[The city-hospital link in the care of severely obese patients]. / Le lien ville-hôpital dans le parcours de soins des patients obèses sévères.

After the initial weekday hospital stay, a personalized, multidisciplinary care pathway is offered to each patient followed at the specialized obesity center (CSO). This article illustrates the support approach adopted by the CSO at Caen Normandy University Hospital.

[Reception and initial assessment when caring for a person with severe obesity]. / Accueil et bilan initial lors de la prise en charge d'une personne en situation d'obésité sévère.

In France, there are 37 specialist obesity treatment centres (CSOs), located in mainland and overseas France. Attached to public or private health establishments, they have two main missions, which they carry out within the framework of national specifications: the multidisciplinary management of severe or complex obesity, and the organisation, coordination and development of the regional obesity care network. This article illustrates the practice of the Caen Normandy CSO.

Revisional surgery after restrictive surgery: midterm outcomes of a tertiary center.

INTRODUCTION: Revisional bariatric surgery (RBS) is a challenging type of procedure for the surgeons due to its specific morbidity and efficiency. The RBS has a higher prevalence nowadays and this study may help to improve scarce data upon this specific topic. METHODS: Data from 252 patients undergoing RBS after laparoscopic adjustable gastric banding (LAGB) or laparoscopic sleeve gastrectomy (LSG) between 2005 and 2019, were analyzed at 2 years of follow up. A subgroup analysis of third procedure was also performed. RESULTS: Overall morbidity occurred in 35 patients (37%) in the LSG group and 40 patients (25%) in the LAGB group (p = 0.045). At 2 years of RBS, mean weight was 92.8 ± 26.7 kg, BMI was 33.1 ± 8.56 kg/m2 for patients who had RBS after LSG. When RBS was performed after LAGB, mean weight at 2 years was 90.1 ± 20.7 kg and BMI was 32.5 ± 6.45 kg/m2. TWL for RBS performed after LSG was 12.7 ± 16.4% versus 25.5 ± 10.3% after LAGB (p < 0.001). CONCLUSION: RBS after LSG seems to lead to higher overall morbidity whereas RBS after LAGB lead to more perioperative issues.

Mid-term Results of an ERAS Program of Bariatric Surgery in a Tertiary Referral Center.

BACKGROUND: To identify preoperative risk factors for discharge failure beyond postoperative day two (POD-2) in bariatric surgery ERAS program in a tertiary referral center. METHODS: all consecutive patients who underwent laparoscopic bariatric treated in accordance with ERAS protocol between January 2017 and December 2019 were included. Two groups were identified, failure of early discharge (> POD-2) (ERAS-F) and success of early discharge (≤ POD-2) (ERAS-S). Overall postoperative morbidity, unplanned readmission rates were analyzed at POD-30 and POD-90, respectively. Multivariate logistic regression was performed to determine the independent risk factors for LOS > 2 days (ERAS-F). RESULTS: A total of 697 consecutive patients were included, 148 (21.2%) in ERAS-F group and 549 (78.8%) in ERAS-S group. All postoperative complications at POD 90, whether medical or surgical were significantly more frequent in ERAS-F group than in ERAS-S group. Neither readmission nor unplanned consultations rates at POD 90 were significantly different between both groups. History of psychiatric disorder (p = 0.01), insulin-dependent diabetes (p < 0.0001), use of anticoagulants medicine (p < 0.00001), distance to the referral center > 100 km (p = 0.006), gallbladder lithiasis (p = 0.02), and planned additional procedures (p = 0.01) were independent risk factors for delayed discharge beyond POD-2. CONCLUSIONS: One in five patients with bariatric surgery failed to discharge earlier despite the ERAS program. Knowledge of these preoperative risk factors would allow us to identify patients who need more recovery time and a tailored approach to the ERAS protocol.

Laparoscopic Sleeve Gastrectomy versus Laparoscopic Roux-en-Y Gastric Bypass: An Analysis of Weight Loss Using a Multilevel Mixed-Effects Linear Model.

BACKGROUND: Regarding weight loss outcomes, the results published after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y (LRYGB) are conflicting. At this time, no clear evidence exists that outcomes from LSG are similar to those for LRYGB. The main objective of this study was to compare the percent of total weight loss (%TWL) between LRYGB and LSG over the first 2 years using a multilevel mixed-effects linear regression. METHODS: Data were collected from a prospectively maintained database of patients who underwent primary laparoscopic bariatric surgery from January 2016 to December 2017 at a French accredited bariatric center. The medical records of 435 consecutive patients were analyzed. %TWL was calculated at each follow-up surgical consultation and used as a repeated outcome variable in our models to assess the long-term %TWL. Due to this hierarchical structure of the data (%TWL at each visit = level 1) within patients (level 2), a multilevel linear regression adjusted for age, sex, preoperative BMI and comorbidities was used. RESULTS: Among the medical records of 435 consecutive patients included, 266 patients underwent LRYGB and 169 underwent LSG. The average %TWL at 2 years was 31.7% for the LRYGB group and 25.8% for the LSG group. The final multivariate model showed that, compared with LRYGB, LSG was associated with a decreased %TWL at over 2 years of follow-up (ß: -4.01; CI95%: -5.47 à -2.54; p ≤ 0.001). CONCLUSION: This observational study suggests that compared with LRYGB, LSG was associated with a decreased %TWL at 2 years using a multilevel model. Further studies are required to confirm the results observed with this statistical model.

Analysis of the Lack of Follow-Up of Bariatric Surgery Patients: Experience of a Reference Center.

Few studies have evaluated the association between non-clinical and clinical determinants in terms of discontinuing follow-up after bariatric surgery. This cohort study aims to assess these associations. Data were collected from a prospectively maintained database of patients who underwent laparoscopic bariatric surgery from January 2012 to December 2019. The Cox model was used to assess the influence of preoperative determinants on follow-up interruptions for more than one year. Multilevel logistic regression was used to evaluate the association between clinical factors and post-operative weight loss with the regularity of follow-up. During the study period, 9607 consultations were performed on 1549 patients. The factors associated with a follow-up interruption from more than 365 days included male gender (HR = 1.323; CI = 1.146−1.527; p = 0.001) and more recent years of intervention (HR = 1.043; CI = 1.012−1.076; p = 0.0068). Revisional bariatric surgery was associated with a lower risk of follow-up interruption (HR = 0.753; CI = 0.619−0.916; p = 0.0045). Independent risk factors of an irregular follow up were higher age (HR = 1.01; CI = 1.002−1.017; p = 0.0086); male gender (OR = 1.272; CI = 1.047−1.545; p = 0.0153); and higher %TWL (Total Weight Loss) (OR = 1.040 CI = 1.033−1.048 p < 0.0001). A higher preoperative BMI (OR = 0.985; CI = 0.972−0.998; p = 0.0263) and revisional surgery (OR = 0.707; CI = 0.543−0.922; p = 0.0106) were protective factors of irregularity. This study suggests that the male gender and most recent dates of surgery are the two independent risk factors for follow-up interruption. Older age, male gender, and higher weight loss were all independent risk factors of an irregular follow-up. Revision bariatric surgery is a protective factor against interruption and irregular follow-up with a higher preoperative BMI. Further studies are needed to obtain long-term results in these patients with discontinued follow-ups.

A series of severe neurologic complications after bariatric surgery in France: the NEUROBAR Study.

BACKGROUND: Neurologic complications after bariatric surgery are rare, but can have dramatic consequences. Little data are available on this topic. OBJECTIVES: The aim of the Neurologic complications after BARiatric surgery (NEUROBAR) study was to define, which factors (anthropometric, nutritional, surgical, etc.) were frequently associated with neurologic complications after bariatric surgery. SETTINGS: Data were collected by the French Centers of Obesity Care Management hosted in University Hospitals. METHODS: An online standardized questionnaire was designed and submitted to the 37 French Centers of Obesity Management. This questionnaire included items about patient characteristics, bariatric surgery, neurologic complications, nutritional status, and management. Patients were retrospectively included from January 2010 to November 2018. RESULTS: Thirteen centers included 38 patients (34 females and 4 males) with neurologic complications after bariatric surgery. The 2 main bariatric procedures were gastric bypass and sleeve gastrectomy. More than half of the patients with neurologic complications had a surgical complication after bariatric surgery (53%) and gastrointestinal symptoms, including vomiting (53%). Vitamin B deficiencies were frequent (74%) including at least 47% of cases with deficiency in Vitamin B1. CONCLUSION: Early identification of patients with surgical complications and gastrointestinal symptoms after bariatric surgery could help prevent neurologic complications related to nutritional deficiencies.

Does the Implementation of Enhanced Recovery After Surgery (ERAS) Guidelines Improve Outcomes of Bariatric Surgery? A Propensity Score Analysis in 464 Patients.

BACKGROUND: The aim of this study was to investigate whether the implementation of enhanced recovery after surgery (ERAS) guidelines according to Thorell and co. in our tertiary referral bariatric center might improve post-operative outcomes. METHODS: ERAS program was introduced in our center since January 1, 2017. Retrospective review of a prospectively collected database identified patients who underwent laparoscopic primary and revisional bariatric surgeries from October 2005 to January 2018. Patients exposed to ERAS program ("ERAS group") were matched in a 1:1 ratio with patients exposed to conventional care (control group) using a propensity score based on age, gender, preoperative body mass index (BMI), diabetes mellitus, and the type of procedures. The primary outcome was total hospital length of stay (LOS) and the secondary outcomes included the post-operative complications and readmission rates. RESULTS: During the study period, 464 patients were included, 232 in each group. Implementation of the ERAS protocol was significantly associated with a reduction of LOS (2.47 ± 1.7 vs 5.39 ± 1.9 days, p < 0.00001). One-third of patients was discharged (77/232, 33%) on the first postoperative day (POD) and more than three quarter of patients on POD 2 (182/232, 77%). At the opposite, no patients of the control group were discharged on POD 2. Overall 30-day and 90-day morbidity and readmission rates were the same in both groups. There was no death in each group. CONCLUSIONS: This large case-matched study using a propensity score analysis suggests that implementation of ERAS program significantly reduced length of hospital stay without significant increases on overall morbidity, and readmission rates.