Reversal to normal anatomy after one-anastomosis/mini gastric bypass, indications and results: a systematic review and meta-analysis.

This review evaluates the indications and outcomes of one-anastomosis/mini gastric bypass (OAGB/MGB) reversal to normal anatomy. A systematic literature search and meta-analysis was performed in PubMed, Web of Science, and Scopus for articles published by October 1, 2020, including the keywords "one anastomosis gastric bypass," "OAGB," "mini gastric bypass," "MGB," "reversal," "reverse," "malnutrition," and "reversal bariatric surgery". After examining 182 papers involving 11,578 patients, 14 studies were included. A reversal was performed in 119 patients on average 23.6 months after the primary OAGB/MGB surgery. The mean body mass index (BMI) was 22.92 ± 3.47 kg/m2 and the mean albumin level was 25.17 ± 4.21 g/L at reversal. The mean length of the common channel (CC) was 383.57 ± 159.35 cm, with a mean biliopancreatic limb (BPL) length of 214.21 ± 48.45 cm. Pooled estimation of the meta-analysis of prevalence studies reported a prevalence of 1% for reversal. The major signs and symptoms of protein-energy malnutrition were the leading causes of the reversal of OAGB/MGB. Bleeding, leakage, and death due to severe liver failure were the most reported complications after reversal, with an overall incidence of 10.9%. In conclusion, OAGB/MGB reversal has a prevalence of 1% and has a complication rate of 10.9%. Protein-energy malnutrition with hypoalbuminemia was the most common etiology. The mean lengths of BPL and CC were reported as 215 cm and 380 cm, respectively, in the cases. Therefore, special attention should be paid to malnutrition in all OAGB/MGB patients during follow-up to prevent severe malnutrition and subsequent increase in reversal procedures.

Remission of Food Addiction Does Not Induce Cross-Addiction after Sleeve Gastrectomy and Gastric Bypass: A Prospective Cohort Study.

BACKGROUND: The hypothesis of "cross-addiction" has never been validated, and numerous aspects speak against it. OBJECTIVES: To compare the differences between sleeve gastrectomy (SG) and gastric bypass (GB) procedures concerning cross-addiction. SETTING: Center for maximum care in Germany. METHODS: We performed a prospective analysis of patients undergoing SG or GB as the first surgical treatment for severe obesity. All patients completed validated questionnaires to evaluate food intake (Yale Food Addiction Scale, YFAS), alcohol intake (Alcohol Use Disorders Identification Test), nicotine use (Fagerstrom Test for Nicotine Dependence), exercise (Exercise Addiction Inventory), drug addiction (20-item Drug Abuse Screening Test), and Internet use disorder (Internet Addiction Test) before the operation (T0) and 6 (T6) and 24 (T24) months postoperatively (ClinicalTrials.gov identifier: NCT02757716). RESULTS: One hundred thirteen patients underwent SG (n = 68) or GB (n = 45). At the follow-up, 61% completed the questionnaires at T6 and 44% at T24. In the YFAS, the percentage of patients diagnosed with food addiction decreased from 69 to 10%, and the mean symptom count decreased from 3.52 ± 1.95 to 1.26 ± 0.99 at T24 (p < 0.0001); these values did not differ between the surgical groups (p = 0.784). No significant evidence of cross-addiction was observed for use of alcohol, nicotine, drugs, the Internet, or exercise in either surgical group. The percentage of patients with moderate nicotine dependence increased in the SG group (+8.9%) at T24, but this was not significant. CONCLUSION: In this single-center cohort study, surgery for obesity caused significant addiction remission regarding food but without inducing cross-addiction after 2 years. Importantly, no significant differences were seen between the SG and GB procedures.

The first consensus statement on revisional bariatric surgery using a modified Delphi approach.

BACKGROUND: Revisional bariatric surgery (RBS) constitutes a possible solution for patients who experience an inadequate response following bariatric surgery or significant weight regain following an initial satisfactory response. This paper reports results from the first modified Delphi consensus-building exercise on RBS. METHODS: We created a committee of 22 recognised opinion-makers with a special interest in RBS. The committee invited 70 RBS experts from 27 countries to vote on 39 statements concerning RBS. An agreement amongst ≥ 70.0% experts was regarded as a consensus. RESULTS: Seventy experts from twenty-seven countries took part. There was a consensus that the decision for RBS should be individualised (100.0%) and multi-disciplinary (92.8%). Experts recommended a preoperative nutritional (95.7%) and psychological evaluation (85.7%), endoscopy (97.1%), and a contrast series (94.3%). Experts agreed that Roux-Y gastric bypass (RYGB) (94.3%), One anastomosis gastric bypass (OAGB) (82.8%), and single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) (71.4%) were acceptable RBS options after gastric banding (84.3%). OAGB (84.3%), bilio-pancreatic diversion/duodenal switch (BPD/DS) (81.4%), and SADI-S (88.5%) were agreed as consensus RBS options after sleeve gastrectomy. lengthening of bilio-pancreatic limb was the only consensus RBS option after RYGB (94.3%) and OAGB (72.8%). CONCLUSION: Experts achieved consensus on a number of aspects of RBS. Though expert opinion can only be regarded as low-quality evidence, the findings of this exercise should help improve the outcomes of RBS while we develop robust evidence to inform future practice.

The role of C-reactive protein after surgery for obesity and metabolic disorders.

BACKGROUND: C-reactive protein (CRP) rise might be different in patients with obesity due to chronic inflammation. OBJECTIVES: The aim was to analyze postoperative CRP rise and its role as an early prognostic marker of infectious complications. SETTING: Center of maximum care in Germany. METHODS: Patients who underwent laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, or laparoscopic one-anastomosis gastric bypass as primary treatment for severe obesity were included. Serum CRP and leukocyte count were measured preoperatively, on postoperative days (POD) 1 and 4 and were analyzed regarding sex, body mass index, waist circumference, obesity-associated diseases, laboratory measurements (glycosylated hemoglobin, triglycerides, cholesterol), surgical procedure, infectious complications, and infectious with anastomotic leakage. RESULTS: Four hundred seventy-one patients underwent surgery. Postoperative CRP rise was similar across sexes but lower in the super-super obese group (P < .05) and higher in the gastric bypass groups (P < .05). Linear regression model showed, that the higher preoperative value of waist circumference, the higher the preoperative CRP (beta value: .159, P = .006) and the lower the postoperative CRP rise on POD1 (beta value: -.171, P = .004) and 4 (beta value: -.170, P = .003). Only in the laparoscopic one-anastomosis gastric bypass group did a higher glycosylated hemoglobin predict a higher postoperative CRP rise (POD1: beta value: .434, P = .012; POD4: beta value: .513, P = .006). Fourteen patients (3%) developed infections, 7 of whom (1.5%) had anastomotic leakage. Leukocyte count was no predictor of infectious complications. The cut-off for CRP was 80.5 mg/L (POD1) and 164 mg/L (POD4), with 57.1% and 85.7% sensitivity and 97.9% and 99.6% specificity for anastomotic leakage. CONCLUSION: Standard postoperative CRP rises less in patients with higher waist circumference and super-super obesity, but more after gastric bypass procedures. CRP but not leukocyte count predicts early anastomotic healing after obesity surgery. These findings should be considered when interpreting CRP values in the routine clinical setting.

Defining Global Benchmarks in Bariatric Surgery: A Retrospective Multicenter Analysis of Minimally Invasive Roux-en-Y Gastric Bypass and Sleeve Gastrectomy.

OBJECTIVE: To define "best possible" outcomes for bariatric surgery (BS)(Roux-en-Y gastric bypass [RYGB] and sleeve gastrectomy [SG]). BACKGROUND: Reference values for optimal surgical outcomes in well-defined low-risk bariatric patients have not been established so far. Consequently, outcome comparison across centers and over time is impeded by heterogeneity in case-mix. METHODS: Out of 39,424 elective BS performed in 19 high-volume academic centers from 3 continents between June 2012 and May 2017, we identified 4120 RYGB and 1457 SG low-risk cases defined by absence of previous abdominal surgery, concomitant procedures, diabetes mellitus, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, anticoagulation, BMI>50 kg/m and age>65 years. We chose clinically relevant endpoints covering the intra- and postoperative course. Complications were graded by severity using the comprehensive complication index. Benchmark values were defined as the 75th percentile of the participating centers' median values for respective quality indicators. RESULTS: Patients were mainly females (78%), aged 38±11 years, with a baseline BMI 40.8 ±â€Š5.8 kg/m. Over 90 days, 7.2% of RYGB and 6.2% of SG patients presented at least 1 complication and no patients died (mortality in nonbenchmark cases: 0.06%). The most frequent reasons for readmission after 90-days following both procedures were symptomatic cholelithiasis and abdominal pain of unknown origin. Benchmark values for both RYGB and SG at 90-days postoperatively were 5.5% Clavien-Dindo grade ≥IIIa complication rate, 5.5% readmission rate, and comprehensive complication index ≤33.73 in the subgroup of patients presenting at least 1 grade ≥II complication. CONCLUSION: Benchmark cutoffs targeting perioperative outcomes in BS offer a new tool in surgical quality-metrics and may be implemented in quality-improvement cycle.ClinicalTrials.gov Identifier NCT03440138.

The Edmonton Obesity Staging System Predicts Perioperative Complications and Procedure Choice in Obesity and Metabolic Surgery-a German Nationwide Register-Based Cohort Study (StuDoQ|MBE).

OBJECTIVE: To examine the relationship between Edmonton Obesity Staging System (EOSS) and perioperative complications as well as surgical procedure. BACKGROUND: The application of EOSS for the selection of patients with obesity is a more comprehensive measure of obesity-related diseases and a predictor of mortality than body mass index (BMI). METHODS: This was a nationwide cohort study using prospectively inserted data from the German register for obesity and metabolic surgery StuDoQ|MBE. All patients undergoing sleeve gastrectomy (SG), Roux-en Y gastric bypass (RYGB), and one-anastomosis gastric bypass (OAGB) between February 2015 and July 2017 as a primary treatment for severe obesity were included. Data included gender, age, BMI, ASA score, EOSS, early postoperative complications next to the Clavien-Dindo grading system, readmission, and 30-day mortality. RESULTS: A total of 9437 patients were included. The mean BMI was 49.5 kg/m2 ± 7.8 (range 35-103.5). The total postoperative complication rate was 5.3%, with the highest rate in EOSS 3 (7.8%) and 4 (6.8%). Thirty-day mortality was 0.2% with the highest mortality after SG in EOSS 3 (1.16%) and EOSS 4 (0.92%) (p = 0.0068). Crosstabs showed a prevalence of Clavien-Dindo III and IV complications of 3.4% (SG), 3.6% (RYGB), and 1.6% (OAGB) in EOSS 2 (p = 0.0032) and 3.5% (SG), 5.1% (RYGB), and 5.6% (OAGB) in EOSS 3. CONCLUSION: The highest postoperative complications and mortality occurred in patients with EOSS ≥ 3. SG and OAGB could be the procedure of choice to reduce perioperative morbidity; nevertheless, it has to be in mind that in EOSS ≥ 3, SG has the highest mortality. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT03556059.

Mini/One Anastomosis Gastric Bypass Versus Roux-en-Y Gastric Bypass as a Second Step Procedure After Sleeve Gastrectomy-a Retrospective Cohort Study.

BACKGROUND: Whether one anastomosis gastric bypass (OAGB) or Roux-en-Y gastric bypass (RYGB) is a better revisional bariatric surgery (RBS) after sleeve gastrectomy (SG) is still under debate. The aim is to compare short-term outcomes of RYGB and OAGB as a RBS after SG, pertaining to their effects on weight loss, resolution of comorbidities, and complications. METHODS: We performed a single-center analysis of 55 patients (n = 34 OAGB, n = 21 RYGB). Indications for revisional surgery included weight regain/loss failure (67%) and intractable gastroesophageal reflux disease (33%). Data were collected up to 1-year follow-up (FU) and included time of revisional surgery, operation time, weight, body mass index, excess weight loss, and total weight loss (TWL), both in percent, complications and resolution of comorbidities. RESULTS: Operation time was 79 ± 36 (OAGB-MGB) and 98 ± 24 min (RYGB) (p = 0.03). In the first 30 postoperative days, three patients in the RYGB group, and no patient in the OAGB group, had postoperative complications. FU was 100%. Minor complication rates at 12 months were 33.3% (RYGB) and 35.3% (OAGB). At 12 months, mean % TWL was 10.3 ± 7.6% (RYGB) and 15.8 ± 7.8% (OAGB) (p = 0.0132). CONCLUSIONS: OAGB after failed SG was found to be a quicker procedure with less perioperative complications. At 1-year FU, no significant differences were seen between RYGB and OAGB regarding readmission and minor complications. Still long-term FU including the risk of malnutrition is needed to have a complete evaluation of OAGB as a RBS for the future.

The Impact of Obesity and Metabolic Surgery on Chronic Inflammation.

BACKGROUND: Obesity and metabolic surgery is known to improve chronic inflammatory status. Whether improvement is related to anatomical changes or weight loss is still to debate. OBJECTIVE: The aim of this clinical trial is to compare the different bariatric procedures sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and One-anastomosis gastric bypass (OAGB), pertaining to their effects on inflammation markers. METHODS: Patients who underwent SG, RYGB, or OAGB as a primary treatment for severe obesity were included. The data collected preoperatively (T0) and 1, 3, and 6 (T6) months after surgery included gender, weight, comorbidities and toxic habits at baseline, body mass index (BMI), waist circumference, total body weight loss in % (TBWL), leukocyte count in × 103/µl, C-reactive protein (CRP) in mg/l, HbA1c in %, aspartate transaminase in U/l, alanine transaminase in U/l, gamma-glutamyltransferase in U/l, bilirubin in mg/dl, cholesterol in mg/dl, and triglycerides in mg/dl. RESULTS: Four hundred sixty-eight patients were included. Drop-out rate was 25.8% at T6. Preoperatively the mean value of leukocytes and CRP was 7.4 × 103/µl ± 2 and 10.5 mg/l ± 8.1. At T6, mean value of leukocytes and CRP was 7.1 × 103/µl ± 1.9 (p = 0.075) and 7.2 mg/l ± 9.5 (p < 0.001). TBWL % at T6 was 24.2 ± 7.6 in the SG, 25.8 ± 5.9 in the RYGB and 25.5 ± 4.6 in the OAGB group. Comparing SG, RYGB, and OAGB in relation to leukocyte count and CRP no significant difference was seen between the groups. CONCLUSION: CRP but not leukocyte count decreased after all three bariatric procedures but without any significance between the three groups. Surgically induced weight loss and not anatomical changes might play an important role for improvement in chronic inflammation. TRIAL REGISTRATION: The National Clinical Trials number was NCT02697695 ( https://clinicaltrials.gov/ct2/show/NCT02697695 ).

Correction to: The Impact of Obesity and Metabolic Surgery on Chronic Inflammation.

In Table 4 the column labeled "p values" and its data should be deleted.

Bariatric Surgery Worldwide: Baseline Demographic Description and One-Year Outcomes from the Second IFSO Global Registry Report 2013-2015.

BACKGROUND: Five International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) surveys since 1998 have estimated the volume and type of bariatric surgery being done in constituent member countries. These reports did not include baseline demographic descriptions. METHODS: An IFSO Global Registry pilot project in 2014 demonstrated that it was possible to amalgamate large numbers of individual patient data from different local and national database systems. Here we describe demographic data from the second report for 54,490 patients from 31 countries operated in the 3 calendar years 2013-2015 and follow up data from 66,560 of 112,544 patients in 2009-2015. RESULTS: Most procedures (97.8%) were performed laparoscopically and 73.3% (95% CI: 73.0-73.7%, range 54.2 to 80.3%) were female. The average age was 42.0 years (95% CI 41.9-42.1, inter-quartile range 33.0-51.0 years) and the median body mass index was 43.3 kg/m2 (inter-quartile range 39.4-48.8 kg/m2). Before surgery, 22.0% patients had type 2 diabetes (inter-country variation 7.4-63.2%); 31.9% were hypertensive (15.8-92.7%); 17.6% had depression (0.0-46.3%); 27.8% took medication for musculoskeletal pain (0.0-58.9%); 18.9% had sleep apnea (0.0-63.2%); and 29.6% of patients had gastro-esophageal reflux disease (9.1-90.9%). Gastric bypass was the most prevalent operation (49.4%), followed by sleeve gastrectomy (40.7%) and gastric banding (5.5%). The 1-year total weight loss for patients with available data was 30.53% (95% CI: 30.22-30.84%) and in the cohort 2009-15 was 30.4% with a follow-up rate of 59.14%. In the 2009-2015 cohort, 64.7% of patients on treatment for diabetes preoperatively were not on treatment postoperatively. CONCLUSIONS: There is widespread variation in access to surgery and in baseline patient characteristics in the countries submitting data to the IFSO Global Registry.

The First Consensus Statement on One Anastomosis/Mini Gastric Bypass (OAGB/MGB) Using a Modified Delphi Approach.

BACKGROUND: An increasing number of surgeons worldwide are now performing one anastomosis/mini gastric bypass (OAGB/MGB). Lack of a published consensus amongst experts may be hindering progress and affecting outcomes. This paper reports results from the first modified Delphi consensus building exercise on this procedure. METHODS: A committee of 16 recognised opinion-makers in bariatric surgery with special interest in OAGB/MGB was constituted. The committee invited 101 OAGB/MGB experts from 39 countries to vote on 55 statements in areas of controversy or variation associated with this procedure. An agreement amongst ≥ 70.0% of the experts was considered to indicate a consensus. RESULTS: A consensus was achieved for 48 of the 55 proposed statements after two rounds of voting. There was no consensus for seven statements. Remarkably, 100.0% of the experts felt that OAGB/MGB was an "acceptable mainstream surgical option" and 96.0% felt that it could no longer be regarded as a new or experimental procedure. Approximately 96.0 and 91.0% of the experts felt that OAGB/MGB did not increase the risk of gastric and oesophageal cancers, respectively. Approximately 94.0% of the experts felt that the construction of the gastric pouch should start in the horizontal portion of the lesser curvature. There was a consensus of 82, 84, and 85% for routinely supplementing iron, vitamin B12, and vitamin D, respectively. CONCLUSION: OAGB/MGB experts achieved consensus on a number of aspects concerning this procedure but several areas of disagreements persist emphasising the need for more studies in the future.