Efficacy and safety of one anastomosis gastric bypass versus Roux-en-Y gastric bypass for obesity (YOMEGA): a multicentre, randomised, open-label, non-inferiority trial.

BACKGROUND: One anastomosis gastric bypass (OAGB) is increasingly used in the treatment of morbid obesity. However, the efficacy and safety outcomes of this procedure remain debated. We report the results of a randomised trial (YOMEGA) comparing the outcomes of OAGB versus standard Roux-en-Y gastric bypass (RYGB). METHODS: This prospective, multicentre, randomised non-inferiority trial, was held in nine obesity centres in France. Patients were eligible for inclusion if their body-mass index (BMI) was 40 kg/m2 or higher, or 35 kg/m2 or higher with the presence of at least one comorbidity (type 2 diabetes, high blood pressure, obstructive sleep apnoea, dyslipidaemia, or arthritis), and were aged 18-65 years. Key exclusion criteria were a history of oesophagitis, Barrett's oesophagus, severe gastro-oesophageal reflux disease resistant to proton-pump inhibitors, and previous bariatric surgery. Participants were randomly assigned (1:1) to OAGB or RYGB, stratified by centre with blocks of variable size; the study was open-label, with no masking required. RYGB consisted of a 150 cm alimentary limb and a 50 cm biliary limb and OAGB of a single gastrojejunal anastomosis with a 200 cm biliopancreatic limb. The primary endpoint was percentage excess BMI loss at 2 years. The primary endpoint was assessed in the per-protocol population and safety was assessed in all randomised participants. This study is registered with ClinicalTrials.gov, number NCT02139813, and is now completed. FINDINGS: From May 13, 2014, to March 2, 2016, of 261 patients screened for eligibility, 253 (97%) were randomly assigned to OAGB (n=129) or RYGB (n=124). Five patients did not undergo their assigned surgery, and after undergoing their surgery 14 were excluded from the per-protocol analysis (seven due to pregnancy, two deaths, one withdrawal, and four revisions from OAGB to RYGB) In the per-protocol population (n=117 OAGB, n=117 RYGB), mean age was 43·5 years (SD 10·8), mean BMI was 43·9 kg/m2 (SD 5·6), 176 (75%) of 234 participants were female, and 58 (27%) of 211 with available data had type 2 diabetes. After 2 years, mean percentage excess BMI loss was -87·9% (SD 23·6) in the OAGB group and -85·8% (SD 23·1) in the RYGB group, confirming non-inferiority of OAGB (mean difference -3·3%, 95% CI -9·1 to 2·6). 66 serious adverse events associated with surgery were reported (24 in the RYGB group vs 42 in the OAGB group; p=0·042), of which nine (21·4%) in the OAGB group were nutritional complications versus none in the RYGB group (p=0·0034). INTERPRETATION: OAGB is not inferior to RYGB regarding weight loss and metabolic improvement at 2 years. Higher incidences of diarrhoea, steatorrhoea, and nutritional adverse events were observed with a 200 cm biliopancreatic limb OAGB, suggesting a malabsorptive effect. FUNDING: French Ministry of Health.

Gastric bypass for obesity in the elderly: is it as appropriate as for young and middle-aged populations?

BACKGROUND: Obesity prevalence increases in elderly population. Bariatric surgery has been underused in patients over 60 because of fears of complications and lower weight loss. We postulated worse outcomes in the elderly in comparison to young and middle-aged population 1 year after gastric bypass. METHODS: We retrospectively analyzed gastric bypass outcomes in young (<40 years), middle-aged (40 to 55 years), and elderly (>60 years) patients between 2007 and 2013. Each subject over 60 (n = 24) was matched with one subject of both the other groups according to gender, preoperative body mass index (BMI), surgical procedure, and history of previous bariatric surgery (n = 72). RESULTS: Older subjects demonstrated higher prevalence of preoperative metabolic comorbidities (70 vs 30 % in the <40-year-old group, p < 0.0001). Mean duration of the surgical procedure, mean length of stay, and early and late complication rates were similar between age groups. A trend towards fewer early complications and less-severe complications in the younger groups was noted. One-year weight loss results were similar between young, middle-aged, and elderly patients (percentage of excess BMI loss (EBL%), 74.4 ± 3.5; 78.9 ± 4.5, and 73.7 ± 4.5 respectively, p = 0.69). Age was not predictive of weight loss failure 1 year after surgery. Remission and improvement rates of comorbidities were similar between age groups 6 months after surgery. CONCLUSIONS: Our study confirms weight loss efficacy of gastric bypass in the elderly with acceptable risks. Further studies evaluating the benefit-risk balance of bariatric surgery in the elderly population will be required so as to confirm the relevance of increasing age limit.

Preoperative fat-free mass: a predictive factor of weight loss after gastric bypass.

Weight loss failure occurs in 8% to 40% of patients after gastric bypass (GBP). The aim of our study was to analyse the predictive factors of weight loss at 1 year so as to select the best candidates for this surgery and reduce the failures. We included 73 patients treated by laparoscopic GBP. We retrospectively analysed the predictive factors of weight loss in kilograms as well as excess weight loss in percentage (EWL%) at 1 year. The population was divided into tertiles so as to compare the sub-group with the highest weight loss with the sub-group with the least satisfactory results. The significantly predictive factors of a better weight loss in kilograms were male, higher initial weight (144 versus 118 kg, p = 0.002), a significant early weight loss and a higher preoperative percentage of fat-free mass (FFM%; p = 0.03). A higher FFM% was also associated with a better EWL% (p = 0.004). The preoperative FFM (in kilograms) was the principal factor accounting for the weight loss at 1 year regardless of age, gender, height and initial body mass index (BMI; p < 0.0001). There was a better correlation between FFM and weight loss (Spearman test, p = 0.0001) than between initial BMI and weight loss (p = 0.016). We estimated weight loss at 1 year according to initial FFM using the formula: 0.5 kg of lost weight per kilogram of initial FFM. The initial FFM appears to be a decisive factor in the success of GBP. Thus, the sarcopoenic patients would appear to be less suitable candidates for this surgery.

Laparoscopic gastric bypass for failure of adjustable gastric banding: a review of 85 cases.

Laparoscopic adjustable gastric banding (LAGB) is the first bariatric procedure in Europe and is becoming more and more popular in North America. However, the failure rate at 5 years can reach 50%. Although there is still no consensus on revisional surgery, the trend seems to be in favor of conversion to gastric bypass (GBP) with encouraging results. The aim of this study was to assess the results, the risks of conversion into GBP after failure of gastric banding. From January 2003 to July 2010, 85 patients had a revisional GBP after failure of LAGB, performed by two experienced surgeons. Post-operative morbidity, functional results, and weight loss were analyzed. The conversion rate was 2.3%. The mean operative time was 166 min. The mean length of stay was 5.2 days. The early morbidity rate was 7% and the mortality rate was nil. The mean body mass index (BMI) at the time of LAGB was 47.2 kg/m(2) with the lowest BMI reached at 35. The mean BMI at conversion into GBP was 42.9 and the final BMI after a mean follow-up of 22 months was 34.8. Of the patients, 57.7% had a final BMI inferior to 35 and 15.3% had a final BMI superior to 40 and these were super obese and older patients. Super-obesity and advanced age appear to be factors of failure of LAGB and revisional GBP. However, conversion into GBP currently remains the choice procedure in case of gastric banding failure with satisfactory results and acceptable morbidity.

High resolution esophageal manometry evaluation in symptomatic patients after gastric banding for morbid obesity.

BACKGROUND: Dysphagia and vomiting are frequent after laparoscopic gastric banding (LAGB). These symptoms could be secondary to esophageal motility disorders. Our aim was to assess esophageal motility and clearance in symptomatic LAGB patients using high resolution manometry (HRM). METHODS: Twenty-two LAGB patients with esophageal symptoms (dysphagia, vomiting, and regurgitations) were included. Esophageal motility was studied using HRM (ManoScan®, Sierra Systems) and classified according to the Chicago classification. RESULTS: The median delay between surgery and manometry evaluation was 6.3 years (range 1-10). Manometric data were considered as normal in only 2 patients. Achalasia was diagnosed in 3 cases, functional EGJ obstruction in 15, hypotensive peristalsis in 2. During swallowing pan-esophageal pressurization was observed in 6 patients, hiatal hernia pressurization in 7 and gastric pouch pressurization in 2. The intra-bolus pressure was elevated in 18 patients. LAGB was deflated in 6 patients and removed in 12. In 2 patients with unchanged symptoms after LAGB removal motility disorders persisted (1 achalasia, 1 functional EGJ obstruction). CONCLUSION: In symptomatic LAGB patients, esophageal dysmotility is frequent. High resolution manometry allows the assessment of esophageal clearance and provides guidance for the choice of treatment.

Ressecção videolaparoscópica de hemangiopericitoma do estômago / Laparoscopic resection for hemangiopericytoma of the stomach

In the present case (77 years-old woman), the diagnosis on an extramucosal lesion by endosonography was leiomyoma or schwanoma. Radiological exam of the upper digestive tract with barium and abdominal computed tomography confirmed the site of the lesion at the level of the lesser curvature. The operative technique followed the steps of the laparoscopic partial gastric resection (wedge resection) for gastric mesenchymal tumours, described elsewhere. The Endo-GIA stapler was introduced through the 12mm port in the right upper quadrant. proper positioning of the stapler over the lesser curvature and a satisfactory margin of tissue around the mass were attained. Nine sequential firings of the Endo-GIA 30 were needed to completely surround the mass. Histopathological diagnosis was a spindlecell tumour measuring 3cm in diameter. Mitotic index was measured at almost null. The neoplastic cells were strongly reactive for vimentine and CD34 and negative for the immunohistochemical markers S-100 protein, muscle actin, desmin and Ag linked to VIII factor. There was a slight reaction with keratin (+/+++). The XIIIA factor reaction revealed less than 5 por cento of dendritic elements. These data favour a vascular cell origin better than smooth muscle cell origin. In conclusion it was a gastric hemangiopericytoma. Follow-up showed no recurrence at seven years