The Impact of Longer Biliopancreatic Limb Length on Weight Loss and Comorbidity Improvement at 5 Years After Primary Roux-en-Y Gastric Bypass Surgery: A Population-Based Matched Cohort Study.

INTRODUCTION: Different limb lengths are used in Roux-en-Y gastric bypass (RYGB) surgery, as there is no consensus which limb length strategy has the best outcomes. The biliopancreatic limb (BPL) is thought to play an important role in achieving weight loss and associated comorbidity resolution. The objective of this study was to assess the impact of a longer BPL on weight loss and comorbidity improvement at 5 years after primary RYGB. METHODS: All patients aged ≥ 18 years undergoing primary RYGB between 2014-2017 with registered follow-up 5 years after surgery were included. Long BPL was defined as BPL ≥ 100 cm and short BPL as BPL < 100 cm. The primary outcome was achieving at least 25% total weight loss (TWL) at 5 years. Secondary outcomes included absolute %TWL and improvement of comorbidities. A propensity score matched logistic and linear regression was used to estimate the difference in outcomes between patients with long and short BPL. RESULTS: At 5 years, long BPL had higher odds to achieve ≥ 25% TWL (odds ratio (OR) 1.19, 95% confidence interval (CI) [1.01 - 1.41]) and was associated with 1.26% higher absolute TWL (ß = 1.26, 95% CI [0.53 - 1.99]). Furthermore, long BPL was more likely to result in improved diabetes mellitus (OR = 2.17, 95% CI [1.31 - 3.60]) and hypertension (OR = 1.45, 95% CI [1.06 - 1.99]). CONCLUSION: Patients undergoing RYGB with longer BPL achieved higher weight loss and were more likely to achieve improvement of comorbidities at 5 years.

Does the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program bariatric risk/benefit calculator hold its weight? An assessment of its accuracy.

BACKGROUND: Bariatric clinical calculators have already been implemented in clinical practice to provide objective predictions of complications and outcomes. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Surgical Risk/Benefit Calculator is the most comprehensive risk calculator in bariatric surgery. OBJECTIVES: Evaluate the accuracy of the calculator predictions regarding the 30-day complication risk, 1-year weight loss outcomes, and comorbidity resolution. SETTING: MBSAQIP-accredited center. METHODS: All adult patients who underwent primary laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy at our institution between 2012 and 2019 were included. Baseline characteristics were used to generate the individualized outcome predictions for each patient through the bariatric risk calculator and were compared to actual patient outcomes. Statistical analysis was performed using c-statistics, linear regression models, and McNemmar chi-square test. RESULTS: One thousand four hundred fifty-three patients with a median age of 45 (37, 55) and consisting of 80.1% females were included in the study. The c-statistics for the complications and comorbidity resolution ranged from .533 for obstructive sleep apnea remission to .675 for 30-day reoperation. The number of comorbidity resolutions predicted by the calculator was significantly higher than the actual remissions for diabetes, hyperlipidemia, hypertension and obstructive sleep apnea (P < .001). On average, the calculator body mass index (BMI) predictions deviated from the observed BMI measurement by 3.24 kg/m2. The RYGB procedure (Coef -.89; P = .005) and preoperative BMI (Coef -.4; P = .012) were risk factors associated with larger absolute difference between the predicted and observed BMI. CONCLUSIONS: The MBSAQIP Surgical Risk/Benefit Calculator prediction models for 1-year BMI, 30-day reoperation, and reintervention risks were fairly well calibrated with an acceptable level of discrimination except for obstructive sleep apnea remission. The 1-year BMI estimations were less accurate for RYGB patients and cases with very high or low preoperative BMI measurements. Therefore, the bariatric risk calculator constitutes a helpful tool that has a place in preoperative counseling.

Insufficient weight loss after banded vs. non-banded primary gastric bypass surgery: insights from an observational 5 year follow-up study.

BACKGROUND: While Roux-en-Y gastric bypass (RYGB) is effective in achieving weight loss and improving obesity-related co-morbidities, insufficient weight loss in the long-term can occur. The goal was to assess whether banded vs. non-banded RYGB reduces the risk of insufficient weight loss at 5-year follow-up. METHODS: This is a retrospective single-center cohort study from Switzerland. We assessed the 5-year metabolic trajectories in terms of body weight, body mass index, glucose control, lipid profile and blood pressure of two surgical cohorts undergoing identical RYGB procedures with or without banding using a uniform 6.5 cm silastic Fobi band. Insufficient weight loss was defined as < 50% excess weight loss (EWL) at 5 years. RESULTS: A total of 55 patients receiving banded (Fobi) and 55 patients receiving non-banded (non-Fobi) RYGB were included in the analysis. 5-year follow-up was 91% for both groups. Percentage of EWL at 5 years was 78.11 ± 26.1% and 73.5 ± 27%.3 for the Fobi vs. non-Fobi group (p = 0.368), respectively. Insufficient weight loss (defined as < 50%EWL) at 5 years or last follow-up was significantly higher in the non-Fobi group compared to the Fobi group (19/55 vs. 9/55, respectively, OR = 2.639 (95% CI 1.066, 6.531), p = 0.036). Surrogate markers for cardiometabolic outcomes consistently improved over time, without differences between the groups. During the follow-up period, Fobi-removal was necessary in nine patients (16.3%). CONCLUSION: Banded-RYGB lowered the odds of insufficient weight loss at 5 years follow-up by approximately 62%. Further research is needed to explore the effect of restriction on eating behaviour and neuroendocrine responses after RYGB.

Roux-en-Y Gastric Bypass Vs Sleeve Gastrectomy in Super Obesity: a Systematic Review and Meta-Analysis.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are safe procedures that may present sub-optimal results in superobesity (SO). A meta-analysis was performed aiming to summarize the available evidence on weight loss (primary outcome) and comorbidities resolution of LRYGB and LSG in patients with SO (BMI ≥ 50 kg/m2). From the 16 included studies, 7 integrated the meta-analysis. LRYGB showed a significantly higher weight loss at 6 to 12-months, but not after 24 months and a higher dyslipidemia resolution at 12 months. When compared with LSG, LRYGB achieved better weight loss after 6 and 12 months and higher dyslipidemia resolution after 1 year. There were no significant differences for resolution of the other co-morbidities studied.

Postoperative 4-Year Outcomes in Septuagenarians Following Bariatric Surgery.

BACKGROUND: Bariatric surgery is the most effective treatment for obesity; however, its utilization in older patients remains low. There is a dearth of literature on long-term effectiveness and safety of bariatric surgery in septuagenarian patients. The aim of this study was to compare the short- and long-term outcomes of bariatric surgery in this population. METHODS: Patients who underwent primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) at our institution between 2011 and 2015 were included. Patients were divided into two age groups: < 70 and ≥ 70 years. Outcomes included postoperative hospital length of stay (LOS), 30-day complications, up to 4-year complications, 90-day mortality, comorbidity resolution, and 4-year weight loss (BMI change-ΔΒΜΙ). The groups were also compared using multivariable analyses adjusting for potential confounders (gender, preoperative BMI, and type of procedure). RESULTS: Twenty-nine septuagenarians who underwent 21 LRYGB (72.4%) and 8 LSG (27.6%) were compared to 1016 patients aged < 70 years operated on during the same time period. Additionally, following the multivariable analyses, the septuagenarians had higher LOS (3 vs 2.3 days, p = 0.01), 4-year complications (38% vs 23%, p = 0.012), and less comorbidities' resolution but similar 4-year ΔBMI (- 8.6 vs - 10, p = 0.421), and 30-day complications (10% vs 6%, p = 0.316). CONCLUSION: Bariatric surgery in carefully selected septuagenarians can be accomplished with acceptable safety and comparable postoperative weight loss at 4 years. Surgeons may consider broadening their selection criteria to include this patient subgroup but may allow the patients to reap its benefits if offered earlier in life.

Clinical Features and Short-Term Outcomes of Bariatric Surgery in Morbidly Obese Patients: Institutional Experience at a Rural Hospital.

Objective: To prospectively evaluate the postoperative morbidity, mortality, and weight loss evolution of patients who underwent a bariatric procedure during 1 year of follow-up. Methods: Since July 2016, a total of 101 patients' data have been prospectively registered in a database. Comorbidities, operating time, hospital stay, early and late complications rate, and weight loss evolution after 1 year of follow-up were recorded. Results: The mean age was 38.41 ± 11.05 years with a mean body mass index (BMI) of 49.02 ± 5.89 kg/m2 (range 38-67). Laparoscopic sleeve gastrectomy (LSG) was performed in 93 patients (92.07%) and Roux-en-Y gastric bypass (RNYGB) in 8 patients (7.92%). Thirty-day morbidity rate was 7.92% (8/101). Within a mean 9.32 ± 2.25 (range 1-19) months follow-up time, mean percent of the excess of weight loss of 1st, 6th, and 12th months were 22.7 ± 6.1, 67.2 ± 11.2, and 81.4 ± 10.5, respectively. Diabetes (n = 38, 37.6%), hypertension (n = 13, 12.9%), and obstructive sleep apnea (n = 5, 4.9%) were resolved in 76%, 68.4%, and 100% of the patients, respectively (p < 0.001). Conclusions: LSG and RNYGB are safe and highly effective, particularly in patients with a BMI >50 kg/m2. Both techniques have been presented with better clinical outcomes regarding significant comorbidity resolution in the early evolution of weight loss.

Bariatric surgery outcomes: is age just a number?

INTRODUCTION: Obesity and its associated comorbidities represent a pervasive problem in the United States across all age groups. There are conflicting data regarding the effectiveness and postoperative recovery of bariatric surgery in elderly patients. The aim of this study was to compare outcomes of bariatric surgery across age groups. MATERIALS AND METHODS: After obtaining institutional review board approval, patients with morbid obesity who underwent non-revisional laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG) at our institution between 2011 and 2015 were included in this retrospective study. Patients were subdivided into five age groups: < 30, 30-39, 40-49, 50-59, and ≥ 60 years. Patient baseline demographics and comorbidities were collected. Postoperative outcomes including reinterventions/reoperations, 30-day-readmissions, 90-day-mortality, comorbidities' resolution, and change in BMI (ΔBMI) up to 4 years were recorded and compared. The groups were compared with ANOVA and chi-square tests and multivariable analyses. RESULTS: LRYGB was performed in 74.7% of the 1026 study patients. Patients ≥ 60 years old demonstrated lower preoperative BMI than patients < 50 years (p < 0.001). Patients 50-59 years old had increased length of stay compared to 30-39 (p = 0.003) and a higher prevalence of all comorbidities was found in older patients (p < 0.001). There was no significant difference in 30-day-readmissions; 90-day-mortality; reoperations; and reinterventions among the study groups. The ΔBMI was higher in younger patients and comorbidity resolution was more likely in younger patients with the exception of obstructive sleep apnea. CONCLUSION: Bariatric surgery can be accomplished safely across all age groups with satisfiable postoperative weight loss. However, older age had higher hospital stay and convalescence and lower comorbidity resolution compared to younger patients. Thus, bariatric surgery should be offered earlier in life to allow the patients to reap its benefits.

Is Laparoscopic Roux-en-Y Gastric Bypass Still the Gold Standard Procedure for Indians? Mid- to Long-Term Outcomes from a Tertiary Care Center.

PURPOSE: Laparoscopic Roux-en-Y gastric bypass (RYGB) is the oldest and most widely performed bariatric surgery worldwide. There is, however, a scarcity of mid- to long-term data of RYGB, especially from the Indian subcontinent. MATERIALS AND METHODS: The study was a single-center, retrospective analysis from patients who underwent RYGB between January 2009 and November 2014 from a tertiary care center in India. Percent of total weight loss (%TWL) was taken as the primary outcome of the study. Secondary outcomes included type 2 diabetes mellitus (T2DM) remission, comorbidity resolution, revisional surgeries, and complications related to RYGB at 1 year, at 3 years, and during the long term, following surgery. Postoperative visits took place at 1 and 3 years, while the long-term outcome was at median 8.3 years (range 5.4-11.2 years), with a follow-up of 92.4% (488/528), 80.5% (424/527) and 69.5% (363/522), respectively. RESULTS: Out of 528 patients studied, 56% were females. The mean body mass index (BMI) was 40.6 ± 6.9 kg/m2. The %TWL in the long-term follow-up was 21.8 ± 11.3%. T2DM remission rates at 1 year, at 3 years, and during the long term were 84.5%, 70.0%, and 60.0%, respectively. Preoperative HBA1c (p = 0.002) and insulin usage (p = 0.016) had a significant predictive effect on T2DM remission. Gastroesophageal reflux disease (GERD) improved significantly (p < 0.001). Early (< 30 days) and late (> 30 days) complications were observed in 2.3% and 4.3% of the patients, respectively. CONCLUSION: Weight loss during mid to long-term follow-up was maintained in the majority of the patients after RYGB. However, a small proportion had significant weight regain in the long term. T2DM, GERD, and other comorbidities were well improved after RYGB.

Revisiting the Ghrelin Changes Following Bariatric and Metabolic Surgery.

Since the description of ghrelin in 1999, several studies have dug into the effects of this hormone and its relationship with bariatric surgery. While some aspects are still unresolved, a clear connection between ghrelin and the changes after metabolic surgery have been established. Besides weight loss, a significant amelioration in obesity-related comorbidities following surgery has also been reported. These changes in patients occur in the early postoperative period, before the weight loss appears, so that amelioration may be mainly due to hormonal changes. The purpose of this review is to go through the current body of knowledge of ghrelin's physiology, as well as to update and clarify the changes that take place in ghrelin concentrations following bariatric/metabolic surgery together with their potential consolidation to outcomes.

Vertical Banded Gastroplasty Revision to Gastric Bypass Leads to Effective Weight Loss and Comorbidity and Dysphagia Symptom Resolution.

PURPOSE: Up to 50% of patients with vertical banded gastroplasty (VBG) experience failure or complications in the mid- and long-term and present for revisional bariatric surgery. This study aimed to review our experience for patient outcomes after VBG revisions and compare their benefits to those of primary laparoscopic Roux-en-Y gastric bypass (LRYGB) operations. MATERIALS AND METHODS: Data from patients who underwent VBG revision between 2009 and 2015 at a center of excellence were reviewed. Patient demographics, symptoms, comorbidities, weight loss, reinterventions, reoperations, and hospital stay were analyzed and compared with those of primary LRYGB patients (control group). RESULTS: Fifty-two patients (88.5% female, 55 ± 9.6 years old) underwent revisional surgery during the study period (86.5% LRYGB, 11.5% VBG reversal, and 2% sleeve gastrectomy). Patients presented 17.3 ± 7.2 years after their VBG for weight regain (55.8%), dysphagia (19.2%), or both (25%). Patients who underwent conversion to LRYGB for weight regain and for mix-symptoms had similar weight loss to the control group (38.2 ± 11.8 vs 35.6 ± 7.7, p = 0.108), along with similar comorbidity resolution. However, even though the early (< 30 days) complication rate was similar between the two groups, the conversion group had higher 4-year reoperation rate (29% vs 9.5%, p < 0.001) and length of stay (5.4 ± 5.3 vs 2.6 ± 3.1, p < 0.001). Additionally, dysphagia resolved in all the patients of our cohort. CONCLUSIONS: VBG conversion to LRYGB leads to significant weight loss, resolution of dysphagia, and comorbidities similarly to the primary LRYGB operations. However, higher mid-term complication rates should be expected.

Long-term outcomes of laparoscopic sleeve gastrectomy from the Indian subcontinent.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed metabolic surgery worldwide. There are few mid- to long-term studies for LSG, especially from the Indian subcontinent. OBJECTIVE: The primary outcome of the study was percent total weight loss (%TWL), and secondary outcomes included type 2 diabetes mellitus remission (T2DM) rates, comorbidity resolution rates, revisional surgeries, and complications related to LSG, 3 and 5 years after surgery. METHOD: The study was a single-center, retrospective analysis from patients who underwent primary as well as revisional LSG between January 2012 and December 2013 from a tertiary care center in India. We included patients who completed a minimum follow-up of 5 years. Details of the patients were collected from outpatient and inpatient case sheet records, during their follow-up. RESULTS: Out of a total of 284 patients, 57% were females. Mean baseline body mass index (BMI) was 44.9 ± 7.9 kg/m2. The diabetic population comprised 14.8% of the total patients. Mean %TWL at 5 years was 26.0 ± 9.9%. T2DM remission at 1, 3, and 5 years were 78.5%, 71.4%, and 66.6%, respectively. Preoperative BMI (p = 0.02), glycosylated hemoglobin (HbA1c) (p = 0.04), duration of diabetes in years (p = 0.04), and preoperative insulin usage (p = 0.04) were the preoperative predictors for T2DM remission. Early (< 30 days) and late (> 30 days) complications were seen in 4.5% and 0.7% of the population, respectively. CONCLUSION: Weight loss after LSG was maintained in the majority of the patients, while a small proportion has significant weight regain at 5 years. T2DM resolution and other comorbidity resolutions were well supported after LSG.

Efficacy of a Required Preoperative Weight Loss Program for Patients Undergoing Bariatric Surgery.

The efficacy of mandatory medically supervised preoperative weight loss (MPWL) prior to bariatric surgery continues to be a controversial topic. The purpose of this observational study was to assess the efficacy of a MPWL program in a single institution, which mandated at least 10% excess body weight loss before surgery, by comparing outcomes of patients undergoing primary bariatric surgery with and without a compulsory preoperative weight loss regimen. We analyzed our database of 757 patients who underwent primary bariatric surgery between March 2008 and January 2015. Patients were placed into two cohorts based on their participation in a MPWL program requiring at least 10% excess weight loss (EWL) prior to surgery. Patients were evaluated at 3, 6, 12, and 24 months after surgery for weight loss, comorbidity resolution, and the occurrences of hospital readmissions. A total of 717 patients met the inclusion criteria of whom 465 underwent surgery without a preoperative weight loss requirement and 252 participated in the MPWL program. One year after surgery, 67.1% of non-participants and 62.5% of MPWL participants showed a resolution of at least one of five associated comorbidities (p = 0.45). Non-participants showed an average of 58.6% EWL, while MPWL participants showed 59.1% EWL at 1 year postoperatively (p = 0.84). Readmission rates, excluding those which were ulcer-related, at 30 days (3.4 vs. 6.40%, p = 0.11) and 90 days (9.9 vs. 7.5%, p = 0.29) postoperatively were not significantly different between the non-participants and MPWL patients, respectively. A mandatory preoperative weight loss program prior to bariatric surgery did not result in significantly greater %EWL or comorbidity resolution 1 year after surgery compared to patients not required to lose weight preoperatively. Additionally, the program did not result in significantly lower 30- or 90-day readmission rates for these patients. The value of a MPWL program must be weighed against the potential loss of bariatric surgery candidates. Patients who fail to lose 10% excess weight preoperatively are thus ineligible for a procedure from which they would otherwise benefit. Our data suggest these patients will have similar positive outcomes.