Current state of the definition and terminology related to weight recurrence after metabolic surgery: review by the POWER Task Force of the American Society for Metabolic and Bariatric Surgery.

Bariatric surgery continues to be the most reliable treatment for the disease of obesity. Despite excellent results, some patients experience weight recurrence with or without concomitant recurrence of co-morbidities. There is currently no standard definition for clinically significant weight recurrence after bariatric surgery so that patients and clinicians have a platform from which to plan treatment. The Post-Operative Weight Recurrence (POWER) Task Force was formed by the American Society for Metabolic and Bariatric Surgery to address this aspect of the disease of obesity. This article reviews the literature of existing definitions for weight recurrence and their limitations. Furthermore, the term weight recurrence is introduced to replace weight regain or recidivism, and the term nonresponder is introduced to replace inadequate weight loss after surgery.

Analysis of Early Job Market Experiences and Perceptions Among Bariatric Surgery Fellowship Graduates and Bariatric Surgery Program Directors.

PURPOSE: Over the past decade, an increasing number of bariatric surgeons are trained in fellowships annually despite only a modest increase in nationwide bariatric surgery volume. The study surveys the bariatric surgery job market trend in order to inform better career-choice decisions for trainees interested in this field. MATERIALS AND METHODS: A national retrospective cohort survey over an 11-year period was conducted. Bariatric surgery fellowship graduates from 2008 to 2019 and program directors (PDs) were surveyed electronically. Univariate analysis was performed comparing responses between earlier (2008-2016) and recent graduates (2017-2019). RESULTS: We identified a total of 996 graduates and 143 PDs. Response rates were 9% and 20% respectively (n = 88, 29). Sixty-eight percent of graduates felt there are not enough bariatric jobs for new graduates. Seventy-nine percent of PDs felt that it is more difficult to find a bariatric job for their fellows now than 5-10 years ago. Forty-eight percent of PDs felt that we are training too many bariatric fellows. Seventy-seven percent of all graduates want the majority of their practice to be comprised bariatric cases; however, only 42% of them reported achieving this. In the univariate analysis, recent graduates were less likely to be currently employed as a bariatric surgeon (64% vs. 86%, p = 0.02) and were less satisfied with their current case volume (42% vs. 66%, p = 0.01). CONCLUSIONS: The temporal increase in bariatric fellowship graduates over the past decade has resulted in a significant decline in the likelihood of employment in a full-time bariatric surgical practice and a decline in surgeons' bariatric case volumes.

Scars Matter: The Importance of Incision Decisions in Bariatric Patients.

This study aims to determine if cosmetic outcomes play an important role for patients undergoing bariatric surgery, when considering a surgical approach. A video-animation describing open, conventional laparoscopic, and reduced incision magnetic assisted surgery was shown. The patient's perceptions of the surgical approaches were recorded using an anonymous survey. Fifty-one patients completed the survey. The median age was 45 (IQR: 36-51), and 38 (74.5%) were women. Cosmesis was found to be an important factor (77%) for selecting a surgical approach. Ninety percent of the patients believe that reduced incision magnet-assisted surgery provides superior cosmesis. Cosmetic results may play a determinant role when choosing a surgical approach.

Magnetic Liver Retraction: an Incision-Less Approach for Less Invasive Bariatric Surgery.

BACKGROUND: In bariatric surgery, retraction of the liver is essential to ensure appropriate visualization of the surgical field. Many devices are currently employed for this purpose. Generally, these devices require constant use of a port, or an additional incision. Magnetic technology provides a novel solution, by allowing liver retraction during bariatric procedures that do not require a dedicated port nor an extra incision. METHODS: Retrospective review of consecutive patients who underwent magnetic-assisted liver retraction during primary or revisional laparoscopic bariatric surgery at the Duke Center for Metabolic and Weight Loss Surgery between October 2016 and August 2017. RESULTS: The 73 cases were comprised of 29 primary sleeve gastrectomies, 24 gastric bypasses, 10 duodenal switches, 3 gastric band removals, and 7 revisions. All cases were completed laparoscopically. Mean pre-operative BMI was 43.6 kg/m2 (range 18.3-67.7 kg/m2). Mean operative times for primary cases were similar to published averages. Two patients experienced minor 30-day morbidities, neither of which were attributed to the device and did not require further interventions. There were no 30-day mortalities. Surgeons described subjective overall surgical exposure as adequate and device utilization as technically simple even for the large livers. CONCLUSIONS: Magnetic-assisted retraction is a novel approach that allows a safe, reproducible, incision-less technique for unconstrained, port-less intra-abdominal mobilization. The device successfully permitted optimal liver retraction during laparoscopic bariatric surgery, enhancing surgical exposure while decreasing the number of abdominal incisions.

Tailoring Bariatric Surgery: Sleeve Gastrectomy, Roux-en-Y Gastric Bypass and Biliopancreatic Diversion with Duodenal Switch.

BACKGROUND: A need exists to select the most appropriate bariatric operation for a particular patient. One-year data comparing sleeve gastrectomy (SG) to Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch (BPD/DS) are sparse. METHODS: The Bariatric Outcomes Longitudinal Database was queried from June 2007 to September 2011 for 30-day and 1-year adverse events, and 1-year weight loss and comorbidity resolution. Propensity scores with inverse probability weighting were used to match for age, gender, body mass index (BMI), ethnicity, and select comorbidities. Multivariate linear and logistic regressions estimated differences and odds ratios (ORs), respectively, for each pairwise bariatric operation comparison. RESULTS: Among 73,702 subjects, 5942 patients underwent SG, 66,324 patients underwent RYGB, and 1436 patients underwent BPD/DS. Compared with SG, decrease in BMI units was greater by 5.3 for BPD/DS and by 2.2 U for RYGB at 1 year. Resolution of gastroesophageal reflux disease (GERD) was best for RYGB (OR = 1.88, 95% confidence interval [CI]: 1.73-2.03) and still good for BPD/DS (OR = 1.57, 95% CI: 1.29-1.90). Hypertension and diabetes mellitus (DM) resolution were better after BPD/DS (OR = 2.12, 95% CI: 1.83-1.64, and OR = 2.53, 95% CI: 2.13-3.00, respectively) and for RYGB were (OR = 1.54, 95% CI: 44-1.64 and OR = 1.63, 95% CI: 1.51-1.75, respectively). Odds of serious adverse events at 1 year were: RYGB, OR = 1.70, 95% CI: 1.45-2.00; BPD/DS, OR = 4.31, 95% CI: 3.06-6.07. CONCLUSIONS: Using SG as reference, RYGB was associated with highest resolution of GERD, whereas BPD/DS was associated with highest resolution of DM and hypertension. These findings can guide decision making regarding choice of bariatric operation.

Predictors of long-term success after laparoscopic Roux-en-Y gastric bypass in African-American women.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) provides sustained weight loss. However, short-term studies have suggested that African Americans (AAs) are not as successful as Caucasians (CAs) after LRYGB. OBJECTIVE: The present study was designed to test the hypothesis that at longer term follow-up AAs are just as successful as CAs after LRYGB. SETTING: University hospital, United States. METHODS: A nested case-control study designed to examine the effect of race as covariate in the long-term success of women undergoing LRYGB. The study matched 3 controls per case subject, and the final numbers for analyses were 78 case patients (AA) and 204 control patients (CA). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using conditional logistic regression analysis. RESULTS: The 2 cohorts (N = 282) were well matched for age (AA 40.3±9.1 years versus CA 41.1±8.9 years), preoperative body mass index (AA 50.6±7.5 kg/m(2) versus CA 50.2±7.1 kg/m(2)), prevalence of type 2 diabetes (T2D) (AA 20.5% versus CA 21.1%), hypertension (AA 69.1% versus CA 52%), and sleep apnea (AA 35.9% versus CA 34.8%). In the AA group, the long-term curve for percentage of excess weight loss (EWL) was significantly (P<.001) lower than the CA group at any time-point. In the present model, diagnosis of T2D in the AA group (OR = 6.1 E8) significantly (P = .002) predicted adequate EWL at 3 years, after controlling for relevant confounders. CONCLUSION: Race significantly affected the long-term EWL at 3 years for patients undergoing LRYGB at the authors' institution. Future research should be directed at determining potential genetic reasons for these differences, including genes associated with T2D.

Conversion of vertical banded gastroplasty to stand-alone sleeve gastrectomy or biliopancreatic diversion with duodenal switch.

INTRODUCTION: Vertical banded gastroplasty (VBG) originated as a simplified bariatric operation to avoid malabsorption and provide lasting results due to a fixed stoma. Short-term results were excellent (50-70 % excess weight loss); however, patients often displayed maladaptive eating behaviors, and many failed to either achieve or sustain adequate long-term weight loss. Complications were also common including severe reflux and regurgitation, gastric outlet stenosis or stricture, gastrogastric fistula, and breakdown of the staple line. METHODS: VBG conversions to Roux-en-Y gastric bypass or sleeve gastrectomy as well as endoscopic interventions such as band removal have been described but have very high complication rates. We describe conversion of VBG to biliopancreatic diversion with duodenal switch using endoscopic guidance to take down the VBG staple line and the mesh around the outlet. RESULTS: This technique can also be used to safely convert a VBG to a stand-alone sleeve gastrectomy. CONCLUSION: Complication rates have been low by this technique, and we encourage others to adopt this technique.

Evidence for a metabolic mechanism in the improvement of type 2 diabetes after sleeve gastrectomy in a rodent model.

BACKGROUND: Sleeve gastrectomy (SG) is at least as effective at producing weight loss as gastric banding but may be superior in producing remission of type 2 diabetes mellitus (T2DM). The objective of this study was to elucidate mechanisms of diabetes improvement in SG beyond caloric restriction. We studied SG in Zucker Diabetic Fatty (ZDF) rats. METHODS: Twenty-eight ZDF rats were randomly assigned to 1 of 3 groups: SG, sham-operated ad lib fed (AL), or sham-operated pair fed (PF). SG and AL rats had free access to food. PF rats were fed the average daily intake of the SG group. Comparisons of caloric intake, weight loss, intraperitoneal glucose tolerance testing (IPGTT), insulin, and total ghrelin were performed preoperatively and at postoperative days 10, 20, and 30. Differences between means were evaluated using one-way ANOVA and the paired t test as appropriate. RESULTS: Postoperatively, SG rats had lower daily caloric intake than the AL controls (78.3±10.5 kcal versus 104.7±4.6 kcal). Both SG and PF groups had sustained weight loss (-5.3±3.8 g and -27.5±2.6 g, respectively); however, SG rats had significantly lower AUC for glucose after IPGTT than both controls. This is in contrast to AL controls that experienced weight gain (34.1±4.7 g) and increases in AUC for glucose after IPGTT. CONCLUSION: Although SG is considered a restrictive procedure, there is evidence for a metabolic effect by virtue of decreased insulin resistance, which may not be reproduced by PF controls.