Early safety outcomes of laparoscopic one anastomosis gastric bypass in patients with class III, IV, and V obesity.

BACKGROUND: The extremely obese patient deserves special consideration: significant comorbidities, technical difficulties, and increased postoperative morbidity and mortality are all expected in this patient population. The study compared early postoperative complications (≤30-day) following one-anastomosis gastric bypass (OAGB) morbidity in patients with morbid obesity class IV obesity, body mass index (BMI) ≥50-59.9 kg/m2, and class V obesity, BMI ≥60 patients. METHODS: We retrospectively reviewed perioperative OAGB outcomes in three BMI groups. Operative time, length of stay (LOS), and overall early postoperative complication rates were studied. Patient-reported complications were ranked by Clavien-Dindo Classification (CDC). RESULTS: Between January 2017-December 2021, consecutive patients with obesity class III (n = 2950), IV (n = 256), and V (n = 23) underwent OAGB. BMI groups were comparable in sex, age, and associated comorbidities. Mean operative time was significantly longer in the higher BMI groups: class III (66.5 ± 25.6 min), IV (70.5 ± 28.7 min), and V (80.0 ± 34.7 min), respectively (p = 0.018); no difference in LOS. In respective BMI classes, ≤30-day complication rates were 3.2%, 3.5%, and 4.3% (p = 0.926). The respective number of patients with CDC grades of one to two were 45 (1.5%), 6 (2.3%), and 1 (4.3%), p = 0.500; and in grade ≥3a, 25 (0.8%), 1 (0.4%), 0 (0.0%), p = 0.669. There was 0.06% mortality (n = 2 in 3229), both in BMI class III. CONCLUSIONS: OAGB is a safe BS procedure in patients with class III, IV, and V obesity in the perioperative term with comparable ≤30-day morbidity in the three BMI groups.

Assessing Bleeding Risk in Bariatric Surgeries: A Retrospective Analysis Study.

OBJECTIVE: To determine the factors that influence bleeding during the course of bariatric surgeries. BACKGROUND: Bariatric surgery is safe with a low percentage of complications compared with other abdominal surgeries. Bleeding is one of the most common complications in surgery for obesity that has the risk of being catastrophic. METHODS: The study includes 8,544 cases that underwent bariatric surgery from January 2013 to March 2016 retrospectively, in 4 private institutions. Multiple demographic data were collected: patient characteristics, diseases, medications, surgery type, operative technique, devices, surgeon's skill, and volume. RESULTS: Bleeding was the most frequent complication that occurred in 122 (1.3%) patients. The Gastric bypass had the highest rate of bleeding (3.05%) of which, 20% were intraoperative bleeding and 80% postoperatively (intra-abdominal in 75%, and intra-luminal in 5%). Simultaneous surgeries, revisional surgeries, stratification of body mass index, stapler line reinforcement, and hospital volume did not affect bleeding occurrence. The determining factors for bleeding were hypertension, chronic lung disease, age >45 years, arrhythmia, and surgeon's skills. CONCLUSION: Bleeding after bariatric surgery has a low occurrence. The factors that influence the occurrence of perioperative bleeding in bariatric surgery are: hypertension, chronic lung disease, age >45 years, arrhythmia, and surgeon's skills.

Low Incidence of Postoperative Leaks When Using Small-Diameter Calibrated Bougies During Laparoscopic Sleeve Gastrectomy: A Retrospective Cohort Study.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a well-established bariatric procedure. A staple line leak is a recognized complication of LSG. Bougie size has been suggested to impact leak rates. In this study, we evaluate the impact of using 32-34F bougie sizes with LSG on early postoperative outcomes including staple line leaks within our practice. METHODS: This is a retrospective cohort analysis of a prospectively maintained database of all LSG procedures performed between January 2012 and December 2018 at a single medical center. Data collected and analyzed included bougie size, postoperative leak rate, need for re-operation, 12-month excess weight loss, and 30-day morbidity and mortality. RESULTS: During the study period, 3153 patients underwent LSG, of whom 1977 (62.7%) were female. Mean age and body mass index (BMI) were 42.9 ± 12.2 years (range 15-76 years) and 42.4 ± 5.2 kg/m2 (range 27-73), respectively. No intraoperative complications or mortality occurred. There was one case of perioperative mortality due to bleeding (0.03%). Early postoperative adverse events occurred in 131 patients (4.1%): 17 leaks (0.5%), 75 bleeds (2.4%), and 39 (1.2%) other. CONCLUSION: The use of smaller-sized (32-34F) bougies had no impact on staple line leaks in the hands of experienced bariatric surgeons at a high-volume center.

Associations of dietitian follow-up counselling visits and physical exercise with weight loss one year after sleeve gastrectomy.

PURPOSE: To examine associations of patients' attendance to follow-up meetings with a registered dietitian (RD) and physical exercise practices with weight loss during the 1 year following laparoscopic sleeve gastrectomy (SG). METHODS: Of 241 patients with obesity who underwent SG during 2012, 184 (76.3%) participated in a 1-year follow-up telephone interview and had information on number of RD follow-up meetings. Clinical information was available from computerized patient files. Multiple logistic regression analysis, adjusting for propensity score, was computed to reveal factors associated with greater weight loss. RESULTS: The mean %TWL was 31.4 ± 6.1 and the mean number of reported RD meetings during the year following SG was 4.6. The proportion of physically active patients increased by 15% (from 23 to 42) among those who attended at least 3 RD follow-up meetings (n = 123), and by 5% (from 18 to 23) among those who attended fewer than 3 meetings (n = 61) (p = 0.05). Patients conducting physical exercise reported a lower level of pain/discomfort on the EQ5D quality-of-life questionnaire (p = 0.03). The adjusted regression model revealed no association between the number of RD follow-up meetings and weight-reduction success, but physical exercise during the year following SG conferred a 2.6 times greater odds of belonging to the upper two tertiles of the % excess body weight loss ( 95% CI 1.2-5.3). CONCLUSIONS: Patients with better adherence to RD follow-up meetings were also more physically active. Patients on physical exercise also achieved greater weight reduction following SG, and reported less pain or discomfort. Nutritional counselling and physical exercise are necessary to ensure maximal and sustainable benefits from SG.  LEVEL OF EVIDENCE: Level III, Cohort study.

Obesity-related acetylcholinesterase elevation is reversed following laparoscopic sleeve gastrectomy.

BACKGROUND: Impaired sympathetic/parasympathetic response, expressed by elevated Acetylcholinesterase (AChE) is associated with obesity, metabolic syndrome and inflammation. However, the association between morbid obesity and AChE and the changes in cholinergic tone following bariatric laparoscopic sleeve gastrectomy (LSG) surgery-induced weight reduction were never analyzed. METHODS: Two studies are presented; the first (the "apparently healthy cohort") was a cross-sectional study and the second (the "LSG cohort") was a prospective-cohort study with 12 months of follow-up. The "apparently healthy cohort" included 1450 apparently healthy participants who volunteered to the Tel-Aviv Medical Center Inflammation Survey (TAMCIS) during a routine annual checkup visit. The "LSG cohort" included 77 morbid obese patients before and at 3, 6, and 12 months following LSG surgery. Main outcomes included anthropometric measurements, Hemoglobin A1c (HbA1C), serum AChE, insulin test and Homeostasis Model Assessment (HOMA). RESULTS: Among the TAMCIS participants, serum AChE activity increased with BMI in a dose-dependent manner until it reached a peak level at BMI of 30-35 kg/m², followed by a plateau. Following LSG, a significant decrease in AChE activity between baseline and 12 months post-surgery was found for men, but not for women (-122.2 ± 135.3, P < 0.001 vs. -21.8 ± 120.5, P = 0.258 nmol substrate hydrolyzed/min per ml, respectively). The reduction in AChE activity was negatively correlated with %excess weight loss (EWL) and positively correlated with %body fat reduction at 12 months post-surgery among women (r = -0.329, P = 0.034 and r = 0.350, P = 0.023, respectively). In men, AChE activity reduction was positively correlated with the HOMA reduction (r = 0.358, P = 0.048). CONCLUSIONS: Obesity-related AChE resistance phenotype may be reversed following LSG and correlates with metabolic outcomes. Further long-term studies will be needed to validate and evaluate the beneficial effect of AChE reduction post bariatric surgery.

Conversion for failed adjustable gastric banding warrants hiatal scrutiny for hiatal hernia.

BACKGROUND: Failure or complications following laparoscopic adjustable gastric banding (LAGB) may necessitate band removal and conversional surgery. Band position and band-induced chronic vomiting create ideal conditions for de novo hiatal hernia (HH) formation. HH presence impedes and complicates conversional surgery by obscuring crucial anatomical landmarks and hindering precise gastric sleeve or pouch formation. The aim of this study was to evaluate the incidence of a HH in patients with an LAGB undergoing conversion compared to patients undergoing primary bariatric surgery (BS). METHODS: Retrospective review of consecutive BS performed between 2010 and 2015. Data collected included demographics, anthropometrics, comorbidities, previous BS, preoperative and intra-operative HH detection, operation time, perioperative complications and length of hospital stay. RESULTS: During the study period, 2843 patients (36% males) underwent BS. Of these, 2615 patients (92%) were "primary" (no previous BS-control group), 197 (7%) had a previous LAGB (study group), and 31 (1%) had a different previous BS and were excluded. Reasons for conversion included weight regain, band intolerance and band-related complications. Mean age and body mass index were similar between the study and the control groups. HH was preoperatively diagnosed by upper gastrointestinal (UGI) fluoroscopy in 9.1% and 9.0% of the LAGB and control groups (p = NS), respectively. However, HH was detected intra-operatively in 20.3% and 7.3%, respectively (p < 0.0001). CONCLUSIONS: Preoperative diagnosis of a HH by UGI fluoroscopy for patients who have undergone LAGB is unreliable. Intra-operative hiatal exploration is highly recommended in all cases of conversional BS after LAGB.

Correct Evaluation of Gastric Wall Thickness May Support a Change in Staplers' Size When Performing Sleeve Gastrectomy.

BACKGROUND: Leakage from the staple line is the most serious complication encountered after sleeve gastrectomy, occurring in 2.4% of surgeries. The use of inappropriately sized staplers, because of variability in stomach wall thickness, is a major cause of leakage. OBJECTIVES: To measure stomach wall thickness across different stomach zones to identify variables correlating with thickness. METHODS: The study comprised 100 patients (52 females). Stomach wall thickness was measured immediately after surgery using a digital caliper at the antrum, body, and fundus. Results were correlated with body mass index (BMI), age, gender, and pre-surgical diagnosis of diabetes, hypertension, hyperlipidemia and fatty liver. RESULTS: Stomach thickness was found to be 5.1 ± 0.6 mm at the antrum, 4.1 ± 0.6 mm at the body, and 2. 6 ± 0.5 mm at the fundus. No correlation was found between stomach wall thickness and BMI, gender, or co-morbidities. CONCLUSIONS: Stomach wall thickness increases gradually from the fundus toward the antrum. Application of the correct staple height during sleeve gastrectomy is important and may, theoretically, prevent leaks. Staplers should be chosen according to the thickness of the tissue.

Assessment of perioperative complications following primary bariatric surgery according to the Clavien-Dindo classification: comparison of sleeve gastrectomy and Roux-Y gastric bypass.

BACKGROUND: Laparoscopic Roux-Y gastric bypass (LRYGBP) is the gold-standard procedure for the treatment of morbid obesity. It has been reported to be somewhat more efficient and durable than laparoscopic sleeve gastrectomy (LSG). However, it is considered more invasive and, therefore, more hazardous. There is a lack of unity in complication reporting following bariatric surgery. Thus, there is a possible misconception regarding the relative safety of the two major bariatric procedures performed worldwide. This may have contributed to a shift in practice with LSG gaining momentum "at the expense" of LRYGBP. The aim of this study was to evaluate the relative safety of primary LSG and LRYGBP according to the Clavien-Dindo complication grading system. METHODS: A total of 2651 and 554 patients underwent primary LSG and LRYGBP, respectively at three high-volume centers. Thirty-day perioperative complications were recorded and graded. Length of hospital stays (LOS) and readmission rates were collected as well. RESULTS: Complications occurred in 110 (3.7%) and 24 (4.3%) patients following LSG and LRYGBP, respectively (p = 0.9). No significant difference was found between the groups regarding overall and complication-grade-specific rates. Individual complication types were unevenly distributed, but not significantly so. Patients with complications were older than those without (47 and 43 years, respectively; p = 0.01). Gender was not a risk factor for complication. Median LOS and readmission rates were not significantly different. CONCLUSIONS: LSG and LRYGBP are equally safe, at least in the perioperative period. Acknowledging and conveying this finding to surgeons and patients alike is important and might cause a pendulum shift in the distribution of bariatric procedures performed.

Concomitant cholecystectomy during laparoscopic sleeve gastrectomy.

BACKGROUND: The prevalence of cholelithiasis in morbidly obese individuals is 19-45%. Laparoscopic sleeve gastrectomy (LSG) has become one of the most performed procedures worldwide. The management of gallstones at the time of LSG is under debate. We herein report our experience with concomitant LSG and cholecystectomy. METHODS: Patients undergoing LSG, between 2006 and 2014 with symptomatic cholelithiasis (SC), underwent concomitant cholecystectomy (SGC), and were compared to those who had LSG alone. Gender, age, and BMI were noted. Preoperative ultrasonography was performed for all patients and gallstone presence was recorded. Operative time, intraoperative mishaps, perioperative complications, length of hospital stay (LOS), and the incidence of subsequent symptomatic gallbladder disease were collected as well. RESULTS: SC was present in 180 patients who underwent SGC. LSG was performed in 2,383, of whom 43 (2%) had asymptomatic cholelithiasis (AC). SGC patients had a higher percentage of females and were older (79% and 46 years vs. 62% and 43 years, respectively). BMI, LOS, and complications were similar. Operative time was prolonged by 35 min in SGC. Two patients with SGC had bile leakage. Of patients with AC, 9.3% required cholecystectomy during the first post-operative year after LSG due to evolution of symptoms, compared to only 2.7% of those with normal preoperative gallbladders. Presenting symptoms and severity of the disease were worse in the first group. CONCLUSIONS: For SC, LSC is safe and warranted. Prophylactic cholecystectomy when gallstones are absent is unnecessary. Management of AC at the time of LSG is still debatable.

Adenocarcinoma of the Gallbladder: Incidental Finding in Patients following Laparoscopic Sleeve Gastrectomy and Cholecystectomy.

BACKGROUND: Gallbladder (GB) cancer is rare. Most cases are incidentally found in specimens after a cholecystectomy. Cholelithiasis is almost always present when this diagnosis is made. Obesity is a known risk factor for gallstone formation and thus may be related to GB cancer. OBJECTIVES: To highlight the importance of evaluating the gallbladder before surgery, resecting the gallbladder whenever required, and screening the resected tissue for malignancy. METHODS: We retrospectively searched a prospectively maintained database of all bariatric procedures during the last 8 years for cases of concomitant laparoscopic sleeve gastrectomy (LSG) and laparoscopic cholecystectomy (LC). Pathologic reports of the gallbladders were reviewed. Demographic data and perioperative parameters were documented. RESULTS: Of 2708 patients reviewed, 1721 (63.55%) were females and 987 (36.45%) males. Excluded were 145 (5.35%) who had a previous cholecystectomy. Of the remaining 2563, 180 (7.02%) had symptomatic gallbladder disease and underwent LSG with LC. Of these, two females (BMI 53 kg/m2 and 47 kg/m2, both age 60) were found by histological examination to have adenocarcinoma in their GB specimens (1.11%). Both were reoperated, which included partial hepatectomy of the GB bed, resection of the cystic stump, lymph node dissection, and resection of the port sites. One patient is doing well, with no evidence of disease at a postoperative follow-up of 4 years. The second patient had recurrent disease with peritoneal spread and ascites 20 months post-surgery and died 18 months later. CONCLUSIONS: GB cancer is a rare finding in cholecystectomy specimens. The incidence of this entity might be higher in obese older females owing to the higher incidence of cholelithiasis in these patients.

Concomitant bariatric and ventral/incisional hernia surgery in morbidly obese patients.

INTRODUCTION: Ventral hernias are not uncommon in the bariatric population. Their management is technically demanding and remains controversial. Hernia complications can be lethal after bariatric surgery (BS). We herein report our experience with concomitant BS and ventral hernia repair (VHR). METHODS: We performed a retrospective analysis of a prospectively maintained database queried for combined procedures. Hernias were repaired after complete reduction (when the defect was not empty) using a dual mesh fixed to the abdominal wall with absorbable tackers. Data collected included demographics, anthropometrics, co-morbidities, peri-operative course, and intermediate weight loss and co-morbidity status. RESULTS: Between 2007 and 2012, a total of 54 patients (34 females, mean body mass index 44.2 kg/m(2)) underwent concomitant BS and VHR. The vast majority of procedures were laparoscopic sleeve gastrectomies (N = 48; 89 %). Others included laparoscopic Roux-en-y gastric bypass (RYGB), open RYGB, and laparoscopic gastric banding (two each). Six patients had complications (11 %): three leaks, two abdominal wall hematomas, and one pulmonary embolism. Hernia recurrence was noted in one patient (1.8 %). Average excess weight loss post-surgery was 49.9 ± 10.3 and 57.7 ± 9.2 % at 6 and 12 months, respectively. The total number of pre-operative co-morbidities was 110. At 12-month follow-up, 50 % (N = 56) were completely resolved and 38 % (N = 42) were improved. CONCLUSION: Concomitant BS and VHR is feasible and safe, obviating the need for two separate procedures while not hampering the outcome of either. Complication rates for the combined surgery do not seem to be adversely affected.

Advantages of minimal incision laparoscopic cholecystectomy.

BACKGROUND: Modifications to conventional laparoscopic cholecystectomy (CLC) are aimed at decreasing abdominal wall trauma and improving cosmetic outcome. Although single-incision laparoscopic surgery (SILS) provides excellent cosmetic results, the procedure is technically challenging and expensive compared to the conventional laparoscopic approach. OBJECTIVES: To describe a novel, hybrid technique combining SILS and conventional laparoscopy using minimal abdominal wall incisions. METHODS: Fifty patients diagnosed with symptomatic cholelithiasis were operated using two reusable 5 mm trocars inserted through a single 15 mm umbilical incision and a single 2-3 mm epigastric port. This technique was clubbed "minimal incision laparoscopic cholecystectomy" (MILC). RESULTS: MILC was completed in 49 patients (98%). In five patients an additional 3 mm trocar was used and in 2 patients the epigastric trocar was switched to a 5 mmtrocar. The procedure was converted to CLC in one patient. Mean operative time was 29 minutes (range 18-60) and the average postoperative hospital stay was 22 hours (range 6-50). There were no postoperative complications and the cosmetic results were rated excellent by the patients. CONCLUSIONS: MILC is an intuitive, easy-to-learn and reproducible technique and requires small changes from CLC. As such, MILC may be an attractive alternative, avoiding the cost and complexity drawbacks associated with SILS.

Mid-term follow-up after laparoscopic sleeve gastrectomy in obese adolescents.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is gaining credibility as a simple and efficient bariatric procedure with low surgical risk. Since surgical treatment for morbid obesity is relatively rare in adolescents, few results have bten accumulated so far. OBJECTIVES: To prove the safety and efficacy of LSG turgery in an adolescent population METHODS: Data were prospectively collected regarding adolescent patients undergoing LSG. All patients underwent pre- and postoperative medical and professional evaluation by a multidisciplinary team. RESULTS: Between the years 2006 and 2011, 32 adolescents underwent LSG in our center (20 females and 12males). Mean age was 16.75 years (range 14-18 years), mean weight was 121.88 kg (83-178 kg), and mean body mass index 43.23 (35-54). Thirty-four comorbid conditions were identified. LSG was the primary bariatric procedure in all the patients. Mean operative time was 60 minutes (range 45-80 min). Tiere were two complications (6.25%): an early staple line leak and a late acute cholecystitis. There were no deaths. Mean percent excess weight loss at 1, 3, 6, 9,12, 24, 36, 48, and 60 months post-surgery was 27.9%, 41.1%, 62.6%, 79.2%, 81.7%, 71%, 75%, 102.9% and 101.6%, respectively. Comorbidities were completely resolved or ameliorated within 1 year folllowing surgery in 82.4% and 17.6%, respectively. CONCLUSIONS: LSG is feasible and safe in morbidly obese adolescents, achieving efficient weight loss and impressive resolution of comorbidities. Further studies are required to evaluate the long-term results of this procedure as well as its place among other bariatric options.

[The relationship between attention deficit hyperactivity disorders (ADHD) and obesity].

The obesity epidemic has been recognized as a worldwide problem. More than 1/3 of the adults and about 15% of children and adolescents are overweight. In the search for the reasons for obesity and refractory obesity, some research efforts have recently been directed into the relationship between obesity and attention deficit hyperactivity disorder (ADHD). This link can be explained by two theoretical approaches: ADHD leads to obesity because of the impulsive behavior of ADHD patients; both obesity and ADHD originate from a similar psycho-pathological mechanism. ADHD is usually diagnosed in childhood with symptoms of hyperactivity, impulsivity, and distraction, often continuing into adulthood with symptoms of disorganization, frustration, and excessive emotional reaction. Treatment of ADHD requires a multidisciplinary approach of medication, psychological treatment, occupational therapy (in children) and nutritional assistance. Most studies of the association between ADHD and obesity were performed on subjects seeking help for obesity problems. In this population (both children and adults), the percentage of ADHD was found to be significantly higher than the prevalence of ADHD in the general population. Overweight subjects with ADHD, who were treated with medications, showed improved patterns of weight loss and maintenance. In addition, patients diagnosed with ADHD had lower compliance with follow-up visits after bariatric surgery. It seems that the problem is in the correct diagnosis of ADHD in obese patients, followed by medical as well as cognitive behavioral treatment, that can turn the impulsivity into an advantage, driving patients to positive pathways such as physical activity.

Early outcomes of one-anastomosis gastric bypass in the elderly population at high-volume bariatric centers.

The increasing rate of obesity and life expectancy will lead to increasing numbers of bariatric procedures in the elderly. We aim to report the early (≤ 30 days) adverse events of One-Anastomosis Gastric Bypass (OAGB) in this patient population. Assuta Bariatric Centers in Israel. Retrospective review of perioperative OAGB outcomes between elderly group (≥ 65 years) and non-elderly group (18-64 years) at high-volume bariatric centers between January 2017-December 2021. Operative time, length of stay (LOS), and overall ≤ 30 days complication rates, as ranked by the Clavien-Dindo Classification (CDC) were compared. There were 6618 patients (non-elderly group) and 104 (elderly group) who underwent OAGB. Gender and preoperative BMI were comparable between the two age groups. The elderly group had significantly higher rate of ischemic heart disease and chronic renal failure. The number of patients with LOS ≥ 3 days was significantly higher in the elderly group [19.4% (n = 20) vs. 6.6% (n = 331), respectively; p < 0.001]. The total early adverse events were higher in the elderly group with no statistical significance [7.7% (n = 8) vs. 3.8% (n = 250), respectively; p = 0.062]. The rate of minor and major adverse events and reoperation rate was comparable between the two groups. The rate of readmissions was significantly higher in the elderly group 5.8% (n = 6) vs. 1.9% (n = 124), respectively p = 0.015. There was 0.06% mortality (n = 2) in the non-elderly group. OAGB is a relatively safe metabolic and bariatric surgery for elderly obese patients with early (≤ 30 days) morbidity rates similar to the non-elderly population.

Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) remains under scrutiny as a stand-alone bariatric procedure. The most feared complication after LSG is staple line leak. METHODS: Eight bariatric centers in Israel participated in this study. A retrospective analysis was performed by querying all the LSG cases performed between June 2006 and June 2010. The data collected included patient demographics, anthropometrics, and operative and perioperative parameters. RESULTS: Among the 2,834 patients who underwent LSG, 44 (1.5%) with gastric leaks were identified. Of these 44 patients, 30 (68%) were women. The patients had a mean age of 41.5 years and a body mass index (BMI) of 45.4 kg/m(2). Intraoperative leak tests and routine postoperative swallow studies were performed with 33 patients, and all but one patient (3%) failed to detect the leaks. Leaks were diagnosed at a median of 7 days postoperatively: early (0-2 days) in nine cases (20%), intermediately (3-14 days) in 32 cases (73%), and late (>14 days) in three cases (7%). For 38 patients (86%), there was clinical suspicion, later confirmed by imaging or operative findings. Computed tomography, swallow studies, and methylene blue tests were performed for 37, 21, and 15 patients, respectively, and the results were positive, respectively, for 31 (84%), 11 (50%), and 9 (60%) of these patients. Reoperation was performed for 27 of the patients (61%). Other treatment methods included percutaneous drainage (n = 28, 63.6%), endoscopic placement of stents (n = 11, 25%), clips (n = 1, 2.3%), and fibrin glue (n = 1, 2.3%). In 33 of the patients (75%), the leak site was found in the upper sleeve near the gastroesophageal junction. The median time to leak closure was 40 days (range, 2-270 days), and the overall leak-related mortality rate was 0.14% (4/2,834). CONCLUSION: Gastric leak is the most common cause of major morbidity and mortality after LSG. Routine tests to rule out leaks seem to be superfluous. Rather, selective utilization is recommended. Management options vary, depending mainly on patient disposition. An accepted algorithm for the diagnosis and treatment of gastric leak has yet to be proposed.

One Anastomosis Gastric Bypass in 6722 Patients: Early Outcomes from a Private Hospital Registry.

BACKGROUND: One-anastomosis gastric bypass (OAGB) is an emerging metabolic bariatric surgery (MBS) type used in both primary OAGB (pOAGB) and revisional OAGB (rOAGB). We studied ≤30-day outcomes of pOAGB and rOAGB and identified predictors of early complications. METHODS: Electronic medical records of all OAGBs performed between January 2017 and December 2021 at a high-volume bariatric clinic in Israel comprising four hospital centers were scanned retrospectively using specialized data software (MDClone software, version 6.1). Data gathered were patients' characteristics, surgical procedure, and ≤30-day complications with Clavien-Dindo Classification (CDC). Multivariate logistic regression analyses were used to identify factors related to early complications of pOAGB and rOAGB. RESULTS: A total of 6722 patients underwent a pOAGB (n = 5088, 75.7%) or rOAGB (n = 1634, 24.3%) procedure at our institution. Preoperative mean age and body mass index (BMI) were 40.6 ± 11.5 years and 41.2 ± 4.6 kg/m2, respectively. Early complications occurred in 258 (3.8%) patients (176 pOAGB and 82 rOAGB) and included mainly bleeding (n = 133, 2.0%), leaks (n = 31, 0.5%), and obstruction/strictures (n = 19, 0.3%). CDC complications for grades 1-2 and grades 3a--5 were 1.5% and 1.6%, respectively. The overall mortality rate was 0.03% (n = 2). Age, operative time ≥3 h, and any additional concomitant procedure were independent predictors of early complications following pOAGB, while a diagnosis of diabetes mellitus and operative time ≥3 h were independent predictors of early complications following rOAGB. CONCLUSIONS: OAGB was found to be a safe primary and revisional MBS procedure in the ≤30-postoperative day term. The most common complications were gastrointestinal bleeding, leaks, and obstruction/stricture.

Long-Term Matched Comparison of Primary and Revisional Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Reports of long-term (> 5-15-year) outcomes assessing the safety and efficacy of primary revisional laparoscopic sleeve gastrectomy (LSG) are few. METHODS: Retrospective long-term comparisons of primary (pLSG) and revisional (rLSG) procedures were matched for gender, age ± 5 years, and body mass index (BMI) ± 5 kg/m2. Weight loss, associated medical condition status, and patient satisfaction were evaluated. RESULTS: Between May 1, 2006, and December 31, 2016, 194 matched patients with severe obesity (mean BMI 44.1 ± 6.7 kg/m2; age 44.2 ± 10.0 years, 67.0% female) underwent pLSG (n = 97) or rLSG (n = 97) and were followed for a mean 12.1 ± 1.5 vs 7.6 ± 2.1 years. Respective mean weight regain from nadir was 15.0 ± 14.4 kg vs 11.9 ± 12.2 kg. Respective percent mean total weight loss and excess weight loss were 20.9 ± 12.7% and 51.8 ± 33.1%, and 18.3 ± 12.8% and 43.4 ± 31.6% at last follow-up, with no significant difference between groups. Resolution of type 2 diabetes (HbA1C < 6.5%, off medications) was 23.1% vs 11.1%; hypertension 36.0% vs 16.0%; and hyperlipidemia 37.1% vs 35.3%. Patients in the pLSG group were significantly more satisfied with LSG (59.8% vs 43.3%, p < 0.05) and more likely to choose the procedure again. CONCLUSIONS: There were no significant differences in long-term weight loss or associated medical condition outcomes in matched pLSG and rLSG patients.

Long-term Reported Outcomes Following Primary Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Long-term laparoscopic sleeve gastrectomy (LSG) outcomes in patients with obesity are scarce. We aimed to examine the outcomes and subjective experience of patients who underwent primary LSG with long-term follow-up. METHODS: The study is a retrospective observational analysis of patients who underwent primary LSG in a single center with 5-15 years of follow-up. Patients' hospital chart data supplemented by a detailed follow-up online questionnaire and telephone interview were evaluated. RESULTS: The study sample included 578 patients (67.0% female) with 8.8 ± 2.5 years of mean follow-up, with a response rate to the survey of 82.8%. Mean baseline age and body mass index (BMI) were 41.9 ± 10.6 years and 42.5 ± 5.5 kg/m2, respectively. BMI at nadir was 27.5 ± 4.9 kg/m2, corresponding to a mean excess weight loss (EWL) of 86.9 ± 22.8%. Proportion of patients with weight regain, defined as nadir ≥ 50.0% EWL, but at follow-up < 50.0% EWL, was 34.6% (n = 200) and the mean weight regain from nadir was 13.3 ± 11.1 kg. BMI and EWL at follow-up were 32.6 ± 6.4 kg/m2 and 58.9 ± 30.1%, respectively. The main reasons for weight regain given by patients included "not following guidelines," "lack of exercise," "subjective impression of being able to ingest larger quantities of food in a meal," and "not meeting with the dietitian." Resolution of obesity-related conditions at follow-up was reported for hypertension (51.7%), dyslipidemia (58.1%) and type 2 diabetes (72.2%). The majority of patients (62.3%) reported satisfaction with LSG. CONCLUSIONS: In the long term, primary LSG was associated with satisfactory weight and health outcomes. However, weight regain was notable.

Gastrointestinal reported outcomes following one anastomosis gastric bypass based on a multicenter study.

OBJECTIVES: To describe gastrointestinal-related side-effects reported following the One Anastomosis Gastric Bypass (OAGB). METHODS: A multicenter study among OAGB patients across Israel (n = 277) and Portugal (n = 111) who were recruited to the study based on time elapsed since surgery was performed. An online survey with information on demographics, anthropometrics, medical conditions, and gastrointestinal outcomes was administered in both countries simultaneously. RESULTS: Respondents from Israel (pre-surgery age of 41.6 ± 11.0 years, 75.8% females) and Portugal (pre-surgery age of 45.6 ± 12.3 years, 79.3% females) presented mean excess weight loss of 51.0 ± 19.9 and 62.4 ± 26.5%, 89.0 ± 22.0 and 86.2 ± 21.4%, and 89.9 ± 23.6 and 98.2 ± 20.9% (P < 0.001 for both countries), at 1-6 months, 6-12 months, and 1-5 years post-surgery, respectively. Median Gastrointestinal Symptom Rating Scale score was similar between time elapsed since surgery groups among respondents from Israel and Portugal (≤1.97 and ≤2.12). A notable proportion of respondents from Israel and Portugal at all time points reported 1-3 bowel movements per day (≤62.8 and ≤87.6%), Bristol stool scale categories which represent diarrhea-like stools (≤51.9 and ≤56.3%), having discomfort due to flatulence (≤79.4 and ≤90.2%), and mild to severe dyspepsia symptoms (≤50.5 and ≤73.0%). CONCLUSIONS: A notable proportion of OAGB patients might experience certain gastrointestinal symptoms postoperatively, including flatulence, dyspepsia, and diarrhea-like stools.