30-day morbidity and mortality of revisional bariatric surgery - An international multi-centre collaborative (BROAD) study.

INTRODUCTION: Revisional bariatric surgery (RBS) for insufficient weight loss/weight regain or metabolic relapse is increasing worldwide. There is currently no large multinational, prospective data on 30-day morbidity and mortality of RBS. In this study, we aimed to evaluate the 30-day morbidity and mortality of RBS at participating centres. METHODS: An international steering group was formed to oversee the study. The steering group members invited bariatric surgeons worldwide to participate in this study. Ethical approval was obtained at the lead centre. Data were collected prospectively on all consecutive RBS patients operated between 15th May 2021 to 31st December 2021. Revisions for complications were excluded. RESULTS: A total of 65 global centres submitted data on 750 patients. Sleeve gastrectomy (n = 369, 49.2 %) was the most common primary surgery for which revision was performed. Revisional procedures performed included Roux-en-Y gastric bypass (RYGB) in 41.1 % (n = 308) patients, One anastomosis gastric bypass (OAGB) in 19.3 % (n = 145), Sleeve Gastrectomy (SG) in 16.7 % (n = 125) and other procedures in 22.9 % (n = 172) patients. Indications for revision included weight regain in 615(81.8 %) patients, inadequate weight loss in 127(16.9 %), inadequate diabetes control in 47(6.3 %) and diabetes relapse in 27(3.6 %). 30-day complications were seen in 80(10.7 %) patients. Forty-nine (6.5 %) complications were Clavien Dindo grade 3 or higher. Two patients (0.3 %) died within 30 days of RBS. CONCLUSION: RBS for insufficient weight loss/weight regain or metabolic relapse is associated with 10.7 % morbidity and 0.3 % mortality. Sleeve gastrectomy is the most common primary procedure to undergo revisional bariatric surgery, while Roux-en-Y gastric bypass is the most commonly performed revision.

Undiagnosed Hyperglycemia Is a Potential Long-term Risk in Metabolic Surgery Patients: 7 Years Follow-up Study.

INTRODUCTION: Diabetes is considered to be a surgically correctable illness. As glycemic control begins soon after surgery, the cessation of anti-diabetic medications is early. Patients believe that their diabetes has been "cured" and the need for blood sugar monitoring is forgotten, leading to undiagnosed hyperglycemia and risk of diabetes-related complications. AIMS: To study the effect of bariatric surgery on long-term glycemic control and identify the patients with undiagnosed hyperglycemia. METHODS: All patients with type 2 diabetes who underwent bariatric surgery at our center from January 2012 to December 2013 were included in the study. For each patient, demographic, preoperative, and postoperative data were retrospectively reviewed. RESULTS: Out of the total 119 patients with diabetes, 91 patients underwent sleeve gastrectomy and 28 underwent Roux-en-Y gastric bypass. Diabetes status at 7 years of follow-up was possible in 53 (44.5%) patients: 44 (48.4%) in SG and 9 (32.2%) in RYGB groups. Overall, complete remission at 7 years was seen in 17 (32.1%) patients and partial remission in 12 (22.6%) patients. Amongst non-remitters (n = 24, 45.3%), 7 (13.2%) patients were on medications with good glycemic control (A1C < 6.5) while 8 (15.1%) patients had poor control (A1C > 6.5) despite ongoing medications. Additionally, 9 (17%) patients had poor glycemic control (A1C > 6.5) and were not receiving any anti-diabetic medications. Patients in whom follow-up A1C was unavailable and their diabetes status remain unknown were 66 (55.5%) at 7 years. CONCLUSION: Our study clearly demonstrates high risk of undiagnosed hyperglycemia. Regular long-term follow-up in diabetic patients is even more desirable than amongst patients undergoing bariatric surgery for weight loss alone. Graphical abstract.

Complications after bariatric surgery: A multicentric study of 11,568 patients from Indian bariatric surgery outcomes reporting group.

BACKGROUND: Complications after bariatric surgery are not uncommon occurrences that influence the choice of operations both by patients and by surgeons. Complications may be classified as intra-operative, early (<30 days post-operatively) or late (beyond 30 days). The prevalence of complications is influenced by the sample size, surgeon's experience and length and percentage of follow-up. There are no multicentric reports of post-bariatric complications from India. OBJECTIVES: To examine the various complications after different bariatric operations that currently performed in India. MATERIALS AND METHODS: A scientific committee designed a questionnaire to examine the post-bariatric surgery complications during a fixed time period in India. Data requested included demographic data, co-morbidities, type of procedure, complications, investigations and management of complications. This questionnaire was sent to all centres where bariatric surgery is performed in India. Data collected were reviewed, were analysed and are presented. RESULTS: Twenty-four centres responded with a report on 11,568 bariatric procedures. These included 4776 (41.3%) sleeve gastrectomy (SG), 3187 (27.5%) one anastomosis gastric bypass (OAGB), 2993 (25.9%) Roux-en-Y gastric bypass (RYGB) and 612 (5.3%) other procedures. Total reported complications were 363 (3.13%). Post-operative bleeding (0.75%) and nutritional deficiency (0.75%) were the two most common complications. Leaks (P = 0.009) and gastro-oesophageal reflux disease (P = 0.019) were significantly higher in SG, marginal ulcers in OAGB (P = 0.000), intestinal obstruction in RYGB (P = 0.001) and nutritional complications in other procedures (P = 0.000). Overall, the percentage of complications was higher in 'other' procedures (6.05%, P = 0.000). There were 18 (0.16%) reported mortalities. CONCLUSIONS: The post-bariatric composite complication rate from the 24 participating centres in this study from India is at par with the published data. Aggressive post-bariatric follow-up is required to improve nutritional outcomes.

Impact of COVID-19 on General Surgical Practice in India.

The coronavirus disease 2019 (COVID-19) pandemic is a global health crisis, and surgeons are at increased occupational risk of contracting COVID-19. The impact of the disease on prevalent general surgical practice is uncertain and continues to evolve. The study aimed to study the impact of COVID-19 on general surgical practice in India and the future implications of the pandemic. A survey questionnaire was designed and electronically circulated 1 month after India entered a national lockdown during COVID-19 pandemic, amongst members of Indian Association of Gastro-intestinal Endo-surgeons (IAGES), a surgical association with nearly eight thousand members from across the country. Survey questions pertaining to pre-COVID era surgical practices, impact on current practice, and financial implications were asked. Responses were collected and statistically analyzed. One hundred fifty-three surgeons completed the survey, of which only 9.2% were women. Majority (41%) were into practice for more than 20 years; 36.6% were into private practice at multiple hospitals (free-lancers). Amongst the respondents, 41.8% had mainly laparoscopic practice with mean outpatient consultation of 26 patients/day and elective surgeries of 43 cases/month prior to lockdown. Post-lockdown, daily outpatient consults reduced to 4 patients per day, and 77% had not performed a single elective procedure. Hydroxychloroquine (HCQ) chemoprophylaxis was reported by 52% surgeons. Personal protective equipment (PPE) was used by 52% for all cases, while 71.5% stated there are insufficient guidelines for future surgical practice in terms of safety. A drop of more than 75% of their monthly income was experienced by 52% surgeons, while 22% faced 50-75% reduction. One third (33%) of respondents own a hospital and are expecting a monthly financial liability of 2.25 million rupees (nearly 30,000 US dollars). COVID-19 has led to a drastic reduction in outpatient and elective surgical practices. There is a definite need for guidelines regarding safety for future surgical practices and solutions to overcome the financial liabilities in the near future.

Surgical practice recommendations for minimal access surgeons during COVID 19 pandemic - Indian inter-society directives.

These are inter-society guidelines for performance of laparoscopic surgery during COVID-19 pandemic that has affected the way of surgical practice. The safety of healthcare workers and patients is being challenged. It is prudent that our surgical practice should adapt to this rapidly changing health environment. The guidance issued is based on global practices and national governmental directives. The Inter-Society Group urges you to be updated with the developing situation and evolving changes.

Is sleeve gastrectomy overcriticized? A single-center Indian experience with 5-year follow-up results.

BACKGROUND: Bariatric surgery has seen a sharp rise in numbers worldwide in the last decade. Being a popular procedure, sleeve gastrectomy (SG) has been widely studied over the years for its efficacy, potential for weight regain, metabolic impact, and de novo gastroesophageal reflux disease (GERD). OBJECTIVES: To evaluate clinical outcomes of laparoscopic SG after 5 years of follow-up in terms of weight loss, co-morbidity resolution, and GERD. SETTING: The study was performed in a center of excellence in bariatric surgery in India. METHODS: All patients who underwent laparoscopic SG from January 2012 to April 2013 were included in the study. Their demographic, preoperative, and postoperative data were prospectively maintained in Microsoft Excel and analyzed statistically. RESULTS: Two hundred eighteen patients underwent SG in 2012-2013. Patients had a preoperative body mass index of 45.8 ± 9.5 kg/m2 (mean ± standard deviation) and excess weight of 54.1 ± 25.6 kg. Percent excess weight loss was 87.6% ± 28.9% at 1 year, 77.2% ± 29.3% at 3 years, and 69.1% ± 27.8% at 5 years. Percent total weight loss at 1 year was 35.5% ± 7.6%, 31.4% ± 9.1% at 3 years, and 29.2% ± 9.8% at 5 years. At 5 years, 11 of 25 (44%) showed complete diabetic remission and 5 of 25 (20%) showed partial remission. De novo GERD was seen in 24 of 153 (15.7%) patients. CONCLUSION: Our study reflects good outcomes after SG in terms of weight loss and diabetes resolution at 5-year follow-up, though GERD remains a matter of concern.

Portion Control Eating-a Determinant of Bariatric Outcomes.

INTRODUCTION: Bariatric surgery leads to significant weight loss but the results vary. Application of dietary principles like portion-controlled eating leads to greater weight loss and fewer complications. AIMS: To evaluate the improvement in weight loss outcomes by incorporating portion-controlled eating behavior in postbariatric patients. METHODS: All patients who underwent bariatric surgery from January 2012 to December 2013 were included in the study. Portion-controlled eating behavior was incorporated in the post-bariatric nutritional protocol. Their demographic, preoperative, and postoperative data were prospectively maintained on Microsoft Office Excel and analyzed statistically. RESULTS: Three hundred and seventy-two (89.6%) underwent laparoscopic sleeve gastrectomy (LSG), while 43 (10.4%) underwent laparoscopic Roux-en-Y gastric bypass (RYGB). In the LSG group, lowest (nadir) BMI was 28.99 ± 5.6 kg/m2 and % Excess weight loss (EWL) was 87.3 ± 27.2%, achieved between 1 and 2 years. In the RYGB group, lowest (nadir) BMI was 27.5 ± 12.09 kg/m and % EWL was 94.32 ± 33.12%. Surgical failure (less than 50% EWL) were 10 (3.27%) in the LSG group and 1 (3%) in the RYGB group. There were no leaks reported in our study. CONCLUSION: Our study highlights the importance of postoperative nutritional interventions like portion-controlled eating for successful bariatric outcome.

Weight Loss and Comorbidity Resolution 3 Years After Bariatric Surgery-an Indian Perspective.

INTRODUCTION: Bariatric surgery has seen a sharp rise in India in the last decade. India is one of the 10 most obese nations of the world, ranking second in number of type 2 diabetics. AIMS: To evaluate clinical outcomes of bariatric surgery after 3 years of follow-up in terms of weight loss, co-morbidity resolution, complaints of gastroesophageal reflux disease and weight regain. METHODOLOGY: All patients who underwent bariatric surgery from January to December 2013 with a minimum follow-up of 3 years were included in the study. Their demographic, preoperative, and postoperative data were prospectively maintained on Microsoft Office Excel and analyzed statistically. RESULTS: One hundred seventy-eight patients (157 lap. sleeve gastrectomy and 21 patients lap. RYGB) completed 3 years of follow-up. In the LSG group, patients had a pre-operative BMI 44.8 ± 8.33 kg/sq. m (mean ± S.D.) and excess body weight 52.3 ± 23.0 kg. In the RYGB group, pre-operative BMI was 42.7 ± 8.82 kg/sq. m and excess body weight 45 ± 18.7 kg. In the LSG group, % excess weight loss (EWL) at 1 year was 87.6 ± 24.4% and 3 years was 71.8 ± 26.7%. In the RYGB group, % EWL at 1 year was 97.2 ± 27.3% and at 3 years was 85.8 ± 25.3%. Diabetes resolution was seen in 32 (80%) in LSG group and 11 (91.7%) in RYGB group (Figs. 1, 2, 3, and 4). CONCLUSION: Our study reflects that there is no statistically significant difference between outcomes of sleeve gastrectomy and Roux-en-Y gastric bypass surgery in terms of weight loss and diabetes resolution at 3 years.

Mesenteric Panniculitis-First Case Series After Bariatric Surgery.

Mesenteric panniculitis is an uncommon pathology, of poorly understood etiology, characterized by progressive inflammation and fibrosis of the small bowel mesentery. This disease has been reported usually after other abdominal surgeries. We present two cases of young male patients who underwent laparoscopic sleeve gastrectomy and developed abdominal symptoms within 45-60 days of surgery. Both were investigated for known post-bariatric complications. While first patient presented (5 months later) at an irreversible stage and died within 8-9 months of primary surgery, in second patient, the disease process could be reversed through early intervention, diagnosis, treatment, and compliance. Mesenteric panniculitis is a rapidly progressive entity, which can be adequately treated by early identification and long-term immune-suppressive therapy.