) patients, in which multi-quadrant operations could be challenging. We aimed to evaluate the effect of robot-assisted (R) versus laparoscopic (L) approaches in Single Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S) and Roux-en-Y Gastric Bypass (RYGB) in SO and Super-Super Obese (SSO, BMI ≥ 60 kg/m2) patients in terms of outcomes and cost-effectiveness. Bariatric procedures performed from 2012 to 2023 were retrospectively reviewed. The inclusion criteria were BMI ≥ 50 kg/m2, primary SADI-S or RYGB. Operative time (OT), early complications, post-operative stay (POS), overall costs and follow-up data were analyzed. A subgroup analysis for surgical procedures and SSO patients was also performed. Among 4596 patients, 174 RYGB and 91 SADI-S in BMI ≥ 50 kg/m2 patients were selected. After Propensity Score Matching analysis, two groups of patients were identified (laparoscopic and robot-assisted), each one composed of 18 RYGB and 26 SADI-S. Intraoperative and post-operative complication rates and POS were comparable. Mean OT was longer in robotic procedures compared with laparoscopy (199.1 ± 65.7 and 109.5 ± 39.1 min, respectively, p < 0.001). The difference in OT was eliminated after only SSO patients were included in the analysis (172.7 ± 24.1 vs 152.6 ± 26.2 min for R-SADI-S and L-SADI-S, respectively, p = 0.107). Robotic surgeries were associated with higher costs (8134.6 ± 1886.7 and 2386.7 ± 388.2 € in R-RYGB and L-RYGB, respectively; 7996.6 ± 873.1 and 3954.6 ± 631.1 € in R-SADI-S and L-SADI-S). Despite increased costs, robotic approach may represent an added value in more complex cases such as SSO patients.

Utilization and Outcomes of Roux-en-Y Gastric Bypass Surgery Following the Affordable Care Act in the United States.

BACKGROUND: The passage of the Affordable Care Act (ACA) in 2010 marked a pivotal moment in American health care policy, significantly expanding access to health care services. This study aims to explore the relationship between the ACA and the utilization and outcomes of Roux-en-Y Gastric Bypass (RYGB) surgery. METHODS: Using data from the National Inpatient Sample (NIS) Database, this retrospective study compares the pre-ACA period (2007-2009) with the post-ACA period (2017-2019), encompassing patients who had RYGB. Multivariable logistic analysis was done accounting for patient's characteristics, comorbidities, and hospital type. RESULTS: In the combined periods, there were 158 186 RYGB procedures performed, with 30.0% transpiring in pre-ACA and 70.0% in the post-ACA. Post-ACA, the proportion of uninsured patients decreased from 4.8% to 3.6% (P < .05), while Black patients increased from 12.5% to 18.5% (P < .05). Medicaid-insured patients increased from 6.8% to 18.1% (P < .05), and patients in the poorest income quartile increased from 20% to 26% (P < .05). Patients in the post-ACA period were less likely to have longer hospital stays (OR = .16: 95% CI .16-.17, P < .01), in-hospital mortality (OR = .29: 95% CI .18-.46, P < .01), surgical site infection (OR = .25: 95% CI .21-.29, P < .01), postop hemorrhage (OR = .24: 95% CI .21-.28, P < .01), and anastomotic leak (OR = .14: 95% CI .10-.18, P < .01) than those in the pre-ACA period. DISCUSSION: Following the implementation of the ACA, utilization of bariatric surgery significantly increased, especially among Black patients, Medicaid beneficiaries, and low-income patients. Moreover, despite the inclusion of more high-risk surgical patients in the post-ACA period, there were better outcomes after surgery.

Association of bariatric surgery with indicated and unintended outcomes: An umbrella review and meta-analysis for risk-benefit assessment.

Bariatric surgery can cause numerous functional changes to recipients, some of which are unintended. However, a systematic evaluation of wide-angled health benefits and risks following bariatric surgery has not been conducted. We systematically evaluated published systematic reviews of randomized controlled trials and observational studies reporting the association between bariatric surgery and health outcomes. We performed subgroup analyses by surgery type and sensitivity analysis, excluding gastric band. Thirty systematic reviews and 82 meta-analyzed health outcomes were included in this review. A total of 66 (80%) health outcomes were significantly associated with bariatric surgery, of which 10 were adverse outcomes, including suicide, fracture, gastroesophageal reflux after sleeve gastrectomy, and neonatal morbidities. The other 56 outcomes were health benefits including new-onset diabetes mellitus (DM) (odds ratio [OR] = 0.39; 95% confidence interval [CI] = 0.19-0.79), hypertension (OR = 0.36; 95% CI = 0.33-0.40), dyslipidemia (OR = 0.33; 95% CI = 0.14-0.81), cancers (OR = 0.65; 95% CI = 0.53-0.80), cardiovascular diseases (CVDs), and women's health. Surgery is associated with reductions in all-cause mortality and death due to cancer, DM, and CVD. Bariatric surgery has both beneficial and harmful effects on a broader than expected array of patients' health outcomes. An expansion of the indication for bariatric surgery could be discussed to include a broader population with metabolic vulnerabilities.

Global assessment of surgical skills (GASS): validation of a new instrument to measure global technical safety in surgical procedures.

BACKGROUND: Broad implementation of the American Board of Surgery's entrustable professional activities initiative will require assessment instruments that are reliable and easy to use. Existing assessment instruments of general laparoscopic surgical skills have limited reliability, efficiency, and validity across the spectrum of formative (low-stakes) and summative (high-stakes) assessments. A novel six-item global assessment of surgical skills (GASS) instrument was developed and evaluated with a focus upon safe versus unsafe surgical practice scoring rubric. METHODS: The GASS was developed by iterative engagement with expert laparoscopic surgeons and includes six items (economy of motion, tissue handling, appreciating operative anatomy, bimanual dexterity, achievement of hemostasis, overall performance) with a uniform three-point scoring rubric ("poor-unsafe", "adequate-safe", "good-safe"). To test inter-rater reliability, a cross-sectional study of four bariatric surgeons with experience ranging from 4 to 28 years applied the GASS and the global operative assessment of laparoscopic skills (GOALS) to 30 consecutive Roux-en-Y gastric bypass procedure operative videos. Inter-rater reliability was assessed for a simplified dichotomous "safe" versus "unsafe" scoring rubric using Gwet's AC2. RESULTS: The GASS inter-rater reliability was very high across all six domains (0.88-1.00). The GASS performed comparably to the GOALS inter-rater reliability scores (0.96-1.00). The economy of motion and bimanual dexterity items had the highest percentage of unsafe ratings (9.2% and 5.8%, respectively). CONCLUSION: The GASS, a novel six-item instrument of general laparoscopic surgical skills, was designed with a simple scoring rubric (poor-safe, adequate-safe, good-safe) to minimize rater burden and focus feedback to trainees and promotion evaluations on safe surgical performance. Initial evaluation of the GASS is promising, demonstrating high inter-rater reliability. Future research will seek to assess the GASS against a broader spectrum of laparoscopic procedures.

Surgeon experience with insurance barriers to offering gastric bypass as an evidence-based operation for pathologic GERD.

INTRODUCTION: Obesity is an increasingly prevalent public health problem often associated with poorly controlled gastroesophageal reflux disease. Fundoplication has been shown to have limited long-term efficacy in patients with morbid obesity and does not address additional weight-related co-morbidities. Roux-en-Y gastric bypass (RYGB) is the gold standard operation for durable resolution of GERD in patients with obesity, and is also used as a salvage operation for GERD after prior foregut surgery. Surgeons report access to RYGB as surgical treatment for GERD is often limited by RYGB-specific benefit exclusions embedded within insurance policies, but the magnitude and scope of this problem is unknown. METHODS: A 9-item survey evaluating surgeon practice and experience with insurance coverage for RYGB for GERD was developed and piloted by a SAGES Foregut Taskforce working group. This survey was then administered to surgeon members of the SAGES Foregut Taskforce and to surgeons participating in the SAGES Bariatrics and/or Foregut Facebook groups. RESULTS: 187 surgeons completed the survey. 89% reported using the RYGB as an anti-reflux procedure. 44% and 26% used a BMI of 35 kg/m2 and 30 kg/m2 respectively as cutoff for the RYGB. 89% viewed RYGB as the procedure of choice for GERD after bariatric surgery. 69% reported using RYGB to address recurrent reflux secondary to failed fundoplication. 74% of responders experienced trouble with insurance coverage at least half the time RYGB was offered for GERD, and 8% reported they were never able to get approval for RYGB for GERD indications in their patient populations. CONCLUSION: For many patients, GERD and obesity are related diseases that are best addressed with RYGB. However, insurance coverage for RYGB for GERD is often limited by policies which run contrary to evidence-based medicine. Advocacy is critical to improve access to appropriate surgical care for GERD in patients with obesity.

Urinary Lithiasis Risk Assessment after Bariatric Surgery.

Malabsorption is a consequence of gastric bypass (GB). GB increases the risk of kidney stone formation. This study aimed to evaluate the accuracy of a screening questionnaire for assessing the risk of lithiasis in this population. We performed a monocentric retrospective study to evaluate a screening questionnaire administered to patients who underwent gastric bypass surgery between 2014 and 2015. Patients were asked to answer a questionnaire that included 22 questions divided into four parts: medical history, episodes of renal colic before and after bypass surgery, and eating habits. A total of 143 patients were included in the study, and the mean age of the patients was 49.1 ± 10.8 years. The time between gastric bypass surgery and the completion of the questionnaire was 50.75 ± 4.95 months. The prevalence of kidney stones in the study population was 19.6%. We found that with a score of ≥6, the sensitivity and specificity were 92.9% and 76.5%, respectively. Positive and negative predictive values were 49.1% and 97.8%, respectively. The ROC curve showed an Area Under the Curve (AUC) of 0.932 ± 0.029 (p < 0.001). We developed a reliable and short questionnaire to identify patients at a high risk of kidney stones after gastric bypass. When the results of the questionnaire were equal to or greater than six, the patient was at a high risk of kidney stone formation. With a good predictive negative value, it could be used in daily practice to screen patients who have undergone gastric bypass and are at a high risk of renal lithiasis.

Bariatric Surgery Performed at a Tertiary Care Hospital and an Ambulatory Hospital: A 5 Year Comparison of Outcomes, OR Efficiencies and Costs.

PURPOSE: To explore change in 30-day post-operative complications, operative times, operating room (OR) efficiencies for bariatric surgery performed at a tertiary care hospital (TH) and an ambulatory hospital with overnight stay (AH) within one hospital network over 5 years; and to compare perioperative costs at the TH and AH. MATERIALS AND METHODS: We performed a retrospective analysis of existing data from a cohort of consecutive adult patients who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG) between September 2016 and August 2021 at TH and AH. RESULTS: A total of 805 patients (762 LRYGB, 43 LSG) had surgery at AH, while 109 (92 LRYGB, 17 LSG) at TH. OR times for LRYGB and LSG performed at AH were significantly shorter versus TH (150 ± 24 vs 178 ± 51 min; p < 0.01) and (123 ± 24 vs 147 ± 34 min; p = 0.01). OR turnovers (19.2 ± 6.0 min vs 28.1 ± 6.1 min; p < 0.01) and Post Anesthetic Care Unit (PACU) times (2.4 ± 0.6 h vs 3.1 ± 1.5 h; p < 0.01) were significantly faster at AH versus TH. Proportion of patients requiring transfer for a complication from AH to TH remained constant over time (range 1.5-6.2%/year; p = 0.14). 30-day complication rates were similar between AH and TH (5.5-11% vs 0-15%; p = 0.12). LRYGB and LSG costs were similar between AH and TH (8,855 ± 1,328CAD vs 8,799 ± 2,729CAD; p = 0.91 and 8,763 ± 1,449CAD vs 7,857 ± 1,825CAD; p = 0.41). CONCLUSION: There was no difference in 30-day post-operative complications for LRYGB and LSG performed at AH and TH. Performing bariatric surgery at AH has the benefit of improved OR efficiency without a significant difference in total perioperative costs.

One Anastomosis Gastric Bypass for Revisional Bariatric Surgery: Assessment of Short-Term Safety.

PURPOSE: With the continued increase in bariatric procedures being performed in the USA, a growing percentage are revisions for weight regain after sleeve gastrectomy (SG) and gastric banding (LAGB). Standard practice in the USA involves conversion to Roux-en-Y gastric bypass (RYGB). Internationally, one anastomosis gastric bypass (OAGB) has become a popular and effective alternative. Without the jejuno-jejunal anastomosis, OAGB has reduced potential related long-term complications. The purpose of this study is to compare the short-term safety of revision to OAGB versus RYGB. MATERIALS AND METHODS: Patients who underwent conversion to OAGB from LAGB or SG for weight regain from January 2019 to October 2021 were compared to BMI, sex, and age-matched patients who underwent conversion to RYGB. RESULTS: In our study, 82 patients were included, 41 in each cohort (41 OAGB vs. 41 RYGB). The majority in both groups underwent conversion from SG (71% vs. 78%). Operative time, estimated blood loss, and length of stay were comparable. There was no difference in 30-day complications (9.8% vs. 12.2%, p = .99) or reoperation (4.9% vs. 4.9%, p = .99). Mean weight loss at 1 month was also comparable (7.91 lbs vs 6.36 lbs). CONCLUSIONS: Patients undergoing conversion to OAGB for weight regain had similar operative times, post-operative complication rates, and 1-month weight loss compared to those who underwent RYGB. While more research is needed, this early data suggests that OAGB and RYGB provide comparable outcomes when used as conversion procedures for to failed weight loss. Therefore, OAGB may present a safe alternative to RYGB.

Cost-Effectiveness of Bariatric Surgery in Tunisia.

Purpose: Obesity is a growing global issue with evidence linking it to an increase in loss of disease-free years, reduced quality of life, increased mortality, and additional economic burden. This study sought to establish the cost-effectiveness of gastric bypass and sleeve gastrectomy, compared to conventional therapy in patients with obesity, from a Tunisian healthcare payor perspective. Patients and Methods: A Markov model compared lifetime costs and outcomes of bariatric surgery with conventional treatment among patients with body mass index (BMI) ≥ 40 kg/m2, BMI ≥ 35 kg/m2 with obesity-related co-morbidities (Group 1), or BMI ≥ 35 kg/m2 with type 2 diabetes mellitus (T2DM) (Group 2). Inputs were sourced from the Tunisian Health Examination Survey, local clinician data and literature sources. Health states were associated with different cost and utility decrements. Changes in body mass index, systolic blood pressure, lipid ratio and diabetes remission rates were modelled on a yearly basis. The incremental cost-effectiveness ratio (ICER), quality-adjusted life years (QALYs) and net monetary benefit (NMB) were key outcomes. Sensitivity and scenario analyses were performed to test the model's robustness. Results: The model showed that the benefits of bariatric surgery were favorable compared to conventional treatment, with an ICER of 1844 TND/QALY in Group 1 patients and 2413 TND/QALY in Group 2 patients. Bariatric surgery resulted in a QALY gain of 3.26 per patient in Group 1 and a gain of 1.77 per patient in Group 2. At a willingness to pay threshold of 31,379 TND/QALY, the incremental NMB was 96,251 TND and 51,123 TND for Group 1 and Group 2, respectively. Conclusion: From the Tunisian healthcare payor perspective, bariatric surgery is cost-effective for patients with obesity and those with T2DM and obesity-related comorbidities. These findings may have impact on future decision-making on funding and reimbursement of bariatric surgery in Tunisia.

MyGood Trip, a Telemedicine Intervention for Physical Activity Recovery After Bariatric Surgery: Randomized Controlled Trial.

BACKGROUND: Despite bariatric surgery showing significant weight loss trajectories for many patients, a substantial proportion regain weight after the first year following surgery. The addition of telemedicine to standard care could support patients with engaging in a more active lifestyle and thus improve clinical outcomes. OBJECTIVE: Our aim was to evaluate a telemedicine intervention program dedicated to the promotion of physical activity including digital devices, teleconsultation, and telemonitoring the first 6 months following bariatric surgery. METHODS: This study employed a mixed methods design based on an open-label randomized controlled trial. Patients were included during the first week after bariatric surgery; then, they were randomized into 2 intervention groups: The TelePhys group received a monthly telemedicine consultation focusing on physical activity coaching, while the TeleDiet group received a monthly telemedicine consultation involving diet coaching. Data were collected using a watch pedometer and body weight scale, both of which were connected wirelessly. The primary outcome was the difference between the 2 groups in the mean numbers of steps at the first and sixth postoperative months. Weight change was also evaluated, and focus groups and interviews were conducted to enrich the results and capture perceptions of the telemedicine provided. RESULTS: Among the 90 patients (mean age 40.6, SD 10.4 years; 73/90, 81% women; 62/90, 69% gastric bypass), 70 completed the study until the sixth month (n=38 TelePhys; n=32 TeleDiet), and 18 participants agreed to be interviewed (n=8 Telephys; n=10 TeleDiet). An increase in the mean number of steps between the first and sixth months was found in both groups, but this change was significant only in the TeleDiet group (P=.01). No difference was found when comparing both intervention groups. Interviewed participants reported having appreciated the teleconsultations, as the individualized tailored counseling helped them to make better choices about behaviors that could increase their likelihood of a daily life in better health. Weight loss followed by social factors (such as social support) were identified as the main facilitators to physical activity. Family responsibilities, professional constraints as well as poor urban policies promoting physical activity, and lack of accessibility to sport infrastructure were their major barriers to postoperative lifestyle adherence. CONCLUSIONS: Our study did not show any difference in mobility recovery after bariatric surgery related to a telemedicine intervention dedicated to physical activity. The early postoperative timing for our intervention may explain the null findings. eHealth interventions aiming to change behaviors and carried out by clinicians require support from structured public health policies that tackle patients' obesogenic environment in order to be efficient in their struggle against sedentary lifestyle-related pathologies. Further research will need to focus on long-term interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT02716480, https://clinicaltrials.gov/ct2/show/NCT02716480.

Endoscopic and histopathological assessment of individuals undergoing one anastomosis gastric bypass: a 2-year follow-up.

BACKGROUND: There is much debate over the occurrence of biliary reflux to the gastric pouch after one anastomosis gastric bypass (OAGB) and its potential risks. OBJECTIVE: To assess endoscopic and histopathological findings following a standardized protocol of biopsy collection two years after OAGB. METHODS: A historical cohort study was conducted, based on a prospectively collected database, which involved 39 participants who underwent OAGB. Participants underwent clinical evaluation and esophagogastroduodenoscopy at the time of surgery and 24 months afterward. Post-operatively, biopsy specimens in esophagogastric junction, pouch, and anastomosis were systematically collected. RESULTS: 92.3% of the participants were female and the mean age was 37 ± 8.5 years. The mean body mass index (BMI) significantly decreased from 37.6 ± 5.7 kg/m2 to 27 ± 4.1 kg/m2 after 2 years (p < 0.001). The mean %TWL was 27.2 ± 10.5%. The prevalence of non-erosive gastritis significantly increased from 25.6 to 51.3% (p = 0.02). Erosive gastritis significantly decreased from 28.2 to 10.3% (p = 0.04). Four cases of marginal ulcers were identified (10.3%). The commonest histopathological finding was mild inflammation in 74.3% (esophagogastric junction), 58.9% (pouch), and 71.8% (anastomosis). There was one case of focal intestinal metaplasia in each site of interest and no cases of dysplasia or severe inflammation. CONCLUSIONS: Using a standardized protocol of post-operative biopsy collection, low rates of severe endoscopic and histopathological abnormalities were observed two years after OAGB. Nevertheless, as most patients have histologically proven inflammation, bile in the gastric pouch, and endoscopic gastritis, long-term surveillance is essential because of the uncertain risk of these abnormalities.

The Effect of Insurance Status on Bariatric Surgery Outcomes: A Retrospective Chart Review Study.

BACKGROUND: Prior studies have shown socioeconomic factors and race to affect weight loss after bariatric surgery, but few have focused on the impact of insurance status. The purpose of this study was to determine if insurance status affects bariatric surgery patients' surgical outcomes and weight loss. METHODS: A retrospective review was conducted of 408 bariatric patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (SG). Patients were stratified by insurance status and surgery type to evaluate weight loss and surgical outcomes. RESULTS: Overall, patients experienced 71.0% excess weight loss at 1-year postoperatively. Patients undergoing LRYGB had greater percent excess weight loss (%EWL) at 1-year (74.5% vs 63.3%, P < .001) than SG patients. Upon multiple regression analysis, insurance type did not affect %EWL. Instead, younger age, female gender, LRYGB procedure, and lower initial BMI were all associated with greater %EWL. CONCLUSIONS: Insurance type is not a useful independent predictor of successful weight loss in bariatric surgery patients.

Assessment of predictors of early postoperative complications after primary robotically assisted Roux-en-Y gastric bypass: a multicenter, retrospective cohort study.

BACKGROUND: Robotic Roux-en-Y gastric bypass (RRYGB) is performed in an increasing number of bariatric centers worldwide. Previous studies have identified a number of demographic and clinical variables as predictors of postoperative complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). Some authors have suggested better early postoperative outcomes after RRYGB compared to LRYGB. The objective of the present study was to assess potential predictors of early postoperative complications after RRYGB. METHODS: A retrospective analysis of two prospective databases containing patients who underwent RRYGB between 2006 and 2019 at two high volumes, accredited bariatric centers was performed. Primary outcome was rate of 30 day postoperative complications. Relevant demographic, clinical and biological variables were entered in a multivariate, logistic regression analysis to identify potential predictors. RESULTS: Data of 1276 patients were analyzed, including 958 female and 318 male patients. Rates of overall and severe 30 day complications were 12.5% (160/1276) and 3.9% (50/1276), respectively. Rate of 30 day reoperations was 1.6% (21/1276). The overall gastrointestinal leak rate was 0.2% (3/1276). Among various demographic, clinical and biological variables, male sex and ASA score >2 were significantly correlated with an increased risk of 30 day complication rates on multivariate analysis (OR 1.68 and 1.67, p=0.005 and 0.005, respectively). CONCLUSION: This study identified male sex and ASA score >2 as independent predictors of early postoperative complications after RRYGB. These data suggest a potentially different risk profile in terms of early postoperative complications after RRYGB compared to LYRGB. The robotic approach might have a benefit for patients traditionally considered to be at higher risk of complications after LRYGB, such as those with BMI >50. The present study was however not designed to assess this hypothesis and larger, prospective studies are necessary to confirm these results.

Cost-effectiveness analysis of revisional Roux-en-Y gastric bypass: laparoscopic vs. robot assisted.

There is controversy over the possible advantages of the robotic technology in revisional bariatric surgery. The aim of this study is to report the experience of a high-volume bariatric center on revisional Roux-en-Y gastric bypass with robot-assisted (R-rRYGB) and laparoscopic (L-rRYGB) approaches, with regards to operative outcomes and costs. Patients who underwent R-rRYGB and L-rRYGB between 2008 and 2021 were included. Patients' baseline characteristics and perioperative data were recorded. The primary endpoint was the overall postoperative morbidity. A full economic evaluation was performed. One-way and two-way sensitivity analyses were performed on laparoscopic anastomotic leak and reoperation rates. A total of 194 patients were included: 44 (22.7%) L-rRYGB and 150 (77.3%) R-rRYGB. The robotic approach was associated with lower overall complication rate (10% vs. 22.7%, p = 0.038), longer operative time, and a reduced length of stay compared to L-rRYGB. R-rRYGB was more expensive than L-rRYGB (mean difference 2401.1€, p < 0.001). The incremental cost-effective ratio (ICER) was 18,906.3€/complication and the incremental cost-utility ratio was 48,022.0€/QALY (quality-adjusted life years), that is below the willingness-to-pay threshold. Decision tree analysis showed that L-rRYGB was the most cost-effective strategy in the base-case scenario; a probability of leak ≥ 13%, or a probability of reoperation ≥ 14% following L-rRYGB, or a 12.7% reduction in robotic costs would be required for R-rRYGB to become the most cost-effective strategy. R-rRYGB was associated with higher costs than L-rRYGB in our base-case scenario. However, it is an acceptable alternative from a cost-effectiveness perspective.

The impact of the affordable care act on access to bariatric surgery in Maryland.

INTRODUCTION: This study aims to investigate the influence of the Affordable Care Act (ACA) on the utilization of Roux-en-Y gastric bypass (RYGB) procedures in Maryland. METHODS: Using the Maryland State Inpatient Database, this retrospective study compared all patients undergoing RYGB during the pre-ACA (2007-2009) and post-ACA (2018-2020) periods, including patient demographic factors, pre-existing conditions, and socioeconomic factors. RESULTS: A total of 16,494 RYGB procedures were performed during the study period, of which 12,089 (73.3 â€‹%) were post-ACA. This was a 179.2 â€‹% increase in patients undergoing RYGB post-ACA; nearly triple that of the pre-ACA period. There was a significant decrease in uninsured patients (5.6 â€‹%-1.5 â€‹%, p â€‹< â€‹0.01) an increase in Black patients (32.1 â€‹%-46.8 â€‹%, p â€‹< â€‹0.01) and Medicaid beneficiaries (6.0 â€‹% pre-ACA to 17.8 â€‹% post-ACA, p â€‹< â€‹0.01). There were significant reductions in adverse outcomes (long hospital stays, hemorrhage, GIT leaks, and mortality) across all insurance types (all p â€‹< â€‹0.01). CONCLUSION: The ACA increased access to RYGB procedures, especially in Black and Medicaid recipients in Maryland, enhancing healthcare across all insurance types.

Economic Impact of the Implementation of an Enhanced Recovery after Surgery (ERAS) Protocol in a Bariatric Patient Undergoing a Roux-En-Y Gastric Bypass.

INTRODUCTION: Enhanced Recovery After Surgery (ERAS) protocols have proven to be cost-effective in various surgical procedures, mainly in colorectal surgeries. However, there is still little scientific evidence evaluating the economic impact of their application in bariatric surgery. The present study aimed to compare the economic cost of performing a laparoscopic Roux-en-Y gastric bypass following an ERAS protocol, with the costs of following a standard-of-care protocol. PATIENTS AND METHODS: A prospective non-randomized study of patients undergoing Roux-en-Y gastric bypass was performed. Patients were divided into two groups: patients following an ERAS protocol and patients following a standard-of-care protocol. The total costs of the procedure were subdivided into pharmacological expenditures, surgical material, and time expenses, the price of complementary tests performed during the hospital stay, and costs related to the hospital stay. RESULTS: The 84 patients included 58 women (69%) and 26 men (31%) with a mean age of 44.3 ± 11.6 years. There were no significant differences in age, gender, and distribution of comorbidities between groups. Postoperative pain, nausea or vomiting, and hospital stay were significantly lower within the ERAS group. The pharmacological expenditures, the price of complementary tests performed during the hospital stay, and the costs related to the hospital stay, were significantly lower in the ERAS group. There were no significant differences in the surgical material and surgical time costs between groups. Globally, the total cost of the procedure was significantly lower in the ERAS group with a mean saving of 1458.62$ per patient. The implementation of an ERAS protocol implied a mean saving of 21.25% of the total cost of the procedure. CONCLUSIONS: The implementation of an ERAS protocol significantly reduces the perioperative cost of Roux-en-Y gastric bypass.