Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery最新文献

Background: Less invasive endoscopic bariatric procedures have become established for the management of obesity disease, and the evidence supporting their impact on future bariatric surgery are limited in literature.

Objectives: The purpose of our study was to assess the technical aspects and early complication rate (within 30 days) of revisional bariatric surgery following an endoscopic sleeve gastroplasty (ESG).

Setting: Private hospital, France.

Methods: From January 2019 to December 2024, all consecutive patients who underwent revisional surgery following ESG were retrospectively reviewed. Data on patient demographic characteristics, case history, intraoperative findings, technique, and adverse events were reviewed.

Results: Fifty-eight patients (51 women, 87.9%; mean age 37.2 years [20-63]; mean body mass index 37.4 ± 4.3) underwent bariatric surgery after a previous ESG, including 37 laparoscopic sleeve gastrectomy (63.8%) and 21 Roux-en-Y gastric bypass (36.2%). The preoperative upper endoscopy analyzed for 42 patients found a complete undo of plication in 19 cases (45.2%), some cinches with the stitch in place in 17 cases (40.5%), and an intact plication in 6 cases (10.3%). Different intraoperative additional techniques were used in 39 cases: fluoroscopic control in 28 cases, intraoperative endoscopy in 6 cases, or opening of the greater curvature in 5 cases. There were 4 intraoperative incidents and 2 postoperative adverse events (1 bleeding; 1 leak). No conversion to open surgery and no mortality was recorded.

Conclusions: The revisional bariatric surgery following ESG is safe, but several technical points are important, and the team should be familiar with additional needed tools. Preoperative endoscopy is mandatory, but the endoscopic removal of anchors is not necessary.

Background: Re-sleeve gastrectomy (ReSG) has emerged as a revisional option for patients with inadequate weight loss or weight regain after primary sleeve gastrectomy (SG). Despite increasing utilization, its role remains controversial due to limited data on outcomes and safety.

Objectives: To evaluate weight loss outcomes, safety, and impact on gastroesophageal reflux disease (GERD) in patients undergoing ReSG after SG.

Setting: High-volume tertiary bariatric surgery center in the United States.

Methods: A retrospective review was performed of patients who underwent ReSG between 2017 and 2023 for weight regain or insufficient weight loss following SG, with radiographic and/or endoscopic evidence of sleeve dilation. Data collected included demographics, comorbidities, perioperative outcomes, complications, and weight loss. Primary outcomes were percentage of excess weight loss (%EWL) and percentage of total weight loss (%TWL) at 1-, 2-, and 3-year follow-up. Secondary outcomes included 30-day morbidity, GERD symptoms, and medication use.

Results: A total of 101 patients underwent ReSG. Thirty-day outcomes were available for all patients. After excluding early conversions, 95 individuals were included in the long-term follow-up. The mean operative time was 96.5 minutes, with a mean length of stay of 1.7 day. The 30-day readmission, reoperation, and complication rates were 9.9% (10), 7.9% (8), and 7.9% (8), respectively. Staple line leak occurred in 5.9% (6) of patients within 30 days of surgery, with most managed surgically. Three patients had early conversion due to staple line leak (2) or severe gastric stenosis (1). No mortalities occurred. Although GERD medication use significantly increased after ReSG, reflux symptoms were well controlled, and an initial decline in GERD symptoms was observed. BMI significantly decreased over time compared to baseline SG and ReSG (P < .05). Of the patients eligible for long-term follow-up, 84.6% (77/91), 78.8% (41/52), and 71.4% (20/28) had available data at 1, 2, and 3 years, respectively. Mean %EWL was 63.7%, 61.4%, and 62.8%; mean %TWL was 31.0%, 30.3%, and 30.9%.

Conclusions: ReSG is a safe and effective revisional procedure after SG for weight recurrence or insufficient weight loss, offering sustained weight loss and symptom improvement with acceptable morbidity.

Background: Metabolic and bariatric surgery (MBS) is an effective treatment for severe obesity. Prior research suggests a volume-outcome relationship, where higher hospital volumes correlate with improved patient safety. However, current accreditation standards may not reflect contemporary practice.

Objectives: To evaluate the impact of hospital volume on postoperative complications, as measured by Patient Safety Indicators (PSI-90), and mortality following bariatric surgery.

Setting: Nationwide Readmissions Database (NRD) from 2018 to 2020, representing 266,743 procedures across 1947 U S. hospitals.

Methods: Bariatric procedures (sleeve gastrectomy (SG), gastric bypass (GP), and duodenal switch (DS)) were categorized into low-, medium-, and high-volume hospitals based on tertiles of case volume. Risk-adjusted odds ratios (ORs) for PSI-90 complications and mortality were compared using high-volume centers as the reference.

Results: Medium-volume centers had significantly increased risk of PSI-90 complications for SG (OR 1.56, P < .001) and DS (OR 2.16, P = .035) compared to high-volume hospitals. No significant difference was found between low- and high-volume hospitals, suggesting patient selection bias at low-volume centers. GP outcomes did not significantly vary across volume tiers.

Conclusions: Higher hospital volume was associated with reduced postoperative complications for SG and DS. The increased complication risk in medium-volume centers suggests the need to reassess accreditation volume thresholds. Future policies should ensure standards align with evolving bariatric surgical practices to optimize patient outcomes.

Background: Research on changes in cannabis use prevalence from pre- to postmetabolic and bariatric surgery (MBS) is limited.

Objectives: To assess the change in legal cannabis use prevalence from pre-to post-MBS and the association between postoperative alcohol and cannabis use.

Setting: Single Michigan health system.

Methods: Patients who received MBS between 2018 and 2021 were invited to participate. The analytic sample included 612 participants who completed online surveys regarding cannabis, alcohol, and other substance use, psychiatric symptoms, and demographic information.

Results: Findings indicate a 52.4% relative increase in cannabis use prevalence from pre-to post-MBS (P = .0001). Specifically, 16% of participants reported postoperative cannabis use of which 45.9% were new initiates. Among initiates, 11.8% screened positive for hazardous cannabis use while 19.2% who used cannabis pre- and post-MBS screened positive for hazardous cannabis use. Of 61.9% participants who reported past year alcohol use, 41.4% screened positive for hazardous alcohol use. Those who screened positive were more likely to initiate cannabis use post-MBS (odds ratio [OR]_adj = 2.8; 95% CI: 1.4, 5.4) and more likely to persist cannabis use post-operatively (OR_adj = 3.0; 95% CI: 1.6, 5.8).

Conclusions: Cannabis use initiation post-MBS is not uncommon. The increase in cannabis use prevalence might be explained by its use as a coping mechanism and cannabis legalization, though most participants underwent MBS after legalization. Results suggest a significant association between past year hazardous alcohol use and higher odds of persistent and new initiate post-MBS cannabis use. MBS programs might consider monitoring patients for cannabis use, particularly among patients using alcohol.

Background: Metabolic and bariatric surgery (MBS) preoperative evaluation involves a psychosocial assessment, but no formal guidelines dictate how these MBS psychosocial assessments are conducted. The Millon Behavioral Medicine Diagnostic (MBMD) is a broadband personality assessment increasingly used in MBS populations. In this study, we used the MBMD to assess the associations of coping styles, psychiatric indicators, stress moderators, treatment prognostics, and management guides on MBS postoperative weight loss outcomes.

Setting: University Hospital, United States.

Methods: Ninety-seven participants underwent MBS and preoperative MBMD evaluation at a single institution and were identified through retrospective record review. Preoperative MBMD scores were compared to surgical outcomes, which included reduction in postoperative body mass index (BMI) as compared to preoperative BMI at both 6 (n = 90) and 12 (n = 63) months post procedure. Associations were assessed using Pearson correlations and linear models.

Results: At 6 months, reduced BMI was positively correlated with increased Inhibited and Dejected coping styles, psychiatric indicators of Anxiety-Tension, treatment prognostics of Interventional Fragility, and management guides for Psychiatric Referral, and higher BMI was associated with increased Confident and Sociable scales. At 12 months, reduced BMI was positively correlated with higher Anxiety-Tension, Social Isolation, and Psychiatric Referral, and negatively correlated to the Confident scale. The Illness Apprehension scale was associated with improved BMI in the Sleeve Gastrectomy group only at 12 months.

Conclusions: We found several MBMD scales associated with weight loss following MBS. Given our study is exploratory and associations are unadjusted, these results should be interpreted as associations that can be further explored in future studies to validate these findings.

Background: Bariatric surgery (BS) and glucagon-like peptide-1- receptor agonists (GLP-1RAs) are established treatments for obesity and cardiovascular risk, but their comparative impact on clinical outcomes remains unclear.

Objectives: To compare long-term outcomes of BS versus GLP-1RA therapy in adults with obesity, focusing on mortality, major adverse cardiovascular events (MACE), and heart failure.

Setting: Multicenter observational studies using national and institutional databases.

Methods: PubMed, Embase, and Cochrane CENTRAL were searched for studies comparing bariatric surgery and GLP-1RAs reporting adjusted hazard ratios for mortality, MACE, or heart failure. Two reviewers independently performed screening and data extraction. Risk of bias was assessed with ROBINS-I, and random-effects meta-analysis was used. Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessed certainty of evidence.

Results: Five cohort studies (N = 39,569) were included. BS was associated with a 43% lower risk of mortality (hazard ratio [HR] .57, 95% CI .34-.95), 35% lower MACE risk (HR .65, 95% CI .51-.83), and 55% lower risk of heart failure (HR .45, 95% CI .39-.51). Per 1000 patients treated, absolute reductions were 25 deaths, 25 cardiovascular events, and 23 heart failure cases. Certainty ranged from low (MACE) to moderate (heart failure).

Conclusions: In this meta-analysis of observational studies, bariatric surgery was associated with lower risks of mortality and cardiovascular outcomes compared to GLP-1RA therapy in adults with obesity. These findings suggest potential differences in long-term effectiveness between treatment strategies, warranting further investigation in randomized controlled trials. Residual confounding and selection bias cannot be fully eliminated given the observational design of the included cohorts.

Background: The growing population of left ventricular assist device (LVAD) patients faces increasing obesity-related comorbidities, which can adversely impact heart transplant candidacy. As these patients live longer, metabolic and bariatric surgery may become necessary, yet safety outcomes remain underexplored.

Objective: This study evaluates safety and outcomes of primary bariatric procedures in LVAD patients using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.

Setting: MBSAQIP participating centers across the United States.

Methods: Using the 2023 MBSAQIP database, we analyzed primary laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) procedures. Patients were stratified by LVAD status. Primary outcomes were 30-day serious complications; secondary outcomes included length of stay, operative time, and postoperative complications.

Results: Of 180,544 patients undergoing bariatric procedures, 133 (.07%) had LVADs. LVAD patients were older (49.5 versus 43.0 years, P < .001), female (60.1% versus 39.8%, P < .0001), and had higher rates of hypertension (79.7% versus 43.6%, P < .001), diabetes (51.8% versus 23.6%, P < .001), and therapeutic anticoagulation (45.9% versus 3.0%, P < .001). Most underwent SG (73.7%). LVAD patients had longer operative times (105.3 versus 84.6 min, P < .001), higher serious complications (11.3% versus 2.5%, P < .001), bleeding (5.3% versus .8%, P < .001), readmission (13.5% versus 2.9%, P < .001), and length of stay (4.9 vs 1.2 days, P < .001). After adjustment, LVAD and RYGB remained independently associated with serious complications (odds ratio [OR] 2.83, 95% confidence interval [CI] 1.62-4.97, P < .001 and OR 1.71; 95% CI 1.60-1.83; P < .001).

Conclusion: Although LVAD patients face increased complications with bariatric surgery, this intervention remains essential for meeting transplant body mass index criteria. Careful patient selection and perioperative optimization are crucial, and further research is needed to improve outcomes in this high-risk population.

Obesity is a growing concern in pediatric populations, with severe obesity impacting 10% of adolescents in the United States. Children and Youth with Special Healthcare Needs (CYSHCN) and those with syndromic obesity face increased risks of comorbidities, including diabetes, cardiovascular disease, and obstructive sleep apnea. Traditional interventions, such as dietary and behavioral modification, are often ineffective in these groups. The American Academy of Pediatrics now recommends treating CYSHCN similarly neurotypical children with obesity, encouraging the use of antiobesity medications and metabolic and bariatric surgery (MBS) for adolescents aged 13 and older. This review examines the outcomes of MBS in pediatric populations with special considerations, focusing on CYSHCN, those with monogenic and syndromic forms of obesity, and preteen children (<13 years of age). Laparoscopic sleeve gastrectomy results in significant weight loss and improvement in obesity-related comorbidities, with similar outcomes between neurodiverse and neurotypical patients. Additionally, emerging data suggest that MBS in children under 13 can be safe and effective when performed at specialized centers. In patients with monogenic and syndromic forms of obesity, MBS may offer long-term benefits where pharmacotherapy falls short.

Background: Sixty percent of hospital expenses arise from operating room costs. We hypothesize there are considerable cost inefficiencies due to surgeon variability.

Objectives: To model the association between variability in disposable operative costs and patient outcomes in a high-volume bariatric surgery service line.

Setting: Large University Health care System.

Methods: Mixed-effects regression models assessed the association between disposable operating costs and robotic use, procedure type, patient factors, and surgeon effects. We also modeled whether increased costs translated to improved operative time (OT), prolonged length of stay (pLOS), readmissions, or reoperations.

Results: We studied 4067 gastric sleeve (SG) (34% robotic), 1375 gastric bypass (RYGB) (33% robotic), and 447 duodenal switch (BPD/DS) (68% robotic) procedures. Average model adjusted costs for laparoscopic and robotic cases: SG $3592 ± 28 and $4451 ± 3; for RYGB was $5370 ± 40 for $5457 ± 64; and for BPD/DS $3780 ± 53 $6367 ± 47; all respectively. Surgeon variability increased costs by up to ±59.4%. The model-adjusted difference in cost between the far outlier surgeons spanned $1827 for the SG, $2678 for the RYGB, and $3305 for the BPD/DS. The use of robotic platforms did not significantly affect readmission or reoperation rates. Higher costs were linked to longer OT (P < .001) and increased pLOS (P = .02). The surgeon had the most significant impact on cost compared to any other variable. Based on the least costly surgeons' costs (by platform and procedure), 25.4% of operative expenses are without measurable benefit.

Conclusions: Substantial surgeon-driven variability in disposable costs does not correlate with improved clinical outcomes, highlighting opportunities for value optimization.

Background: Marginal ulcers (MUs) are one of the most common late complications after gastric bypass. In France, the absence of reliable epidemiological data has precluded the formulation of recommendations concerning dosage or total duration of treatment and the establishment of an endoscopic monitoring strategy.

Objectives: The aim of this study was to describe the frequency and time to onset of MUs following gastric bypass surgery in a nationwide database and to assess risk factors for developing this complication.

Setting: We conducted a population-based study. Patients were included using the French Hospital Discharge Database.

Methods: All patients who underwent gastric bypass between January 2015 and December 2021 were included and followed up for 1 year. Ulcer diagnosis was based on upper gastrointestinal endoscopy (including day care) or revision surgery. Patients with undocumented clinical suspicion of ulcer were excluded.

Results: A total of 83,450 patients were included. The incidence of ulcers in the year following surgery was 2.11%, with 25% occurring in the first month. The significant factors identified in multivariable analysis were history of Helicobacter pylori infection (adjusted hazard ratio [aHR]: 1.25 [1.07-1.45]), men (aHR: 1.46 [1.31-1.63]), history of ulcers (aHR: 1.51 [1.16-1.97]), smoking (aHR: 1.91 [1.57-2.33]), and postoperative complications (aHR = 6.89 [6.22-7.61]). Increased body mass index and previous bariatric surgery appeared to be protective.

Conclusions: Among French adult patients who had gastric bypass surgery, 2.11% developed a MU within the first year postoperatively. History of bariatric surgery seems well accounted for. However, greater emphasis should be placed on smoking cessation and the consideration of postoperative complications that may arise during the follow-up period.