Effect of anti-reflux suture on gastroesophageal reflux symptoms after one anastomosis gastric bypass: a randomized controlled trial.

PURPOSE: Gastroesophageal reflux disease (GERD) is an issue after one anastomosis gastric bypass (OAGB) and modification of OAGB with adding an anti-reflux system may decrease the incidence of postoperative GERD. This study aimed to compare the efficacy of the anti-reflux mechanism to treat preoperative GERD and prevent de novo GERD. METHODS: A prospective randomized clinical trial study was conducted on patients with a body mass index of 40 and more from August 2020 to February 2022. Patients undergoing one anastomosis gastric bypass with and without anti-reflux sutures (groups A and B, respectively). These patients had follow-ups for one year after the surgery. GERD symptoms were assessed in all the patients using the GERD symptom questionnaire. RESULTS: The mean age was 39.5 ± 9.8 years and 40.7 ± 10.2 years in groups A and B respectively. GERD symptoms remission occurred in 76.5% and 68.4% of patients in groups A and B, respectively. The incidence of de novo GERD symptoms was lower in group A, compared to group B (6.2% and 16.1% in groups A and B respectively), without any statistically significant difference (p-value: 0.239). CONCLUSION: GERD symptoms and de novo GERD after OAGB seems to be under-reported after OAGB. This study suggests that applying an anti-reflux suture can decrease de novo GERD symptoms.

Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus.

Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

Patient Selection in One Anastomosis/Mini Gastric Bypass-an Expert Modified Delphi Consensus.

PURPOSE: One anastomosis/mini gastric bypass (OAGB/MGB) is up to date the third most performed obesity and metabolic procedure worldwide, which recently has been endorsed by ASMBS. The main criticisms are the risk of bile reflux, esophageal cancer, and malnutrition. Although IFSO has recognized this procedure, guidance is needed regarding selection criteria. To give clinicians a daily support in performing the right patient selection in OAGB/MGB, the aim of this paper is to generate clinical guidelines based on an expert modified Delphi consensus. METHODS: A committee of 57 recognized bariatric surgeons from 24 countries created 69 statements. Modified Delphi consensus voting was performed in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was considered to indicate a consensus. RESULTS: Consensus was achieved for 56 statements. Remarkably, ≥ 90.0% of the experts felt that OAGB/MGB is an acceptable and suitable option "in patients with Body mass index (BMI) > 70, BMI > 60, BMI > 50 kg/m2 as a one-stage procedure," "as the second stage of a two-stage bariatric surgery after Sleeve Gastrectomy for BMI > 50 kg/m2 (instead of BPD/DS)," and "in patients with weight regain after restrictive procedures. No consensus was reached on the statement that OAGB/MGB is a suitable option in case of resistant Helicobacter pylori. This is likely as there is a concern that this procedure is associated with reflux and its related long-term complications including risk of cancer in the esophagus or stomach. Also no consensus reached on OAGB/MGB as conversional surgery in patients with GERD after restrictive procedures. Consensus for disagreement was predominantly achieved "in case of intestinal metaplasia of the stomach" (74.55%), "in patients with severe Gastro Esophageal Reflux Disease (GERD)(C,D)" (75.44%), "in patients with Barrett's metaplasia" (89.29%), and "in documented insulinoma" (89.47%). CONCLUSION: Patient selection in OAGB/MGB is still a point of discussion among experts. There was consensus that OAGB/MGB is a suitable option in elderly patients, patients with low BMI (30-35 kg/m2) with associated metabolic problems, and patients with BMIs more than 50 kg/m2 as one-stage procedure. OAGB/MGB can also be a safe procedure in vegetarian and vegan patients. Although OAGB/MGB can be a suitable procedure in patients with large hiatal hernia with concurrent hiatal hernia, it should not be offered to patients with grade C or D esophagitis or Barrett's metaplasia.

IFSO Update Position Statement on One Anastomosis Gastric Bypass (OAGB).

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued a position statement on the role of one anastomosis gastric bypass (OAGB) in the field of bariatric/metabolic surgery in 2018 De Luca et al. (Obes Surg. 28(5):1188-206, 2018). This position statement was issued by the IFSO OAGB task force and approved by the IFSO Scientific Committee and IFSO Executive Board. In 2018, the OAGB task force recognized the necessity to update the position statement in the following 2 years since additional high-quality data could emerge. The updated IFSO position statement on OAGB was issued also in response to inquiries to the IFSO by society members, universities, hospitals, physicians, insurances, patients, policy makers, and media. The IFSO position statement on OAGB has been reviewed within 2 years according to the availability of additional scientific evidence. The recommendation of the statement is derived from peer-reviewed scientific literature and available knowledge. The IFSO update position statement on OAGB will again be reviewed in 2 years provided additional high-quality studies emerge.

The First Modified Delphi Consensus Statement for Resuming Bariatric and Metabolic Surgery in the COVID-19 Times.

The purpose of this study was to achieve consensus amongst a global panel of expert bariatric surgeons on various aspects of resuming Bariatric and Metabolic Surgery (BMS) during the Coronavirus Disease-2019 (COVID-19) pandemic. A modified Delphi consensus-building protocol was used to build consensus amongst 44 globally recognised bariatric surgeons. The experts were asked to either agree or disagree with 111 statements they collectively proposed over two separate rounds. An agreement amongst ≥ 70.0% of experts was construed as consensus as per the predetermined methodology. We present here 38 of our key recommendations. This first global consensus statement on the resumption of BMS can provide a framework for multidisciplinary BMS teams planning to resume local services as well as guide future research in this area.

Short-Term Changes on Body Composition and Bone Mass After One-Anastomosis Gastric Bypass: a Prospective Observational Study.

PURPOSE: Bariatric surgery generates a large weight loss. It is considered a successful surgery when 50% of the excess weight loss is reached. However, this measure does not include some variables that may have a direct impact on a patient's health, such as fat-free mass (FFM) or bone mass. Therefore, the aim of this study is to evaluate body composition and bone mass in patients undergoing one-anastomosis gastric bypass (OAGB). METHODS: A prospective observational study was performed in patients undergoing OAGB. Body composition and bone mass were evaluated by bioelectrical impedance analysis at baseline (1 day prior to surgery), at 6 and 12 months after surgery. RESULTS: A total of 94 patients (67% females and 33% males) were included in the study. The excess BMI loss at 6 and 12 months after surgery was 97.9 ± 20.1% and 110.2 ± 30.5% respectively. The FFM showed a reduction of 6.6 ± 4.8 kg (p < 0.01) 6 months after surgery and of 7.9 ± 4.9 kg (p < 0.01) at 12 months, meaning a decrease of 10.5 ± 7.3% and a 12.9 ± 6.6% respectively. The bone mass decrease was 10.1 ± 6.9% (p < 0.01) and 12.9 ± 6.5% (p < 0.01) at 12 months after OAGB. CONCLUSIONS: OAGB obtains a relevant weight loss in patients with morbid obesity, mainly, due to fat mass reductions. However, this procedure also provokes FFM and bone mass decreases, especially in females, but not significantly greater than other restrictive or mixed procedures.

Analgesic effect of postoperative laparoscopic-guided transversus abdominis plane (TAP) block, associated with preoperative port-site infiltration, within an enhanced recovery after surgery protocol in one-anastomosis gastric bypass: a randomized clinical trial.

BACKGROUND: The use of ultrasonography to assist needle placement during transverse abdominal plane (TAP) technique has provided direct visualization of surround anatomical musculature and facial planes. However, the increased girth in patients undergoing bariatric surgery is challenging to visualize via ultrasonography which may lead to poor postoperative analgesia. OBJECTIVE: The aim of the study is to investigate whether the addition of postoperative laparoscopic-guided TAP block as part of a multimodal analgesic regimen within the ERAS protocol compared to no block provides better postoperative analgesia in patients undergoing one-anastomosis gastric bypass surgery. PATIENTS AND METHODS: A prospective clinical trial was performed. Patients were randomized into two groups: patients undergoing postoperative laparoscopic-guided TAP (TAP-lap) and patients not receiving TAP-lap (Control). Multimodal analgesia included preoperative port-site infiltration with Bupivacaine 0.25% in both groups and systemic Acetaminophen. Pain quantification as measured by visual analogic scale (VAS) was assessed at 6 and 24 h after surgery, and 24-h postoperative opioid consumption. RESULTS: One hundred and forty patients were included, 70 in each group. The mean operation time was 78.5 ± 14.4 min in TAP-lap and 75.9 ± 15.6 min in Control (NS). The mean postoperative pain, as measured by VAS, 6 h after surgery was 23.1 ± 11.3 mm in TAP-lap and 41.8 ± 16.2 mm in Control (p = 0.001). 24 h after surgery was 16.6 ± 11.4 mm in TAP-lap and 35.4 ± 12.7 mm in Control (p = 0.001). Morphine rescues were necessary in 14.2% in Control and 2.8% in TAP-lap (p = 0.035). CONCLUSION: Laparoscopic-guided TAP block as part of a multimodal analgesia regimen can reduce postoperative pain and opioid consumption, without increasing operative time.

Are There Ideal Small Bowel Limb Lengths for One-Anastomosis Gastric Bypass (OAGB) to Obtain Optimal Weight Loss and Remission of Comorbidities with Minimal Nutritional Deficiencies?

BACKGROUND: Ideal jejunal and ileal lengths in bariatric/metabolic procedures to be left in alimentary continuity still remain unclear. We aimed to evaluate different lengths of biliopancreatic limb (BPL) and common limb (CL) performed in a series of patients submitted to OAGB, and correlate them with weight loss and nutritional deficits. PATIENTS AND METHODS: A prospective observational study of 350 consecutive morbidly obese patients undergoing OAGB was performed. BPL and CL lengths were determined intraoperatively; BPL/TBL and CL/TBL ratios were then calculated. Anthropometric variables, remission of comorbidities and specific supplementation needs were recorded at 1, 2 and 5 years after surgery. RESULTS: Three hundred patients were included for final analysis. BPL length and BPL/TBL ratio directly correlated with Units of BMI lost (UBMIL). Conversely, CL length and CL/TBL ratio showed an inverse correlation with UBMIL. Establishing a BMI ≤ 25 kg/m2 as ideal, the most accurate AUC, to predict achieving an ideal BMI at 1, 2 and 5 years after surgery, was obtained for the CL/TBL ratio, followed by the CL length at 1, 2 and 5 years. An ideal range was established between 0.40 and 0.43 for the CL/TBL ratio, and 200 to 220 cm for the CL length. Among these ranges, there were no cases of protein or calorie malnutrition. CONCLUSION: TBL measurement is essential to obtain optimal outcomes after OAGB, both in terms of excellent weight loss and remission/improvement of comorbidities, as well as with a low risk of nutritional deficiencies. The CL/TBL ratio, followed by CL length, are the most accurate parameters to predict a 5-year postoperative BMI ≤ 25 kg/m2.

A 5-Year Follow-up in Children and Adolescents Undergoing One-Anastomosis Gastric Bypass (OAGB) at a European IFSO Excellence Center (EAC-BS).

BACKGROUND: The children and adolescent population with obesity has increased worldwide, both in developing areas and in developed countries. Consequently, the prevalence of morbid obesity among this population has also increased, leading to an exponential growth of bariatric approaches in this population. Many surgeons fear eventual nutritional sequelae after malabsorptive approaches and prefer restrictive or mixed procedures. METHODS: A retrospective review of all the morbidly obese patients between 13 and 19 years, undergoing a one-anastomosis gastric bypass (OAGB) as bariatric procedure between 2004 and 2012, was performed. RESULTS: A total of 39 patients were included, 8 males (20.5%) and 31 females (79.5%), with a mean age of 17.8 ± 2 years (range 13-19 years). Mean preoperative weight was 114.3 ± 20.4 kg and mean BMI 42.2 ± 5.9 kg/m2. Preoperative comorbidities include only type 2 diabetes mellitus (T2DM) in 7.9% of the patients, hypertension in 10.3%, and dyslipidemia in 23.1%. Five years after surgery, mean BMI was 25.9 ± 5.3 kg/m2 and total weight loss 32.1 ± 15.7%. Remission rate of T2DM, hypertension and dyslipidemia was 100%. All the patients received multivitamin and vitamin D supplementation. Anemia secondary to iron deficiency occurred in one female, requiring intravenous iron supplementation during 1 year and later on oral supplementation. CONCLUSIONS: OAGB is a valid alternative for long-term weight loss and remission of comorbidities in childhood and adolescence. No cases of malnutrition or growth disorders were observed.

Whipple disease after bariatric surgery: from malabsorption to malnutrition status.

Introduction: Malabsorptive bariatric techniques are associated with nutritional deficiencies. However, when patients do not respond to supplemental intensive treatments they should be closely followed because they can hide other pathological conditions. We present the case of a 47-year-old man with morbid obesity (body mass index [BMI]: 48 kg/m2) who underwent bariatric surgery. In 2016, he presented severe pneumonia and hospitalization at the Intensive Unit Care was required. After this episode, his nutritional state impaired, presenting 6-7 diarrhea/steatorrhea events per-day and requiring several hospitalizations due to the persistence of severe hypoproteinemia. He was given parenteral high-protein associated with low-fat oral diet. He presented a temporary biochemical improvement, but the hypoproteinemia recurred. Finally, tests revealed the presence of Tropheryma whipplei as protein-losing enteropathy. Whipple's disease (WD) is a rare cause of diarrhea and malnutrition, and these symptoms can be confused with the postoperative status of malabsorptive bariatric techniques. WD requires early diagnosis with prolonged antibiotic treatment to avoid severe complications.

Introducción: Las técnicas bariátricas malabsortivas suelen asociarse a deficiencias nutricionales. Sin embargo, cuando los pacientes no responden a tratamientos intensivos suplementarios, deben valorarse otras condiciones patológicas. Presentamos el caso de un hombre de 47 años, obeso mórbido (índice de masa corporal [IMC]: 48 kg/m2) sometido a cirugía bariátrica, que dos años más tarde presentó neumonía severa, por lo que requirió ingreso en la Unidad de Cuidados Intensivos. Posteriormente, el estado nutricional se deterioró, presentando 6-7 episodios de diarrea-esteatorrea/día y requiriendo varias hospitalizaciones por hipoproteinemia severa. Recibió infusión parenteral rica en proteínas asociada con una dieta baja en grasas y presentó mejoría analítica temporal. Finalmente, las pruebas revelaron la presencia de Tropheryma whipplei, una bacteria que genera enteropatía pierde-proteínas. La enfermedad de Whipple (EW) es una causa poco común de diarrea y malnutrición. Estos síntomas pueden confundirse con el posoperatorio de técnicas bariátricas malabsortivas. La EW requiere un diagnóstico precoz con un tratamiento antibiótico prolongado para evitar complicaciones graves.

Whipple disease after bariatric surgery: from malabsorption to malnutrition status / La enfermedad de Whipple después de cirugía bariátrica: de la malabsorción a la malnutrición

Malabsorptive bariatric techniques are associated with nutritional deficiencies. However, when patients do not respond to supplemental intensive treatments they should be closely followed because they can hide other pathological conditions. We present the case of a 47-year-old man with morbid obesity (body mass index [BMI]: 48 kg/m2) who underwent bariatric surgery. In 2016, he presented severe pneumonia and hospitalization at the Intensive Unit Care was required. After this episode, his nutritional state impaired, presenting 6-7 diarrhea/steatorrhea events per-day and requiring several hospitalizations due to the persistence of severe hypoproteinemia. He was given parenteral high-protein associated with low-fat oral diet. He presented a temporary biochemical improvement, but the hypoproteinemia recurred. Finally, tests revealed the presence of Tropheryma whipplei as protein-losing enteropathy. Whipple's disease (WD) is a rare cause of diarrhea and malnutrition, and these symptoms can be confused with the postoperative status of malabsorptive bariatric techniques. WD requires early diagnosis with prolonged antibiotic treatment to avoid severe complications

Las técnicas bariátricas malabsortivas suelen asociarse a deficiencias nutricionales. Sin embargo, cuando los pacientes no responden a tratamientos intensivos suplementarios, deben valorarse otras condiciones patológicas. Presentamos el caso de un hombre de 47 años, obeso mórbido (índice de masa corporal [IMC]: 48 kg/m2) sometido a cirugía bariátrica, que dos años más tarde presentó neumonía severa, por lo que requirió ingreso en la Unidad de Cuidados Intensivos. Posteriormente, el estado nutricional se deterioró, presentando 6-7 episodios de diarrea-esteatorrea/día y requiriendo varias hospitalizaciones por hipoproteinemia severa. Recibió infusión parenteral rica en proteínas asociada con una dieta baja en grasas y presentó mejoría analítica temporal. Finalmente, las pruebas revelaron la presencia de Tropheryma whipplei, una bacteria que genera enteropatía pierde-proteínas. La enfermedad de Whipple (EW) es una causa poco común de diarrea y malnutrición. Estos síntomas pueden confundirse con el posoperatorio de técnicas bariátricas malabsortivas. La EW requiere un diagnóstico precoz con un tratamiento antibiótico prolongado para evitar complicaciones graves

Author Correction: Evaluation of Weight Loss Indicators and Laparoscopic One-Anastomosis Gastric Bypass Outcomes.

A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has been fixed in the paper.

Mini Gastric Bypass-One Anastomosis Gastric Bypass (MGB-OAGB)-IFSO Position Statement.

PREAMBLE: The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has played an integral role in educating both the metabolic surgical and the medical community at large about the role of innovative and new surgical and/or endoscopic interventions in treating adiposity-based chronic diseases.The mini gastric bypass is also known as the one anastomosis gastric bypass. The IFSO has agreed that the standard nomenclature should be the mini gastric bypass-one anastomosis gastric bypass (MGB-OAGB). The IFSO commissioned a task force (Appendix 1) to determine if MGB-OAGB is an effective and safe procedure and if it should be considered a surgical option for the treatment of obesity and metabolic diseases.The following position statement is issued by the IFSO MGB-OAGB task force and approved by the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence. It will be reviewed in 2 years.

Evaluation of Weight Loss Indicators and Laparoscopic One-Anastomosis Gastric Bypass Outcomes.

Mini-gastric bypass/One-anastomosis gastric bypass (MGB-OAGB) is an effective bariatric technique for treating overweight and obesity, controlling and improving excess-weight-related comorbidities. Our study evaluated OAGB characteristics and resulting weight evolution, plus surgical success criteria based on various excess weight loss indicators. A prospective observational study of 100 patients undergoing OAGB performed by the same surgical team (two-year follow-up). Surgical characteristics were: surgery duration, associated complications, bowel loop length, hospital stay, and weight loss at 6 postoperative points. 100 patients were treated (71 women, 29 men); mean initial age was 42.61 years and mean BMI, 42.61 ± 6.66 kg/m2. Mean surgery duration was 97.84 ± 12.54 minutes; biliopancreatic loop length was 274.95 ± 23.69 cm. Average hospital stay was 24 hours in 98% of patients; no surgical complications arose. Weight decreased significantly during follow-up (P < 0.001). Greatest weight loss was observed at 12 months postsurgery (68.56 ± 13.10 kg). Relative weight loss showed significant positive correlation, with greatest weight loss at 12 months and %excess BMI loss > 50% achieved from the 3-month follow-up in 92.46% of patients. OAGB seems to be effective in treating obesity, with short hospital stays. Relative weight loss correlates optimally with absolute outcomes, but both measures should be used to evaluate surgical results.