Analysis of Factors Related to Gastroesophageal Reflux After Gastric Bypass at 10-Year Follow-up: A Retrospective Single-institutional Study.

BACKGROUND/AIM: Long-term gastroesophageal reflux (GERD) after gastric bypass for obesity is underestimated. The present study aimed to evaluate the rate of treated GERD and the factors influencing it in a cohort of patients who underwent gastric bypass. PATIENTS AND METHODS: Patients who underwent one-anastomosis gastric bypass (OAGB) or Roux-en-Y gastric bypass (RYGB) as a primary bariatric procedure between 2010 and 2011 at a French private referral center were included in the study. The primary endpoint was the 10-year prevalence of GERD. RESULTS: In total, 422 patients underwent RYGB and 334 underwent OAGB with a biliopancreatic limb of 150 cm. The mean age was 38.9±11.3 years, and 81.6% of patients were female; the mean preoperative body mass index was 42.8±5 kg/m2 Preoperative GERD was diagnosed in 40.8% of patients in the total cohort, 31.7% in the RYGB group versus 49.1% in the OAGB group (p<0.0001). At 10-year follow-up, the rate of GERD was 21.1%, with no difference between the two groups. Remission of preoperative GERD and de novo GERD were comparable between the two types of bypass. Surgery for GERD resistant to medical treatment was more frequent in the OAGB group. At multivariate analysis, factors significantly correlated with long-term GERD were: Preoperative GERD, total weight loss at 120 months <25%, glycemic imbalances and anastomotic ulcers. CONCLUSION: Identification and correction of modifiable factors may help reduce the incidence of long-term GERD.

Use of Preoperative Endoscopic Capsule-Based pH Testing Before Bariatric Surgery.

BACKGROUND: Vertical sleeve gastrectomy is the most performed bariatric operation in the US; however, a significant number of patients suffer from persistent or new-onset reflux. No consensus for objective preoperative evaluation in these patients exists. We compared capsule-based pH testing vs GERD symptom scoring to determine extent of preoperative GERD to aid in procedure selection for bariatric surgery. STUDY DESIGN: An IRB-approved retrospective review of consecutive patients at a single institution was performed from April 2021 to December 2022. During initial consultation for bariatric surgery, a validated GERD symptom subjective survey was administered. All patients demonstrating interest in sleeve gastrectomy or had a history of reflux underwent upper endoscopy with capsule-based pH testing. RESULTS: Sixty-two patients underwent preoperative endoscopy with capsule-based pH testing and completed GERD symptom assessment survey(s). Median BMI was 43.4 kg/m 2 and 66.1% of patients were not taking a proton-pump inhibitor before performance of pH testing. There was negligible linear association between the objective DeMeester score obtained by capsule-based pH probe and GERD symptom survey scores. Median GERD symptom survey scores did not differ between patients with and without a diagnosis of GERD based on pH testing (all p values >0.11). CONCLUSIONS: An objective method for identifying severe GERD in the preoperative assessment may aid in the decision tree for procedure selection and informed consent process. Patients with significant preoperative GERD may be at higher risk for future GERD-related sleeve complications. Capsule-based pH testing may prove to be superior to subjective symptom scoring systems in this patient population.

Healthcare payment mechanism: Execution results of bundled payment program for bariatric surgery diagnosis in its first year of implementation in Chile. / Mecanismos de pago en salud: resultados de ejecución del pago asociado a diagnóstico en cirugía bariátrica en su primer año de implementación en Chile.

Introduction: More than 600 thousand people in Chile live with morbid obesity. Effective, safe, cost-effective therapeutic interventions are critical for healthcare systems and insurance schemes. In 2022, two bundled payment codes for bariatric surgery (gastric bypass and gastric sleeve) were incorporated into the National Health Fund's free-choice modality fee scheme. The objective was to characterize the execution of this payment mechanism program associated with bariatric surgery diagnosis in its first year of implementation.More than six hundred thousand people in Chile are estimated to live with morbid obesity. Effective, safe, cost-effective therapeutic interventions are critical for health systems and insurance schemes. In 2022, FONASA incorporated two Bariatric Surgery codes into the Free Choice Modality: Gastric Bypass and Sleeve Gastrectomy. Our objective was to characterize the execution of the Bariatric Surgery Bundled Payment Program in its first year of implementation. Methods: Descriptive and observational study of the pragmatic approach of the national execution of the payment associated with diagnosis in bariatric surgery. We examined sociodemographic variables (sex, age brackets, and National Health Fund tranches) and characterization of surgeries by code broken down by public or private provider, period of issue, unit cost, co-payment, and medical loans between March and December 2022. Results: We recorded n = 13 118 surgeries (45.81% bypass versus 54.19% sleeve), of which n = 2424 (18.48%) used medical loans. A total of 85.01% (p = 0.01) of the procedures were in women, in people between 35 and 39 years of age (20.15%), and 45.12% in beneficiaries of tranche B. Private providers performed a total of 99.21% of the surgeries. Ten accounted for 50% of the activity (range n = 1200 to 426 surgeries per year; n = 4.8 to 1.7 surgeries per working day). Total program expenditure was $71 626 948 350 CLP, accounting for 5.04% of the total activity of the national Diagnosis Associated Payment Program. Conclusions: The implementation of this bariatric surgery voucher benefited more than 13 thousand people living with obesity, mostly women of productive ages and with purchasing capacity. As an equity strategy, regardless of the access route through the voucher, it will be important to safeguard the activity in the public network.

Introducción: Más de 600 mil personas en Chile viven con obesidad mórbida. La incorporación de intervenciones terapéuticas eficaces, seguras y costo-efectivas es crítica para los sistemas de salud y esquemas de aseguramiento. En el año 2022 se incorporaron al arancel de modalidad de libre elección del Fondo Nacional de Salud dos códigos de pago asociado a diagnóstico para cirugía bariátrica: gástrico y manga gástrica. El objetivo fue caracterizar la ejecución del programa de mecanismo de pago tipo pago asociado a diagnóstico de cirugía bariátrica en su primer año de implementación. Métodos: Estudio descriptivo y observacional de abordaje pragmático de la ejecución nacional del pago asociado a diagnóstico en cirugía bariátrica. Se examinaron variables de caracterización sociodemográfica (sexo, tramos etarios y tramos del Fondo nacional de Salud) y caracterización de cirugías según código desagregadas por prestador público o privado, periodo de emisión, gasto unitario, copago, y préstamos médicos, entre marzo y diciembre de 2022. Resultados: Se registraron n = 13 118 cirugías (45,81% versus 54,19% manga), de las cuales n = 2424 (18,48%) emplearon préstamos médicos. Un 85,01% (p = 0,01) de los procedimientos fueron en mujeres; en personas entre 35 y 39 años (20,15%); y 45,12% en beneficiarios del tramo B. El 99,21% de las cirugías se realizó en prestadores privados. Diez de estos concentraron el 50% de la actividad (rango n = 1200 a 426 cirugías anuales; n = 4,8 a 1,7 cirugías por día hábil). El gasto total del programa fue $71 626 948 350 CLP, explicando un 5,04% de la actividad total del Programa nacional de Pago Asociado a Diagnóstico. Conclusiones: La implementación de este bono para cirugía bariátrica benefició a más de 13 mil personas que viven con obesidad, mayormente mujeres, en edades productivas, y con capacidad de compra. Como estrategia de equidad, independientemente de la vía de acceso mediante el bono, será importante cautelar la actividad en la red pública.

The safety and efficacy of nonvitamin K antagonist oral anticoagulants in morbidly obese patients with atrial fibrillation: a meta-analysis.

BACKGROUND AND AIM: Atrial fibrillation (AF) is the most frequently observed cardiac arrhythmia in clinical settings. Obesity can influence the efficacy of the treatment administered, which requires a larger dose and more time to accomplish therapeutic targets due to altered pathophysiology. Our study aimed to assess the overall efficacy and safety of nonvitamin K antagonist oral anticoagulants (NOACs) versus warfarin in AF patients with morbid obesity (BMI > 40 kg/m2 and/or weight > 120 kg) to prevent complications. METHODS: We conducted a literature search on PubMed, Web of Science, the Cochrane Library, and Scopus till October 2022 for articles addressing the efficacy and safety of NOACs versus warfarin for the treatment of AF in morbidly obese patients. We performed the meta-analysis with RevMan software version 5.4 and Open Meta Analyst. The main outcomes assessed were stroke, major bleeding, and minor bleeding after anticoagulation, as did the history of comorbidities and risk factors in morbidly obese patients. Quality assessment was performed using Cochrane's ROB-2 tool and the Newcastle-Ottawa scale. RESULTS: Regarding major bleeding events, pooled data showed that patients taking NOACs had a significantly lower risk than patients taking warfarin (OR = 0.54, 95% CI: [0.41-0.70]; p < 0.00001). However, for minor bleeding, there was a nonsignificant effect of NOACs on reducing the risk of bleeding (OR = 0.72, 95% CI = 0.47-1.09; p = 0.12), which became highly significant in favor of NOACs after sensitivity analysis (OR = 0.55, 95% CI = 0.49-0.61]; p < 0.00001). There was a significant difference in the incidence of stroke between the NOAC group and the warfarin group (OR = 0.69, 95% CI = 0.60-0.80]; p < 0.00001). According to the results of the single-arm study analysis, the overall effect of all the outcomes was associated with a high risk of disease development in patients receiving NOACs. CONCLUSION: Our meta-analysis showed a favorable effect of NOACs vs warfarin in morbidly obese patients. Some outcomes were not significantly different, which calls for future research to better assess their safety and efficacy in this particular weight group. TRIAL REGISTRATION: The study was registered with PROSPERO under registration number CRD42022362493 on October 2022.

Effectiveness of the Modified Hemoglobin, Albumin, Lymphocyte, and Platelet Score in Predicting Weight Loss After Laparoscopic Sleeve Gastrectomy.

Introduction: The overexpression of proinflammatory cytokines in obesity has suggested an association between obesity and inflammation. In this study, we aimed to predict the success of weight loss at the end of the first year of patients who underwent laparoscopic sleeve gastrectomy (LSG) for morbid obesity using hemoglobin, albumin, lymphocyte, and platelet (HALP) score and modified HALP (m-HALP) score. Materials and Methods: Patients were divided into two groups according to the success of weight loss. The groups were compared in terms of HALP score, m-HALP score, demographic parameters, and preoperative laboratory tests. The diagnostic performance measurements of the m-HALP score were calculated. In addition, logistic regression analysis was performed for the factors affecting weight loss in the first year after LSG. Results: Seventy-two patients were evaluated. The median m-HALP score of the patients with an excess weight loss percentage (EWL%) <60 threshold was 562 (416.6-891.9), the median m-HALP score of the patients with an EWL% above the 60 threshold was 394.3 (347.9-543), and the difference between the outcome groups was significant (P = .002).The accuracy of m-HALP score in identifying the patients whose EWL would be <60% 1 year after the surgery was 63.9 (95% confidence interval = 51.7-74.9). Conclusion: This study showed that the m-HALP score is effective in predicting weight loss after bariatric surgery.

Association between COVID-19 diagnosis and postoperative outcomes in sleeve gastrectomy and Roux-en-Y gastric bypass: A national cohort study.

BACKGROUND: We seek to determine the association between COVID-19 diagnosis and postoperative outcomes following bariatric surgery. METHODS: Using the Metabolic and Bariatric Surgery Accreditation Quality Improvement Project (MBSAQIP) database, patients undergoing sleeve gastrectomy and gastric bypass without a COVID-19 diagnosis were 2:1 propensity-score matched to those with COVID-19 infection pre or postoperatively. RESULTS: 1369 (0.74 â€‹%) and 1331 (0.72 â€‹%) patients had a COVID-19 diagnosis within 14 days prior to or 30 days after their operation, respectively. Patients with preoperative COVID-19 infection had equivalent outcomes to COVID-19 negative patients (all p â€‹> â€‹0.05). Postoperative COVID-19 diagnosis was associated with worse outcomes including increased risk of anastomotic/staple line leak (1.1 â€‹% vs 0.1 â€‹%, p â€‹< â€‹0.001), postoperative pneumonia (2.9 â€‹% vs 0.1 â€‹%, p â€‹< â€‹0.001), and 30-day reoperation (2.1 â€‹% vs 0.9 â€‹%, p â€‹= â€‹0.002). CONCLUSIONS: Postoperative diagnosis of COVID-19 after bariatric surgery is associated with worse outcomes; however, it is safe to perform these procedures on patients recently convalesced from COVID-19 infection.

[Robotic sleeve gastrectomy: single-center experience]. / Roboticheskaya «rukavnaya gastrektomiya¼: opyt kliniki.

OBJECTIVE: To demonstrate safe introduction of a new technology (Da Vinci robotic system) into laparoscopic bariatric practice. MATERIAL AND METHODS: We analyzed treatment outcomes in patients with morbid obesity who underwent robot-assisted sleeve gastrectomy between 2020 and 2023. The same team of surgeons performed all operations. Evolution of technique and preparation of the operating theatre were recorded. Demographic data of patients, surgery time (docking and total surgery time), simultaneity of intervention, intraoperative and postoperative complications, as well as weight loss after 6 months were retrospectively analyzed. RESULTS: There were 15 robot-assisted sleeve gastrectomies between 2020 and 2023. Of these, 14 patients underwent surgery without complications. One patient was diagnosed with portal vein thrombosis that required anticoagulation. Median surgery time 194 [173.5; 241] min, period between incision and docking - 35 [30; 36] min. The length of hospital-stay was 3 days. The median weight loss after 6 months was 37.5% [29.5; 51.2]. CONCLUSION: This study demonstrates safe introduction of a new technology to prepare the bariatric team for more complex surgical interventions in the future.

[The first experience of robot-assisted bariatric surgery using the Senhance system in patients with morbid obesity]. / Pervyi opyt robot-assistirovannoi bariatricheskoi khirurgii s ispol'zovaniem sistemy Senhance v lechenii patsientov s morbidnym ozhireniem.

OBJECTIVE: To study the results of robot-assisted bariatric surgery using the Senhance system in patients with morbid obesity. MATERIAL AND METHODS: A prospective cohort study included 74 patients who underwent bariatric surgery (Senhance digital laparoscopy system) between January 2022 and May 2023. Of these, 12 patients underwent robot-assisted longitudinal gastrectomy, 20 patients - robot-assisted Roux-en-Y gastric bypass, 36 patients - robot-assisted gastric bypass with one anastomosis/mini-gastric bypass, 6 patients - surgical exploration. We assessed duration of surgery, docking, placement of trocars and robotic manipulators, the need for their intraoperative displacement, incidence of intraoperative complications and conversions to laparoscopic surgery, intraoperative blood loss and early postoperative complications, severity of pain syndrome on the 1st day after surgery. RESULTS: Mean surgery time was 87 [67, 120], 116 [78, 139], 96 [79, 125] and 141 [112, 184] min, respectively. Intraoperative blood loss was less than 50 ml. There were no complications requiring surgical treatment, cardiovascular, respiratory and other complications within 1 month. CONCLUSION: Robot-assisted bariatric surgery using the Senhance system is feasible and safe for patients. Immediate results of robotic surgery are comparable to those after laparoscopy. However, large experience and cost-effectiveness analysis are required to assess the feasibility of robotic systems in bariatric surgery.

[Treatment of ventral hernias in patients with morbid obesity]. / Taktika lecheniya ventral'nykh gryzh u patsientov s morbidnym ozhireniem.

The review is devoted to the treatment of ventral hernias in patients with morbid obesity. This issue is important due to significant number of such patients and no unambiguous clinical recommendations. The advantages of simultaneous surgery (with bariatric intervention) are obvious, i.e. lower risk of postoperative hernia incarceration and no need for re-hospitalization with another intervention. High risk of bariatric population makes it necessary to minimize surgery time and surgical trauma. A staged approach with reducing body weight surgically or conservatively before hernia repair is often chosen. Hernia repair should be performed using laparoscopic or robotic techniques with obligatory use of mesh implants. Panniculectomy or abdominoplasty as the main surgery is a valid option. Currently, it is necessary to develop clear criteria for selecting patients with morbid obesity for staged and simultaneous treatment of ventral hernias.

What Value of Sixth Month Excess Weight Loss (Postsleeve Gastrectomy) Is Necessary for Better Sleep Quality?

BACKGROUND: Obesity, caused by caloric intake over output, is a global health problem. The relationship between sleep and obesity is discussed in the literature. Little is known about the compliance of sleep quality and patients' weight loss. This study aimed to review how sleep quality is affected by bariatric surgery, assess whether compliance with sleep quality can be predicted after bariatric surgery, and establish its correlation with excess weight loss. METHODS: A cross-sectional study was conducted for patients undergoing bariatric surgery (laparoscopic sleeve gastrectomy). Sleep quality was assessed with the Pittsburgh sleep quality index (PSQI) scale preoperatively and in the sixth postoperative month. A PSQI global score above 5 indicated poor sleep quality. Participants were divided into 2 groups: good and poor sleep quality. Receiver operating characteristics and logistic regression analysis were also performed to predict sleep quality. RESULTS: The questionnaire was completed by 100 subjects. All PSQI components, except the sixth (sleep medication) component, improved in patients at the sixth postoperative month versus baseline values. In the receiver operating characteristic analysis to test the availability of excess weight loss (EWL%) cutoff values relative to predict successful sleepers, 65.1 of the sixth month EWL% was found for the diagnosis of successful sleeper patients with 72.6% sensitivity and 63% specificity (area under the curve: 0.706, P =0.002, 95% CI, 0.586 to 0.825). CONCLUSIONS: For patients undergoing weight loss surgery, while assessing the sixth postoperative month, the EWL% value over 65.1 was recommended for better sleep quality.

The impact of Hafnia alvei HA4597™ on weight loss and glycaemic control after bariatric surgery - study protocol for a triple-blinded, blocked randomized, 12-month, parallel-group, placebo-controlled clinical trial.

BACKGROUND: Subjects with obesity exhibit changes in gut microbiota composition and function (i.e. dysbiosis) that contribute to metabolic dysfunction, including appetite impairment. Although bariatric surgery is an effective treatment for obesity with a great impact on weight loss, some subjects show weight regain due to increased energy intake after the surgery. This surgery involves gut microbiota changes that promote appetite control, but it seems insufficient to completely restore the obesity-associated dysbiosis - a possible contributor for weight regain. Thus, modulating gut microbiota with probiotics that could improve appetite regulation as a complementary approach to post-operative diet (i.e. Hafnia alvei HA4597™), may accentuate post-surgery weight loss and insulin sensitivity. METHODS: This is a protocol of a triple-blinded, blocked-randomized, parallel-group, placebo-controlled clinical trial designed to determine the effect of Hafnia alvei HA4597™ supplementation on weight loss and glycaemic control 1 year after bariatric surgery. Patients of Hospital CUF Tejo, Lisbon, that undergo Roux-en-Y gastric bypass are invited to participate in this study. Men and women between 18 and 65 years old, with a BMI ≥ 35 kg/m2 and at least one severe obesity-related comorbidity, or with a BMI ≥ 40 kg/m2, and who are willing to take 2 capsules of Hafnia alvei HA4597™ probiotic supplements (equivalent to 5 × 107 CFU) vs. placebo per day for 90 days are included in this study. Assessments are carried out at baseline, 3, 6, 9, and 12 months after the surgery. Loss of weight in excess and glycated haemoglobin are considered primary outcomes. In addition, changes in other metabolic and inflammatory outcomes, gut microbiota composition and metabolites, as well as gastrointestinal quality of life are also being assessed during the trial. DISCUSSION: The evidence obtained in this study will provide relevant information regarding the profile of the intestinal microbiota of individuals with severe obesity and the identification of the risk/benefit ratio of the use of Hafnia alvei HA4597™ as an adjunctive treatment in the maintenance of metabolic and weight control one year after the surgical intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT05170867. Registered on 28 December 2021.

Long-term outcomes of laparoscopic sleeve gastrectomy in those with class I obesity: safety, efficacy, and quality of life.

BACKGROUND: Class I obesity carries significant morbidity and mortality risk similar to higher grades of obesity, and persons with class I obesity have a high risk of progression to class II and III obesity. While bariatric surgery has made strides in safety and efficacy, it remains inaccessible for persons with class I obesity (body mass index [BMI] of 30-35 kg/m2). OBJECTIVES: To assess safety, weight loss durability, co-morbidity resolution, and quality of life after laparoscopic sleeve gastrectomy (LSG) in persons with class I obesity. SETTING: Multidisciplinary medical center that specializes in obesity management. METHODS: A longitudinal prospective single-surgeon registry was queried for data pertaining to persons with class I obesity who underwent primary LSG. Primary endpoint was weight loss. Secondary endpoints included change in obesity-related co-morbidities, adverse events, and post hoc analysis of symptoms of gastroesophageal reflux disease (GERD) and Bariatric Analysis and Reporting Outcome System results. Follow-up was divided into short- (1-3 yr), intermediate- (4-7 yr), and long-term (8-12 yr). We evaluated percent excess weight loss (%EWL) using linear mixed models adjusting for age, sex, years since operation, and baseline BMI. Least-squares means estimates and 95% confidence intervals (CI) were generated. RESULTS: Of 13,863 bariatric procedures, a total of 1851 patients were included. Mean baseline BMI, age, and male:female ratio were 32.6 ± 2.1 kg/m2, 33.7 ± 9.2 years, and 1:5, respectively. Adjusted mean %EWL (95% CI) at short-, intermediate-, and long-term follow-up were 111% (95% CI, 91%-131%), 110% (95% CI, 89%-131%), and 141% (95% CI, 57%-225%), respectively. Of 195 patients with type 2 diabetes, 59% experienced complete remission, and of 168 patients with hypertension, 43% experienced complete remission. Being on oral antidiabetes medication was a significant predictor of sustained remission compared with being on insulin or combination therapy (P < .001). Sixty-nine patients had symptoms of GERD before surgery, which improved in 55 (79.7%). Thirty-three patients developed de novo symptoms of GERD. The average Bariatric Analysis and Reporting Outcome System score was 4.5 ± 1.7, with 83% of participants rating their quality of life after surgery as good, very good, or excellent. CONCLUSION: Those with class I obesity who undergo LSG experience normalization of weight, sustained remission of co-morbidity, and good quality of life without significant risk of morbidity or mortality.

Persistent post-bariatric-surgery hypoglycemia: A long-term follow-up reassessment.

BACKGROUND AND AIM: Post-bariatric-surgery hypoglycemia (PBH) is a serious complication of bariatric surgery (BS). In our previous study about three quarters of the patients developed PBH. However long-term follow-up data is lacking to determine whether this condition improves with time. The aim of the current study was to re-assess post-BS patients who participated in our previous study and determine whether there are changes in the frequency and/or severity of hypoglycemic events. METHODS AND RESULTS: Twenty-four post-BS, post Roux-en-Y gastric-bypass (RYGB = 10), post omega-loop gastric-bypass (OLGB = 9) and post sleeve-gastrectomy (SG = 5) individuals were reevaluated in a follow-up study 34.4 ± 4 months after their previous assessment and 67 ± 17 months since surgery. The evaluation included: a dietitian assessment, a questionnaire, meal-tolerance test (MTT) and a one-week masked continuous glucose monitoring (CGM). Hypoglycemia and severe hypoglycemia were defined by glucose levels ≤54 mg/dl and ≤40 mg/dl, respectively. Thirteen patients reported questionnaire meal-related complaints, mainly non-specific. During MTT, hypoglycemia occurred in 75% of the patients, and severe hypoglycemia in a third, but none was associated with specific complaints. During CGM, 66% of patients developed hypoglycemia and 37% had severe hypoglycemia. We did not observe significant improvements in hypoglycemic events compared to the previous assessment. Despite the high frequency of hypoglycemia, it did not necessitate hospitalizations or lead to death. CONCLUSIONS: PBH did not resolve within long-term follow-up. Intriguingly, most patient were unaware of these events which can lead to underestimation by the medical staff. Further studies are needed to determine possible long term sequela of repeated hypoglycemia.

Prepregnancy Roux-en-Y gastric bypass vs sleeve gastrectomy: a systematic review, pairwise, and network meta-analysis of obstetrical and neonatal outcomes.

OBJECTIVE: This study aimed to systematically investigate a wide range of obstetrical and neonatal outcomes with respect to 2 types of prepregnancy bariatric surgery, Roux-en-Y gastric bypass and sleeve gastrectomy, through: (1) providing a meta-analysis of the effect of bariatric surgery (Roux-en-Y gastric bypass vs no surgery and, separately, sleeve gastrectomy vs no surgery) on adverse obstetrical and neonatal outcomes, and (2) comparing the relative benefit of Roux-en-Y gastric bypass vs sleeve gastrectomy using both conventional and network meta-analysis. DATA SOURCES: We searched PubMed, Scopus, and Embase systematically from inception up to April 30, 2021. ELIGIBILITY CRITERIA: Studies reporting on pregnancies' obstetrical and neonatal outcomes with respect to 2 types of prepregnancy bariatric surgery-Roux-en-Y gastric bypass and sleeve gastrectomy-were included. The included studies either indirectly compared between the procedure and controls or directly compared between the 2 procedures. METHODS: We performed a systematic review followed by pairwise and network meta-analysis in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In the pairwise analysis, multiple obstetrical and neonatal outcomes were tabulated and compared between 3 groups: (1) Roux-en-Y gastric bypass vs controls, (2) sleeve gastrectomy vs controls, and (3) Roux-en-Y gastric bypass vs sleeve gastrectomy. Primary outcomes included small for gestational age, large for gestational age, gestational hypertension/preeclampsia, and gestational diabetes mellitus. Secondary outcomes included preterm birth, anemia, cesarean delivery, and biochemical profile. The random-effects model was used to pool the mean differences or odds ratios and the corresponding 95% confidence intervals. Heterogeneity was assessed using the I2 value. The Newcastle-Ottawa scale was used to assess individual study quality. To resolve inconclusive findings and to rank current treatments, network meta-analysis was conducted for the primary outcomes. Quality of evidence was assessed with the Confidence in Network Meta-Analysis approach and the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) tool within the summary of findings table. RESULTS: A total of 20 studies were included, reporting on 40,108 pregnancies, of which 5194 underwent Roux-en-Y gastric bypass, 405 underwent sleeve gastrectomy, and 34,509 were controls. Compared with controls, Roux-en-Y gastric bypass increased the risk of small for gestational age infants (odds ratio, 2.56; 95% confidence interval, 1.77-3.70; I2, 29.1%; P<.00001), decreased the risk of large for gestational age infants (odds ratio, 0.25; 95% confidence interval, 0.18-0.35; I2, 0%; P<.00001), decreased gestational hypertension/preeclampsia (odds ratio, 0.54; 95% confidence interval, 0.30-0.97; I2, 26.8%; P=.04), decreased gestational diabetes mellitus (odds ratio, 0.43; 95% confidence interval, 0.23-0.81; I2, 32%; P=.008), increased maternal anemia (odds ratio, 2.70; 95% confidence interval, 1.53-4.79; I2, 40.5%; P<.001), increased neonatal intensive care unit admission (odds ratio, 1.36; 95% confidence interval, 1.04-1.77; I2, 0%; P=.02), and decreased mean gestational weight gain (mean difference, -3.37 kg; 95% confidence interval, -5.62 to -1.11; I2, 65.3%; P=.003). Only 3 studies compared sleeve gastrectomy with controls, and found no significant differences in primary outcomes or in mean gestational weight gain. The network meta-analysis showed that Roux-en-Y gastric bypass (malabsorptive procedure) resulted in greater decrease of large for gestational age, gestational hypertension/preeclampsia, and gestational diabetes mellitus, and a greater increase in small for gestational age infants when compared with sleeve gastrectomy (restrictive procedure). However, the small number of studies, small number of sleeve gastrectomy patients, limited outcomes, and data heterogeneity resulted in low-to-moderate network GRADE of evidence. CONCLUSION: This network meta-analysis showed that Roux-en-Y gastric bypass, compared with sleeve gastrectomy, resulted in greater decrease in large for gestational age, gestational hypertension/preeclampsia, and gestational diabetes mellitus, but in greater increase in small for gestational age infants. Certainty of evidence in the network meta-analysis was of a low-to-moderate GRADE. Evidence is still lacking for periconception biochemical profile, congenital malformations, and reproductive health outcomes for both interventions; thus, future well-designed prospective studies are needed to further characterize these outcomes.

Anaemia in patients with self-reported use of iron supplements in the BAriatric surgery SUbstitution and nutrition study: A prospective cohort study.

BACKGROUND AND AIMS: After bariatric surgery, micronutrient deficiencies may lead to anaemia. To prevent post-operative deficiencies, patients are recommended lifelong micronutrient supplementation. Studies investigating the effectiveness of supplementation to prevent anaemia after bariatric surgery are scarce. This study aimed to investigate the relationship between nutritional deficiencies and anaemia in patients who report use of supplementation two years after bariatric surgery versus patients who do not. METHODS AND RESULTS: Obese (BMI≥35 kg/m2) individuals (n = 971) were recruited at Sahlgrenska University Hospital in Gothenburg, Sweden between 2015 and 2017. The interventions were Roux-en-Y gastric bypass (RYGB), n = 382, sleeve gastrectomy (SG), n = 201, or medical treatment (MT), n = 388. Blood samples and self-reported data on supplements were collected at baseline and two years post treatment. Anaemia was defined as haemoglobin <120 g/L for females and <130 g/L for males. Standard statistical methods, including a logistic regression model and a machine learning algorithm, were used to analyse data. The frequency of anaemia increased from baseline in patients treated with RYGB (3·0% vs 10·5%; p < 0·05). Neither iron-dependent biochemistry nor frequency of anaemia differed between participants who reported use of iron supplements and those who did not at the two-year follow-up. Low preoperative level of haemoglobin and high postoperative percent excessive BMI loss increased the predicted probability of anaemia two years after surgery. CONCLUSION: The results from this study indicate that iron deficiency or anaemia may not be prevented by substitutional treatment per current guidelines after bariatric surgery and highlights there is reason to ensure adequate preoperative micronutrient levels. TRIAL REGISTRATION: March 03, 2015; NCT03152617.

[Non-surgical treatment of staple-line suture leakage after redo sleeve gastrectomy]. / Endoskopicheskoe klipirovanie nesostoyatel'nosti linii steplernogo shva posle povtornoi prodol'noi rezektsii zheludka.

Redo bariatric procedures are common. However, redo sleeve gastrectomy is not a frequent case of repeated bariatric surgery and can be performed rather as a necessary measure in difficult intraoperative conditions. We report a patient who underwent laparoscopic adjustable gastric band placement, its blockage and surgical removal, sleeve gastrectomy and redo sleeve gastrectomy. After that, staple-line suture failure developed that required endoscopic clipping.

Short-term neonatal outcomes of pregnancies complicated by maternal obesity.

BACKGROUND: Maternal obesity complicates a high number of pregnancies. The degree to which neonatal outcomes are adversely affected is unclear. OBJECTIVE: This study aimed to evaluate neonatal outcomes of pregnancies complicated by maternal obesity. STUDY DESIGN: This study was a secondary analysis of a cohort of deliveries occurring on randomly selected days at 25 hospitals from 2008 to 2011. Data were collected by certified abstractors. This analysis included singleton deliveries between 24 and 42 weeks of gestation. Body mass index was calculated on the basis of maternal height and most recent weight before delivery. Normal and overweight (reference group; body mass index, 18.5-29.9 kg/m2), obese (body mass index, 30.0-39.9 kg/m2), morbidly obese (body mass index, 40.0-49.9 kg/m2), and super morbidly obese (body mass index, ≥50 kg/m2) patients were compared. Patients in the reference group were matched in a 1:1 ratio with those in all other groups with obesity using the baseline characteristics of age, race and ethnicity, previous cesarean delivery, preexisting diabetes mellitus, chronic hypertension, parity, cigarette use, and insurance status. The primary outcome was composite neonatal morbidity, including fetal or neonatal death, hypoxic-ischemic encephalopathy, respiratory distress syndrome, intraventricular hemorrhage grade 3 or 4, necrotizing enterocolitis, sepsis, birth injury, seizures, or ventilator use. We used a modified Poisson regression to examine the associations between body mass index and composite neonatal outcome. Preterm delivery at <37 weeks of gestation and the presence of maternal preeclampsia or eclampsia were included in the final model because of their known associations with neonatal outcomes. RESULTS: Overall, 52,162 patients and their neonates were included after propensity score matching. Of these, 21,704 (41.6%) were obese, 3787 (7.3%) were morbidly obese, and 590 (1.1%) were super morbidly obese. A total of 2103 neonates (4.0%) had the composite outcome. Neonates born to pregnant people with morbid obesity had a 33% increased risk of composite neonatal morbidity compared with those in the reference group (adjusted odds ratio, 1.33; 95% confidence interval, 1.17-1.52), but no significant association was observed for persons with obesity (adjusted odds ratio, 1.05; 95% confidence interval, 0.97-1.14) or with super morbid obesity (adjusted odds ratio, 1.18; 95% confidence interval, 0.86-1.64). CONCLUSION: Compared with the reference group, gravidas with morbid obesity were at higher risk of composite neonatal morbidity.