Metabolic outcomes after revisional bariatric surgery: a systematic review and meta-analysis.

BACKGROUND: It has been well-established that primary bariatric surgery is effective in inducing improvement of diabetes and other associated co-morbidities in patients with obesity. Evidence demonstrating the influence of revisional bariatric surgery on this trajectory, however, is lacking. OBJECTIVES: We performed a systematic review and meta-analysis to examine the impact of revisional bariatric surgery on obesity-related metabolic outcomes. SETTING: University Hospital, Singapore METHODS: We examined outcomes of remission and improvement of diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea. Revisional surgeries included sleeve gastrectomy, Roux-en-Y gastric bypass, pouch revision, duodenal switch, and minigastric bypass. RESULTS: Our search identified 33 relevant studies including a total of 1593 patients. Meta-analysis of proportions demonstrated a 92% improvement in diabetes with 50% achieving remission after revisional bariatric surgery. Of patients, 81% achieved improvement of hypertension with 33% achieving complete remission. In both groups, the highest proportion of improvement was observed after revisional duodenal switch. Although reported by fewer studies, a remission of hyperlipidemia was reported in 37% of patients and improvement of obstructive sleep apnea was seen in 86% of patients. CONCLUSIONS: Revisional bariatric surgery improves the outcomes of obesity-related co-morbidities and should be considered in patients with persistent metabolic disease after primary bariatric surgery.

Revisional Bariatric Surgery: Focus on Quality of Life.

Bariatric surgery is considered to be the most effective treatment for morbid obesity. At present, revisional surgery is considered in patients who experience complications, or in whom the intended weight loss is not achieved. However, as there is no consensus on what constitutes failure of primary surgery, there are no guidelines on who should receive revisional surgery. Physical parameters alone may be insufficient and quality of life has emerged as an alternative to provide a holistic appraisal of the outcome of primary surgery and the need for further revisional surgery in bariatric patients. Quality of life surveys such as short form health survey (SF-36) or Moorehead-Ardelt II (MA-II) assess the patients' perception of their weight and can also be used to assess the impact of post-operative complications such as gastro-esophageal reflux disease or dysphagia. However, unrealistic expectations of weight loss have been shown to be prevalent in bariatric patients and patients who seek revisional surgery on the basis of disappointment with the primary outcome are unlikely to be satisfied with the revisional outcome. Indications for re-operative surgery must be tailored to improve the quality and longevity of each individual patient's life. Long term studies are required to investigate and validate quality of life as an indication for revisional surgery.

The diagnosis and management of H. pylori infection in Singapore.

Helicobacter pylori (H. pylori) is an infection that has a role in causing dyspepsia and complications such as peptic ulcer disease and gastric malignancies. In the primary care setting, one can adopt a stepwise approach with the 'test-and-treat' strategy to manage H. pylori-associated dyspepsia in young patients without alarm symptoms. Empiric first-line therapies should be for a two-week duration; options include clarithromycin-containing triple therapy alone or with the addition of bismuth, concomitant therapy and bismuth quadruple therapy. Post-treatment carbon urea breath test must be performed at least four weeks after the end of treatment to confirm the cure. Options for empiric second-line treatment include bismuth quadruple therapy and levofloxacin-containing triple therapy. Patients with persistent or alarm symptoms should be referred for further evaluation. Patients with persistent infection should be referred for gastroscopy so that gastric biopsies can be obtained for H. pylori culture and antibiotic susceptibility testing.

Early weight loss after laparoscopic sleeve gastrectomy predicts midterm weight loss in morbidly obese Asians.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) is a popular bariatric procedure in morbidly obese Asians. OBJECTIVES: To investigate the effect of initial weight loss on midterm weight maintenance and remission of co-morbidities after laparoscopic SG in morbidly obese Asians. SETTING: University Hospital, Singapore. METHODS: Data of patients who underwent laparoscopic SG were analyzed. Change in body mass index (BMI), percentage of total weight loss (%WL), and of excess weight loss (%EWL) was calculated and remission of obesity-related co-morbidities was examined. Linear regression analysis was performed to determine the effect of initial weight loss on successful weight maintenance. Receiver operative characteristic curve analysis was used to define optimal cutoff values. RESULTS: Two hundred and seventy-two patients were included in this study. Mean preoperative weight and BMI were 115.4±25.5 kg and 42.5±8.0 kg/m2, respectively. Mean follow-up duration was 27.6±16.4 months. Successful weight loss of>50% EWL was achieved by 65.7%, 65.5%, and 50.8% of patients at 1, 2, and 3 years, postoperatively. There was a significant correlation of %EWL at 3 months with %EWL up to 3 years (P≤.005). Receiver operative characteristic analysis showed initial EWL of 35% at 3 months best predicted successful weight loss at 1 year (sensitivity 73.1%, specificity 81.4%). Patients achieving>35% EWL were significantly more likely to achieve remission of co-morbidities (P≤.005) at 1 year after surgery. CONCLUSION: Early weight loss at 3 months predicts weight maintenance up to 3 years and remission of co-morbidities at 1 year after laparoscopic SG in Asians.