Association between the presence of Helicobacter pylori and the development of de novo anemia in adults undergoing sleeve gastrectomy.

Background: Sleeve gastrectomy has gained prominence in obesity treatment, yet it is not without complications, such as the development of anemia in the medium term. Given the high prevalence of Helicobacter pylori infection in Peru, it is imperative to explore its potential association with this postoperative complication. Objective: To evaluate the association between the presence of Helicobacter pylori and the development of anemia 12 months after sleeve gastrectomy. Methods: A retrospective cohort study was carried out based on an analysis of secondary data from a private clinic in Lima, Peru, which included two groups of people over 18 years of age who had undergone sleeve gastrectomy between 2010 and 2020. We considered the subjects who had the previous diagnosis of Helicobacter pylori as well as those who did not have the infection, according to the detection of the bacteria by endoscopy before surgery. Results: A total 313 individuals were analyzed, and it was found that the prevalence of Helicobacter pylori was 46.0% and the incidence of anemia 12 months after sleeve gastrectomy was 18.2%. The presence of Helicobacter pylori increased the risk of de novo anemia (Relative Risk = 1.56; 95% confidence intervals: 1.02-2.41; p = 0.043). When stratifying by sex, the association was maintained only for the male group (Relative Risk = 2.84; 95% confidence intervals: 1.02-7.02; p = 0.047). Conclusions: It was identified that the presence of Helicobacter pylori had a significant association with the development of de novo anemia, mainly in male subjects, 1 year after undergoing sleeve gastrectomy.

Does the Repair of an Accidentally Discovered Hiatal Hernia and Gastropexy Affect the Incidence of De Novo Postoperative GERD Symptoms After Laparoscopic Sleeve Gastrectomy?

Background: The relationship between laparoscopic sleeve gastrectomy (LSG) and gastroesophageal reflux disease (GERD) is intricate. Hiatal hernia repair or gastropexy can have an impact on postoperative GERD. Aim: To assess the effect of the repair of an accidentally discovered HH and/or gastropexy on the development of de novo postoperative GERD symptoms after LSG. Methods: This retrospective study included all obese patients who underwent LSG at our hospital from January 2018 to June 2022. The data retrieved from patients' files comprised demographic and clinical data, including BMI, GERD symptoms, and comorbidities. Hiatal hernias, surgical technique, gastropexy, duration, and intraoperative complications were recorded. Postoperative data included early and late postoperative complications, weight loss, de novo GERD, and medication use. Results: The study included 253 patients, 89 males (35.2%) and 164 females (64.8%), with a mean age of 33.3±10.04 years. De novo GERD was detected in 94 individuals (37.15%). HH was accidentally found and repaired in 29 patients (11.5%). Only 10.3% of LSG and HH repair patients had de novo GERD symptoms, compared to 40.6% of non-HH patients. 149 patients (58.9%) had gastropexy with LSG. Postoperative de novo GERD symptoms were comparable for LSG with gastropexy (40.5%) and LSG alone (40.9%). Conclusion: After one year, concurrent hiatal hernia repair and LSG seem to be safe and beneficial in lowering postoperative de novo GERD symptoms. The inclusion of gastropexy with LSG had no significant impact on postoperative de novo GERD. Both HH repair and gastropexy lengthened the operation but did not increase its complications.

Six-year analysis of 30-day post-operative leaks for primary sleeve gastrectomy: a MBSAQIP database study.

BACKGROUND: Sleeve gastrectomy is the most performed bariatric surgery. Post-operative gastric sleeve leaks, although rare, are dreaded complications. This study aims to perform an updated investigation of the factors associated with sleeve leaks. METHODS: This retrospective cohort study analyzed 692,554 cases from the MBSAQIP database (2016-2021) with CPT code 43,775 for primary sleeve gastrectomy. We excluded emergency operations, conversions/revisions, endoscopic interventions, patient with prior foregut surgery, and open operations. Multivariate logistic regression analysis (STATA version 15) was performed to identify factors associated with sleeve gastrectomy leaks. RESULTS: Out of 692,554 patients, 600,910 (86.77%) patients underwent laparoscopic sleeve gastrectomy, and 91,644 (13.23%) patients underwent robotic sleeve gastrectomy. 1179 (0.17%) developed leaks within 30 days; 177(0.19%) were in the robotic group and 1002 (0.17%) in the laparoscopic group with no significant difference in leak rates between two groups on multivariate analysis. Black patients had lower odds of having leaks as compared to white patients (Odds Ratio (OR): 0.68 (0.56-0.82); p < 0.01). Hispanic patients had lower odds of having leak as compared to non-Hispanics. Factors associated with higher leak odds (p < 0.05) included hypertension, GERD, smoking, immunosuppression, increased operating time, and albumin < 3.5 g/dl. Higher odds of leaks were observed in years 2016-2019 vs 2020-2021 (OR: 1.44 (1.25-1.65), p < 0.01). Higher odds of leak in operations with general surgeons compared to bariatric surgeons was found (OR: 1.46 (1.04-2.02), p = 0.02); observed only on robotic group on subgroup analysis (OR: 2.2 (1.2-4.2), p = 0.02). Staple line reinforcement, oversewing, and performance of leak test showed no differences in leak rate. Bougie size and distance from pylorus were not associated with changes in leak rate. CONCLUSION: This study provides updated insights into the factors associated with sleeve leaks, reinforcing information gained from prior studies. A higher association of leak among general surgeons could represent a learning curve for new robotic general surgeons. The overall decreasing trend for gastric sleeve leak is encouraging and may be a sign of improved techniques.

Laparoscopic sleeve gastrectomy as a bridge to colorectal cancer surgery for obese patients: a case report.

BACKGROUND: Severe obesity greatly influences the difficulty of colorectal cancer surgery and has been reported to prolong operative time, increase the rate of laparotomy, and elevate increase postoperative complications. We investigated the efficacy of laparoscopic sleeve gastrectomy (LSG) for preoperative weight loss to ensure safe colorectal cancer surgery. CASE PRESENTATION: A 51 year-old female with a body mass index of 43.5 kg/m2 was referred to our hospital due to a positive fecal occult blood test. She was diagnosed as having a laterally spreading tumor of the cecum by colonoscopy. Endoscopic submucosal dissection was attempted but proved difficult due to the size of the lesion and its proximity to the appendiceal orifice. We planned bariatric surgery prior to colorectal surgery, and she underwent LSG without any complications. Seven months after the LSG, she had lost 30.7 kg, and her final preoperative body mass index was 27.8 kg/m2. Single-incision laparoscopic ileocecal resection was then performed safely. The pathological diagnosis was adenocarcinoma in adenoma of the cecum, TisN0M0. CONCLUSION: LSG was effective in reducing visceral fat and making it possible to perform safe surgery for colorectal cancer in a severely obese patient.

Menstrual Changes in Women Who Undergo Sleeve Gastrectomy in Saudi Arabia.

Introduction Obesity affects over 650 million globally, with rising rates posing significant public health challenges, especially among Saudi Arabian women. Obesity correlates with menstrual irregularities and reproductive health issues such as polycystic ovary syndrome (PCOS). Bariatric surgery (BS), particularly laparoscopic sleeve gastrectomy (LSG), is increasingly used due to its safety and effectiveness in treating obesity-related conditions. This study explores LSG's impact on menstrual cycles and fertility in Saudi women, aiming to optimize patient care and understand surgical effects on hormonal dynamics and reproductive health. Methodology It is a cross-sectional design among Saudi women post-sleeve gastrectomy from December 2023 to May 2024. Variables included age, marital status, and region, with primary outcomes focusing on menstrual cycle changes post surgery. Results Our study includes 387 participants, and demographic characteristics showed a significant proportion aged 26-35 years (n=147, 38.0%) and 36-45 years (n=119, 30.7%), with the majority being married (n=230, 59.4%). Regional distribution highlighted the south as the most represented (n=139, 35.9%), followed by the central (n=74, 19.1%). About 30.2% (n=117) reported chronic conditions. Post surgery, 70.5% (n=273) experienced menstrual changes, with regular cycles being the most common (n=102, 26.3%). Logistic regression indicated younger age as a protective factor against menstrual changes (p=0.028), while pre-surgery menstrual irregularities significantly predicted post-surgery changes (p=0.002). Regional analysis showed no significant association between geographic location and post-surgery menstrual changes (p=0.140). Overall, quality of life post-surgery was rated highly by participants, with 70.8% (n=274) giving ratings of 4 or 5. Conclusion Our study highlights a high prevalence of post-sleeve gastrectomy menstrual changes, predominantly regular cycles. Younger age appears protective, while pre-existing menstrual irregularities strongly predict postoperative changes. Regional differences did not significantly influence outcomes. Overall, participants reported high satisfaction with their quality of life post surgery.

Predicting serious postoperative complications and evaluating racial fairness in machine learning algorithms for metabolic and bariatric surgery.

BACKGROUND: Predicting the risk of complications is critical in metabolic and bariatric surgery (MBS). OBJECTIVES: To develop machine learning (ML) models to predict serious postoperative complications of MBS and evaluate racial fairness of the models. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) national database, United States. METHODS: We developed logistic regression, random forest (RF), gradient-boosted tree (GBT), and XGBoost model using the MBSAQIP Participant Use Data File from 2016 to 2020. To address the class imbalance, we randomly undersampled the complication-negative class to match the complication-positive class. Model performance was evaluated using the area under the receiver operating characteristic curve (AUROC), precision, recall, and F1 score. Fairness across White and non-White patient groups was assessed using equal opportunity difference and disparate impact metrics. RESULTS: A total of 40,858 patients were included after undersampling the complication-negative class. The XGBoost model was the best-performing model in terms of AUROC; however, the difference was not statistically significant. While the F1 score and precision did not vary significantly across models, the RF exhibited better recall compared to the logistic regression. Surgery type was the most important feature to predict complications, followed by operative time. The logistic regression model had the best fairness metrics for race. CONCLUSIONS: The XGBoost model achieved the highest AUROC, albeit without a statistically significant difference. The RF may be useful when recall is the primary concern. Undersampling of the privileged group may improve the fairness of boosted tree models.

Protein Supplement Tolerability and Patient Satisfaction after Bariatric Surgery.

PURPOSE: Disproportional fat-free mass loss often occurs post-bariatric surgery, partly due to insufficient protein intake during the post-surgery recovery phase. We compared five protein-enhancing strategies (PES) on patient tolerability, satisfaction and protein intake. MATERIALS AND METHODS: Ninety-four participants, scheduled for bariatric surgery, were enrolled and allocated to either of the following: (1) whey powder, (2) hydrolysed collagen powder, (3) plant-based powder, (4) protein-rich products, (5) protein gel, or control. PES groups were instructed to add 30 g of powder or 2 gels or protein products to their diet. Patient satisfaction and tolerability were evaluated with questionnaires. Dietary intake was assessed prior to and during PES use. RESULTS: Seven patients dropped out (i.e. loss of contact, personal reasons or post-surgery complications) yielding an analytical cohort of 87 participants. The majority of patients (61%) did not experience dietary complaints from PES and could use PES ≥ 5 days of the week. PES non-usage was mainly related to taste dislike (58%). Hydrolysed collagen scored highest on tolerability and satisfaction: 86% of the participants could use HC ≥ 5 days and 71% were satisfied with the product. PES increased protein intake from 54.7 ± 21.5 g/day to 64.7 ± 23.4 g/day during the intervention (p = 0.002), which differed from the control group (+ 10.1 ± 24.5 g/day vs. - 6.3 ± 23.8 g/day for controls, p = 0.019). Whey showed the highest increase, namely + 18.3 ± 16.3 g/day (p = 0.009). CONCLUSION: PES were tolerated by the majority of participants, and an improved protein intake with PES use was seen. However, the taste of the products could be improved to further enhance satisfaction and tolerability.

Bariatric Metabolic Surgery Might be More of a Benefit than a Risk During a Pandemic Outbreak.

Introduction: This report aimed to analyze the outcomes of patients with obesity who were on a bariatric program during the SARS-Cov-2 pandemic outbreak and compare those who received surgery with the ones who were not operated on. Methods: This was a retrospective study between 2020 and 2021. Patients were divided into two groups: those who underwent surgery (O) and those who were not operated (NO). The evolution of the risk factors identified for severe COVID infection and death was studied (ASMBS criteria). For this study, a follow-up period of 12 months was initiated. Results: In the O group, 83 patients were included and 99 were in the NO group. In the O group, patients with body mass index (BMI) > 35 Kg/m2 before surgery resolved the condition in 73.5% (61) cases, and this was done in the first 30 days by 38 (45.7%). Type 2 diabetes mellitus remission was documented in 18 patients (85.7%) of the O group, and the mean time elapsed for remission was 102.2 days (P < .01). Hypertension remitted in 66.7% (20) of the patients in group O in 82.4 days (P < .01). The subgroup of patients with obesity and one high-risk associated condition (30.2%, 25) resolved both in 44% (11) cases and one in 48% (12) cases. In the group of patients with obesity and two high-risk associated conditions (15.6%, 13), 47% (6) patients resolved the three conditions, 38% (5) resolved two conditions, and 15% (2) resolved one condition. Among the NO group, no comorbidity resolutions were recorded (P < .01). Admission because of COVID infection was necessary for 7.1% of NO and 1.2% of O (P = .04). Conclusion: Bariatric metabolic surgery would not increase the risk of COVID infection or of suffering serious complications resulting from it. Patients undergoing bariatric metabolic surgery rapidly resolved high-risk comorbidities and had less need for hospitalization because of SARS-CoV-2 infection.

Using Pre-operative Insulin Dose to Predict Diabetes Remission After Roux-En-Y Gastric Bypass and Sleeve Gastrectomy.

BACKGROUND: Obesity is intricately associated with type-2 diabetes (T2D) and other cardiovascular conditions, increasing morbidity, mortality, and health care costs. Metabolic and bariatric surgeries (MBS) have shown promising results in significant weight loss and T2D remission, but existing predictive scores for post-MBS diabetes remission do not consider insulin dosage, potentially overlooking a critical factor. METHODS: A retrospective analysis of patients with T2D who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). The study focused on insulin dosage impact, divided into quartiles, on remission rates post-MBS. The effectiveness of RYGB vs SG was compared within insulin dose quartiles with up to 5 years of follow up. RESULTS: A total of 508 patients (64% female, 94.9% White, mean age 53.5 ± 10.5 years, BMI (46.0 ± 8.3 kg/m2) were included in the analysis. This study demonstrates a profound association between insulin dosage quartiles and T2D remission after MBS. Patients with lower insulin requirements showed superior remission rates; those in the lowest quartile had remission rates of 73%, 70%, and 62% at 1, 3, and 5 years, respectively, compared to 34%, 37%, and 36% in the highest quartile (P < 0.001 across all intervals). RYGB surgery showed a significantly better remission in the second and third insulin quartiles, suggesting its effectiveness over SG for patients with mid-range insulin requirements. CONCLUSION: This study underscores the importance of considering insulin dosage when predicting T2D remission post-MBS. The findings advocate for a more nuanced selection of MBS procedures based on individual insulin profiles, potentially enhancing diabetes remission outcomes.

Shedding more than weight: Metabolic and bariatric surgery and the journey to insulin independence in insulin-treated type 2 diabetes.

BACKGROUND: Type 2 diabetes (T2D) imposes a significant health burden, necessitating lifelong pharmacological interventions, with insulin being one of the cornerstone therapies. However, these regimens are associated with health risks and psychological stressors. This study aimed to examine the rates of insulin-treated T2D remission and cessation or reduction in the dosage of insulin therapy after metabolic and bariatric surgery (MBS). METHODS: This was a retrospective analysis of patients with a preoperative diagnosis of insulin-treated T2D who underwent primary laparoscopic sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), or biliopancreatic diversion with duodenal switch (BPD/DS) with a minimum of 3 and up to 5 years of follow-up. The average daily dose for each type of insulin, measured in units, was calculated at annual intervals. RESULTS: Among 287 patients included, 201 (70%) underwent RYGB, 66 (23%) underwent SG, and 20 (7%) underwent BPD/DS. The average follow-up period was 4.6 ± 0.7 years. At 5 years follow-up, the mean total weight loss was the highest in the BPD/DS subgroup at 37.5% ± 11.6%. Insulin usage decreased significantly from complete dependency at baseline to 36.2% just 1 year postoperatively, and the use of noninsulin antidiabetic drugs decreased from 79.4% initially to 26.1%. These results were sustained throughout the study period. The subgroup analysis indicated that, 5 years after surgery, T2D remission was the highest after BPD/DS (73.7%) compared with RYGB (43.2%) and SG (23.3%) (P < .001). CONCLUSION: MBS is a transformative approach for achieving significant remission in insulin-treated T2D and reducing insulin requirements. Our findings reinforce the efficacy of these surgical interventions, particularly highlighting the promising potential of procedures that bypass the proximal small intestine, such as BPD/DS and RYGB.

Macrophages and Mast Cells in the Gastric Mucosa of Patients with Obesity Undergoing Sleeve Gastrectomy.

Background. Adipose tissue macrophages (ATMs) and mast cells (MCs) play a role in immune responses. More recently, their involvement in tumor angiogenesis and chronic inflammatory conditions in patients with obesity has been discovered. Furthermore, a higher BMI (Body Mass Index) value corresponds to a higher inflammatory state. In particular, gastric tissue in obesity (GTO) is characterized by Macrophages, Mast Cells Positive to Triptase (MCPT), and neo-formed microvessels (MVD). Materials and Methods. We collected gastric tissue samples from December 2021 to December 2022. The patients selected had a BMI > 35 kg/m2 with different comorbidities. Regarding the surgery, surgeons executed a Laparoscopic Sleeve Gastrectomy (LapSG). Gastric tissue was analyzed by immunohistochemistry and morphometrical assay, comparing "obese-related" gastric tissue to normal gastric tissue. Furthermore, tissue parameters were correlated with important clinicopathological features. Results. We collected thirty gastric tissue samples from thirty patients with obesity. Blood tests, Electrocardiogram (ECG), esophagogastroduodenoscopy (EGDS) associated with a urea breath test, and chest X.R. were performed. A significant correlation between ATMs, MCPT, MVD, and BMI was found in GTO. Pearson t-test analysis was conducted (r ranged from 0.67 to 0.71; p-value < 0.05). Conclusions. These preliminary data suggest that ATMs, MCPT, and MVD related to BMI can play a role in both gastric tissue angiogenesis and inflammation inducing a tissue change that could lead to gastric inflammation or cancer diseases.

Rare Complications Following Laparoscopic Sleeve Gastrectomy.

Metabolic and bariatric surgery (MBS) is the most effective and durable therapeutic intervention for patients with obesity. In recent years, laparoscopic sleeve gastrectomy (SG) has become the most commonly performed primary MBS procedure owing to its technical feasibility and excellent short-term outcomes. Despite these favorable results and perceived advantages, SG is associated with several unique complications. Complications such as a postoperative leak or bleeding have been more commonly observed and reported than others, and their management approaches are well described. However, other complications following SG are far less familiar to surgeons, which may delay recognition and result in poor patient outcomes. Of these complications, we describe splenic injuries; esophageal perforation; staple line malformations; stapling of intraluminal devices; phytobezoar formation; gastro-colic, gastro-pleural and gastro-bronchial fistula; pancreatic leak; and portomesenteric venous thrombosis. It is paramount for surgeons to be aware of these underreported issues and have the resources to learn how to recognize and manage them when they arise. This review aims to describe rare (i.e., reported incidence <1%) and underdescribed complications after SG, focusing on causes, clinical presentation, prevention strategies, and management.

Gestational Weight Gain Following Metabolic Bariatric Surgery: A Scoping Review.

Metabolic bariatric surgery remains the most effective and durable treatment for severe obesity. Women of reproductive age represent the largest demographic group undergoing these procedures. Metabolic bariatric surgery can have both beneficial and adverse effects on pregnancy outcomes. One of the most common adverse effects is fetal growth restriction. To mitigate these adverse effects, it is crucial to explore lifestyle modifications aimed at promoting a healthy pregnancy. Modifiable factors during pregnancy after metabolic bariatric surgery include the amount of gestational weight gain. The aim of this comprehensive review is to provide an overview of what is known about gestational weight gain in pregnancy after bariatric metabolic surgery. This review is focused on the two most performed procedures: sleeve gastrectomy and Roux-en-Y gastric bypass.

Varying concentrations of tyrosine kinase inhibitors in chronic myeloid leukemia patients following bariatric surgery: a case series.

Bariatric surgery is increasingly performed to treat severe obesity. As a result of anatomical and physiological changes in the gastrointestinal tract, the pharmacokinetics (PK) of oral drugs can be altered, affecting their efficacy and safety. This includes the class of tyrosine kinase inhibitors (TKIs) which are used to treat chronic myeloid leukemia (CML). This case series describes the clinical course of four CML cases with a history of bariatric surgery. The patients used various TKIs (nilotinib, dasatinib, bosutinib, ponatinib, and imatinib) for which 15 drug levels were measured. The measured TKI concentrations were in part subtherapeutic, and highly variable when compared to mean levels measured in the general population. Multiple drug levels were measured in these patients, as the clinicians were aware of the possible impact of bariatric surgery. The drug levels were used as additional input for clinical decision-making. All four patients required TKI switches and/or dose modifications to achieve an effective and tolerable treatment. Eventually, adequate clinical and molecular remissions were achieved in all cases. In summary, TKI concentrations of patients undergoing bariatric surgery may be subtherapeutic. Moreover, there is substantial interindividual and intraindividual variation, which may be explained by the complex interference of bariatric surgery and associated weight loss. For clinical practice, therapeutic drug monitoring is advised in patients with a history of bariatric surgery in case of suboptimal response or loss of response.

Association of changes in appendicular skeletal muscle mass with weight loss and visceral fat reduction after laparoscopic sleeve gastrectomy.

PURPOSE: Laparoscopic sleeve gastrectomy (LSG) drastically affects body composition. However, studies focusing on the association between the changes in the pre-and postoperative muscle mass and postoperative results are limited. We evaluated the association between changes in the muscle mass and weight loss and fat reduction. METHODS: This retrospective study included 29 consecutive patients who underwent both LSG and a bioelectrical impedance analysis (BIA) consecutively. We investigated changes in the body composition on the BIA and visceral fat area (VFA) on computed tomography and correlational changes in muscle mass with weight loss and fat reduction. RESULTS: The total weight loss (%TWL) 12 months after surgery was 30.9%. The VFAs pre- and postoperatively were 224 and 71.0 cm2, respectively. The fat mass (FM), percentage of FM, appendicular skeletal muscle mass (ASM), and skeletal muscle mass index (SMI) decreased from pre- to postoperatively (54.8 vs. 32.2 kg; 49.0 vs. 41.2%, 26.7 vs. 23.9 kg, 9.24 vs. 8.27, respectively), whereas the percentage of ASM (%ASM) increased (22.1 vs. 28.0%). The rate of change in %ASM positively correlated with weight loss and fat reduction (%TWL, rs = 0.65; %VFA loss, rs = 0.62). CONCLUSION: The rate of change in %ASM was positively correlated with weight loss and fat reduction.

Association between operative position and postoperative nausea and vomiting in patients undergoing laparoscopic sleeve gastrectomy.

BACKGROUND: Bariatric surgery is one of the most effective ways to treat morbid obesity, and postoperative nausea and vomiting (PONV) is one of the common complications after bariatric surgery. At present, the mechanism of the high incidence of PONV after weight-loss surgery has not been clearly explained, and this study aims to investigate the effect of surgical position on PONV in patients undergoing bariatric surgery. AIM: To explore the effect of the operative position during bariatric surgery on PONV. METHODS: Data from obese patients, who underwent laparoscopic sleeve gastrectomy (LSG) in the authors' hospital between June 2020 and February 2022 were divided into 2 groups and retrospectively analyzed. Multivariable logistic regression analysis and the t-test were used to study the influence of operative position on PONV. RESULTS: There were 15 cases of PONV in the supine split-leg group (incidence rate, 50%) and 11 in the supine group (incidence rate, 36.7%) (P = 0.297). The mean operative duration in the supine split-leg group was 168.23 ± 46.24 minutes and 140.60 ± 32.256 minutes in the supine group (P < 0.05). Multivariate analysis revealed that operative position was not an independent risk factor for PONV (odds ratio = 1.192, 95% confidence interval: 0.376-3.778, P = 0.766). CONCLUSION: Operative position during LSG may affect PONV; however, the difference in the incidence of PONV was not statistically significant. Operative position should be carefully considered for obese patients before surgery.

Magnetic single-anastomosis side-to-side duodeno-ileostomy for revision of sleeve gastrectomy in adults with severe obesity: 1-year outcomes.

INTRODUCTION: Uncomplicated surgical approaches that minimize anastomotic complications while improving revisional metabolic/bariatric surgical (MBS) outcomes are needed. METHODS: This prospective single-center study assessed the feasibility, safety, and efficacy of the novel linear magnetic anastomosis system (LMAS [3 cm]) in performing a side-to-side duodeno-ileostomy (MagDI) bipartition to revise clinically suboptimal primary sleeve gastrectomy (SG). Patients with severe obesity with/without type 2 diabetes (T2D) with suboptimal weight loss, regain, and/or T2D recurrence post SG underwent revisional MagDI. A distal and proximal magnet were delivered endoscopically to the ileum and duodenum and aligned via laparoscopic assistance. Gradual magnet fusion formed a DI bipartition. PRIMARY ENDPOINTS: technical feasibility, safety (Clavien-Dindo [CD] severe adverse event classification) at 1 year. Secondary endpoints: MBS weight and T2D reduction. RESULTS: July 29, 2022-March 28, 2023, 24 patients (95.8% female, mean age 44.9 ± 1.5 years, and body mass index [BMI] 39.4 ± 1.3 kg/m2) underwent MagDI. Feasibility was attained via correct magnet placement (mean operative time 63.5 ± 3.3 min), patent anastomoses created, and magnet passage per anus in 100.0% of patients. There were 4 CD-III mild or moderate severe AEs, 0.0% associated with the LMAS or MagDI: 0.0% anastomotic leakage, obstruction, bleeding, infection, reintervention, or death. Mean BMI reduction was 2.1 kg/m2 (p < 0.05); total weight loss 5.3%, excess weight loss 16.4%; and the patient with T2D improved. CONCLUSION: The single-anastomosis MagDI procedure using the novel 3-cm LMAS to revise clinically suboptimal SG was technically straightforward, incurred no major complications, mitigated weight regain, and renewed clinically meaningful weight loss. GOV IDENTIFIER: NCT05322122.

Robotic bariatric surgery reduces morbidity for revisional gastric bypass when compared to laparoscopic: outcome of 8-year MBSAQIP analysis of over 40,000 cases.

INTRODUCTION: Robotic-assisted metabolic and bariatric surgery (MBS) is gaining popularity. Revisional MBS is associated with higher perioperative morbidity compared to primary MBS. The optimal surgical approach to minimize complications in these complex cases is unclear. The goal of this study was to assess robot utilization in revisional MBS and compare laparoscopic and robotic revisional MBS outcomes in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. METHODS: A retrospective review of the MBSAQIP database was performed identifying revisional sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) cases from 2015 to 2022. Primary MBS, open/emergent cases, cases converted to another approach, and combined cases other than esophagogastroduodenoscopy were excluded. 30-Day outcomes for laparoscopic and robotic cases were compared using multivariate logistic regression adjusting for patient demographics, comorbidities, and operative variables. RESULTS: 41,404 Cases (14,474 SG; 26,930 RYGB) were identified. From 2015 to 2022, the percentage of revisional SG and RYGB cases performed robotically increased from 6.1% and 7.3% to 24.2% and 32.0% respectively. Laparoscopic SG had similar rates of overall morbidity, leak, bleeding, readmission, reoperation, and length of stay compared to robotic. Laparoscopic RYGB had significantly higher rates of overall morbidity (6.2% vs. 4.8%, p < 0.001, AOR 0.80 [0.70-0.93]), blood transfusion (1.5% vs. 1.0%, p < 0.05, AOR 0.74 [0.55-0.99]), superficial incisional SSI (1.2% vs. 0.4%, p < 0.001, AOR 0.30 [0.19-0.47]), and longer length of stay (1.87 vs. 1.76 days, p < 0.001) compared to robotic. Laparoscopic operative times were significantly shorter than robotic (SG: 86.4 ± 45.8 vs. 113.5 ± 51.7 min; RYGB: 130.7 ± 64.7 vs. 165.5 ± 66.8 min, p < 0.001). CONCLUSION: Robot utilization in revisional bariatric surgery is increasing. Robotic surgery has lower postoperative morbidity and shorter length of stay in revisional RYGB when compared to laparoscopic. Robotic platforms may have the capacity to improve the delivery of care for patients undergoing revisional bariatric surgery.

Comparison of Postoperative Bleed Rates and Location of Bleed Between Vessel Sealing Devices after Laparoscopic Sleeve Gastrectomy.

Background: Laparoscopic sleeve gastrectomy (SG) is a commonly performed bariatric procedure. At our institution, two vessel sealing devices, Thunderbeat® (Olympus) and Maryland LigaSure™ (Covidien) are utilized for intraoperative dissection. Methods: A retrospective review of all patients who underwent primary SG from July 2013 through August 2022 was performed to evaluate postoperative bleeding (POB) rates between the two devices. The primary outcome measured was POB as defined by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), with secondary outcomes including reoperation, source of bleed, and overall safety. Results: A total of 8157 underwent SG. Average BMI and age were 43.2 kg/m2 and 37.1 years, respectively. A total of 6600 (80.9%) were female. Thunderbeat® was utilized in 5143 (63%) cases and Maryland LigaSure™ was used in 3014 (37%) cases. There was no significant difference in overall bleeding between the Thunderbeat® (18/5143, .35%) and the Maryland LigaSure™ (19/3014, .63%; P = .0689). However, there was a difference noted when comparing reoperation for bleeding between Thunderbeat® (9/5143, .17%) and Maryland LigaSure™ (13/3014, .43%; P = .0291). Furthermore, the location of bleeding in the reoperations was more common from the cut edge of the mesentery compared to the staple line with the Maryland LigaSure™ versus the Thunderbeat® (P = .038). Conclusions: The Thunderbeat® device is comparatively more hemostatic than the Maryland LigaSure™ for SG. The location of postoperative bleed may be related to vessel sealing devices used.

Magnetic sphincter augmentation vs subtotal gastrectomy with Roux-en-Y reconstruction for the treatment of postsleeve gastrectomy gastroesophageal reflux disease.

BACKGROUND: Obesity affects more than one-third of Americans and can be treated with bariatric surgery, most commonly sleeve gastrectomy (SG). SG has been shown to increase the incidence of gastroesophageal reflux disease (GERD) in some patients, which can be refractory to medical management. Surgical options for post-SG GERD include magnetic sphincter augmentation (MSA) and subtotal gastrectomy with Roux-en-Y reconstruction (SGRY). A comparative analysis of MSA and SGRY for post-SG GERD was performed to evaluate postoperative outcomes. METHODS: A retrospectively maintained prospectively gathered database from 2018 to 2023 was used to identify patients who underwent MSA or SGRY for the indication of GERD after SG. Differences among patient characteristics; GERD assessments, including the health-related quality of life (HRQL) questionnaire and the reflux symptom index (RSI); and procedure outcomes were collected and analyzed according to surgery type. RESULTS: A total of 92 patients (85 females and 7 males) met the inclusion criteria. The study included 17 patients in the MSA group, 71 patients in the SGRY group, and 4 patients who underwent both procedures. The average preoperative body mass index (BMI) of all patients was 33.3. Compared with patients who underwent MSA, those who underwent SGRY presented with higher BMI (29.4 vs 34.2, respectively; P = .013), preoperative GERD-HRQL (35 vs 52, respectively; P = .046), and RSI (14 vs 28, respectively; P = .017). Postoperatively, patients who underwent SGRY demonstrated a higher decrease in mean postoperative DeMeester score than those who underwent MSA (44.2 vs 13.9, respectively; P = .040), with 22 patients (50%) in the SGRY group vs 10 patients (20%) in the MSA group achieving normalization. CONCLUSION: Although MSA remains a viable surgical alternative, our study indicated that SGRY can produce better symptom control and decrease acid exposure compared with MSA in patients with post-SG GERD.