Single anastomosis duodenal switch versus Roux-en-Y gastric bypass in patients with BMI ≥ 50 kg/m2: a multi-centered comparative analysis.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) has consistently demonstrated excellent weight loss and comorbidity resolution. However, outcomes vary based on patient's BMI. Single anastomosis duodeno-ileostomy with sleeve (SADI-S) is a novel procedure with promising short-term results. The long-term outcomes of SADI-S in patients with BMI ≥ 50 kg/m2 are not well described. We aim to compare the safety and efficacy of SADI-S with RYGB in this patient population. METHODS: We performed a multicenter retrospective study of patients with a BMI ≥ 50 kg/m2 who underwent RYGB or SADI-S between 2008 and 2023. Patient demographics, peri- and post-operative characteristics were collected. Complication rates were reported at 6, 12, 24, and 60 months postoperatively. A multivariate linear regression was used to evaluate and compare weight loss outcomes between both procedures. RESULTS: A total of 968 patients (343 RYGB and 625 SADI-S; 68.3% female, age 42.9 ± 12.1 years; BMI 57.3 ± 6.7 kg/m2) with a mean follow-up of 3.6 ± 3.6 years were included. Patients who underwent RYGB were older, more likely to be female, and have a higher rate of sleep apnea (p < 0.001), hypertension (p = 0.015), dyslipidemia (p < 0.001), and type 2 diabetes (p = 0.016) at baseline. The rate of bariatric surgery-specific complications was lower after SADI-S compared to RYGB. We reported no bariatric surgery related deaths after 1 year following both procedures. SADI-S demonstrated statistically higher and sustained weight loss at each time interval compared to RYGB (p < 0.001) even after controlling for multiple confounders. Lastly, the rate of surgical non-responders was lower in the SADI-S cohort. CONCLUSIONS: In our cohort, SADI-S was associated with higher and sustained weight-loss results compared to RYGB. Comorbidity resolution was also higher after SADI-S. Both procedures demonstrate a similar safety profile. Further studies are required to validate the long-term safety of SADI-S compared to other bariatric procedures.

Reflux After Sleeve Gastrectomy: Safety and Effectiveness of Laparoscopic Ligamentum Teres Cardiopexy, a Single-Center Experience.

BACKGROUND: Obesity is a well-known risk factor for gastroesophageal reflux disease (GERD). Even though symptoms may be mitigated or resolved with the weight loss caused by sleeve gastrectomy (SG), it may be associated with higher incidences of postoperative GERD. Ligamentum teres cardiopexy (LTC) is an alternative to Roux-en-Y gastric bypass, the gold standard treatment for GERD. METHODS: This study was a retrospective single-center chart review, all patients in this cohort underwent LTC to treat refractory GERD at our institution. The option for LTC was presented after patients' refusal to undergo RYGB conversion. We collected baseline characteristics, standard demographics, pre-operative tests and imaging, and SG information, as well as intraoperative and perioperative data regarding LTC, and postoperative complications. RESULTS: Our cohort included 29 patients; most were Caucasian (44.8%) females (86.2%). The mean weight and BMI before LTC were 216.5 ± 39.3 lb and 36.1 ± 5.4 kg/m2, respectively. Mean total body-weight loss (TBWL) at 12 and 24 months were 28.7% ± 9.5% and 28.4% ± 12.4%, respectively. The mean interval between the index bariatric surgery and LTC was 59.9 ± 34.9 months, mean operative time was 67 ± 18.2 min, and median length of stay (LOS) was 1 day (IQR = 1-2 days). Twelve patients (57.1%) were able to discontinue antisecretory medications, while 9 (42.9%) still required them to remain asymptomatic. Mortality and reoperation rates were 0% and the incidence of complication was 19.4% (n = 6). CONCLUSIONS: LTC is a safe and effective surgical alternative to treat refractory GERD symptoms after SG.

Management of Malnutrition and Hepatic Impairment After Duodenal Switch.

BACKGROUND: Malnutrition and liver impairment after duodenal switch (DS) are possible and undesired complications, often conservatively treated. However, in specific cases, surgical revision may be necessary. This study aims to describe outcomes achieved by two bariatric surgery centers and address effectiveness and safety of revisional surgical procedures to resolve these complications. METHODS: A retrospective chart review was performed in two bariatric surgery centers from 2008 to 2022. Patients who required revisional surgery to treat malnutrition and/or liver impairment refractory to nutritional and total parenteral nutrition intervention (TPN) after duodenal switch were included. No comparisons were performed due to the descriptive nature of this study. RESULTS: Thirteen patients underwent revisional surgery, the mean age was 44.7, the 53.8% were females, and the mean preoperative BMI was 54.7 kg/m2; the mean time between DS and revisional procedure was 26.5 months, and 69.1% of patients were placed on TPN. One patient developed hepatic encephalopathy; one patient presented with ascites, pleural effusion, and renal insufficiency, undergoing reoperation after revisional procedure due to a perforated ileal loop. Mortality rate was 0%; all patients regained weight after the revisional procedure, and the mean total protein and albumin blood levels 12 months after surgery were 6.3 and 3.6 g/dl, respectively. CONCLUSIONS: While refractory malnutrition and/or liver failure are rare among patients post-DS, if underdiagnosed and untreated, this can lead to irreversible outcomes and death. All revisional procedures included in this study resulted in improvement of the nutritional status and reversal of liver impairment, with low complication rates.

Comparative multicenter analysis of sleeve gastrectomy, gastric bypass, and duodenal switch in patients with BMI ≥70kg/m2: a 2-year follow-up.

Patients undergoing metabolic and bariatric surgery (MBS) with body mass index (BMI) ≥ 70 kg/m2 are considered a high-risk group. There is limited literature to guide surgeons on the perioperative safety as well as the different procedural outcomes of MBS in this cohort. Our aim is to compare the safety profiles, early- and medium-term outcomes of sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and duodenal switch (DS) in patients with BMI ≥ 70 kg/m2. A total of 156 patients with BMI ≥ 70kg/m2 underwent MBS (SG = 40, RYGB = 40, and DS = 76). Mean baseline BMI was 75.5 kg/m2. Total weight loss (%TWL) at 24 months was highest in the DS group compared to RYGB (40.6% versus 33.8%, P value = .03) and SG (40.6% versus 28.5%, P value = .006). There was no significant difference in %TWL between RYGB and SG (33.8% versus 28.5%, P value = .20). The 30-day complication rates were similar [SG (7.5%), RYGB (10%), and DS (9.2%) (P value = 1.0)]. There was one reported leak (DS). The 30-day mortality was zero. MBS is safe and effective in patients with BMI ≥ 70 kg/m2. All procedures had comparable safety profiles and complication rates. While DS achieved the highest %TWL at 24 months, similar comorbidity resolution rates among the procedures attenuate its clinical significance.

Marginal Ulcer and Dumping Syndrome in Patients after Duodenal Switch: A Multi-Centered Study.

BACKGROUND: The current design of biliopancreatic diversion with duodenal switch (BPD/DS) and single anastomosis duodenal-ileal bypass with sleeve (SADI-S) emphasizes the importance of the pylorus' preservation to reduce the incidence of marginal ulcer (MU) and dumping. However, no institutional studies have yet reported data on their prevalence. We aimed to assess the incidence of MU and dumping after duodenal switch (DS) and identify the associative factors. METHODS: A multi-center review of patients who underwent BPD/DS or SADI-S between 2008 and 2022. Baseline demographics, symptoms, and management of both complications were collected. Fisher's exact test was used for categorical variables and the independent t-test for continuous variables. RESULTS: A total of 919 patients were included (74.6% female; age 42.5 years; BMI 54.6 kg/m2) with mean follow-up of 31.5 months. Eight patients (0.9%) developed MU and seven (0.8%) had dumping. Patients who developed MU were more likely to be using non-steroidal anti-inflammatory drugs (NSAID) (p = 0.006) and have a longer operation time (p = 0.047). Primary versus revisional surgery, and BDP/DS versus SADI-S were not associated with MU or dumping. CONCLUSIONS: The incidences of MU and dumping after DS were low. NSAID use and a longer operation time were associated with an increased risk of MU, whereas dumping was attributed to poor dietary habits.

Long-Term Outcomes of Sleeve Gastrectomy: Weight Recurrence and Surgical Non-responders.

INTRODUCTION: Sleeve gastrectomy (SG) is an effective procedure with remarkable weight loss and low complication rates. However, up to 30% of cases require revisional surgery in non-responders or patients who experience weight recurrence. We aim to report the rate of weight recurrence/non-responders (WR/NR) in patients who underwent SG and had more than 5 years of follow-up. METHODS: We performed a multicenter retrospective study of patients who underwent initial SG from 2008 to 2017. Patient demographics and weight loss outcomes up to 12 years after SG were collected. Surgical non-responders were defined as 20% weight regain compared to maximum weight loss. A chi-square test for categorical variables and a two-sample t-test for continuous variables were used. Data are summarized as mean ± standard deviation. RESULTS: From a total of 1263 patients, we included 339 patients (78% female, age 47.3 ± 11.2 years; baseline weight 125.8 ± 27.6 kg) with at least 5 years of follow-up (mean follow-up of 7.1 ± 1.8 years) (Table 1). Surgical non-response was demonstrated in 15.9% of patients (n=54) and 64.0% (n=217) had weight recurrence after SG (Fig. 1). There was a statistically significant difference in history of hypertension (p=0.046) and diabetes (p=0.032) as well as %TBWL at 1 year (p=0.005) and at longest follow-up (p<0.001) between patients who experienced WR/NR and those who did not. CONCLUSIONS: Only 20% of patients who underwent SG and followed up for more than 5 years were able to maintain appropriate weight loss.

Implementing novel modalities into an institutional enhanced recovery after bariatric surgery (ERABS) protocol.

INTRODUCTION: Enhanced recovery after bariatric surgery pathways are associated with improved postoperative outcomes. This study aims to assess efficacy and safety of three novel protocol contributions (transversus abdominis plane blocks, ketamine and fosaprepitant), as well as their impact on length of stay (LOS) and on postoperative complications. METHODS: Effectiveness and safety were retrospectively investigated in patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) over a 6-year period in a single institution. Group 1 patients were not exposed to any of our suggested interventions, whereas Group 2 were exposed to all of three. RESULTS: Between January 2015 and August 2021, 1480 patients underwent primary SG (77.6%) or RYGB (22.4%); of those, 1132 (76.5%) and 348 (23.5%) were in Groups 1 and 2, respectively. Mean BMI and age were 45.87 versus 43.65 kg/m2 and 45.53 versus 44.99 years in groups 1 and 2, respectively. Suggested interventions were associated with lower operative times (84.79 ± 24.21 vs. 80.78 ± 32.8 min, p = 0.025). In Group 2, the mean LOS decreased in 0.18 day (1.79 ± 1.04 vs. 1.60 ± 0.90; p = 0.004). Overall complication rates were 8% and 8.6% for groups 1 and 2, respectively; readmission rates were 5.7% (64 pts) vs. 7.2% (25 pts), p > 0.05. Reoperations were less prevalent in Group 2 (1.5% vs. 1.1%; p = 0.79). CONCLUSION: Focus on optimized pain management, allied to a superior PONV control, may be relevant contributors for a lower LOS without negative impacts in complications rates.

Impact of Emend on Perioperative Bariatric Surgery Antiemetic Utilization, Patient Satisfaction, and Costs.

PURPOSE: Postoperative nausea and vomiting (PONV) is one of the most common adverse effects of anesthesia and surgery, resulting in patient discomfort and dissatisfaction. Latest research has demonstrated the efficacy of NK-1 receptor antagonists in PONV management and its use in chemotherapy nausea prophylaxis. The authors of this article would like to provide evidence to support the use fosaprepitant, as monotherapy, in postoperative care, replacing a polypharmacological standard of care regimen. METHODS: This was a retrospective chart review of 400 patients who received standard of care antiemetic regimen or received fosaprepitant (No-Fosaprepitant vs. Fosaprepitant groups, respectively). The primary outcome of this study is to evaluate the impact of fosaprepitant (administered intravenously) on perioperative antiemetic use, treatment cost, and patient satisfaction. RESULTS: Total PONV medication cost decreased with the replacement of standard of care regimen for fosaprepitant, from 46.47±20.54 United States Dollars in the no-Fosaprepitant group to 25.69±14.84 United States Dollars in the Fosaprepitant group. There was a significant reduction in antiemetic doses between groups; 0.37±0.745 versus 7.61±5.202 for ondansetron ( P =0.001), 92±1.279 versus 2.21±2.399 for promethazine ( P =0.001), 0.25±0.685 versus 1.41±0.577 for scopolamine patch ( P =0.001), and 0.05±0.218 versus 1.14±0.398 for dexamethasone ( P =0.001). Patient satisfaction, measured by a questionnaire, was a 11.6% higher in the Fosaprepitant group. CONCLUSION: Fosaprepitant is a relevant alternative in preventing and treating PONV in patients who underwent bariatric/metabolic surgical procedures.

Impact of Perioperative Ketamine on Postoperative Bariatric Surgery Opioid Use and Length of Stay.

SETTINGS: Postoperative pain management is an ever-growing challenge with the rise of the opioid crisis. Ketamine is an NMDA channel blocker, considered an alternative to perioperative opioid use; small concentrations are safe. Objective: The primary objective of this study was to evaluate the impact of perioperative ketamine administration on postoperative opioid use and the length of hospital stay in bariatric patients. METHODS: Four hundred (366) charts were retrospectively reviewed; of those, 187 received ketamine and were placed in the Ketamine group, 179 received standard-of-care pain management and were part of the No-Ketamine group. Data was collected using medical databases from July 2020 to January 2021. RESULTS: A greater length of stay was recorded in the No-Ketamine group (45.67±20.6 hours) when compared with the Ketamine group (40.6±14.3 hours); P <0.05. The Ketamine group had a mean MME of 17.5±16.5 whereas the No-Ketamine had a mean MME of 22.3±17.7, P <0.05. CONCLUSIONS: Ketamine may be a feasible alternative to reduce opioid use and hospital length of stay. We believe that ketamine can be an important contribution to ERABS pathways, being responsible for improved outcomes after bariatric/metabolic surgical procedures.

Impact on Mid-Term Health-Related Quality of Life after Duodenal Switch: a Systematic Review and Meta-Analysis.

PURPOSE: Metabolic and bariatric surgery (MBS) could improve health-related quality of life (HrQoL) for selected patients with obesity. Although biliopancreatic diversion with duodenal switch (BPD-DS) is regarded as the most effective MBS technique in achieving weight loss, no consensus has been reached on the impact of BPD-DS on HrQoL. The aim of this meta-analysis is to assess the mid-term HrQoL after BPD-DS in the management of patients with obesity. MATERIALS AND METHODS: Cochrane, Embase, APA PsycInfo, PubMed, Scopus, and Web of Science were searched for articles from their inception to August 2022 by two independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) system. The review was registered prospectively with PROSPERO (CRD42022352073). RESULTS: From 223 studies screened, twelve studies met the eligibility criteria, with a total of 937 patients with obesity undergoing BPD-DS. Minimal clinically important differences (MCID) were reached for the physical component summary score (PCS) of the 36-Item Short-Form Health Survey (SF-36) (MD = 13.4) and impact of weight on quality of life (IWQOL)-Lite total score (MD = 48.7). Similarly, MCIDs were attained in the Laval questionnaire and SF-36 subscales. CONCLUSION: Our meta-analysis demonstrated an improvement in mid-term HrQoL after BPD-DS. Despite the promising trends demonstrated in this meta-analysis, further studies with large sample sizes are needed to evaluate the impact of HrQoL on patients with obesity after BPD-DS.

Sleeve-Dor Fundoplication - An Innovative Surgical Technique to Avoid the Epidemic Long Term de Novo Gastroesophageal Reflux and Barrett´s Esophagus After Sleeve Gastrectomy for Obesity.

BACKGROUND: Sleeve gastrectomy (SG) in current literature showed an increased risk of "de novo" gastroesophageal reflux disease (GERD) and increased risk for Barrett's esophagus in longer follow-up series, with a possibility of esophageal adenocarcinoma in this population. Adding primarily an anterior Dor Fundoplication to SG (Sleeve-Dor) may protect the patient for future and can potentially avoid these chronic complications for patients with obesity. METHODOLOGY: A standard SG is performed laparoscopically, and a small redundance of the fundus is maintained as a wrap, and this will be fixed to the right crura without dissection of the anatomy of the hiatus. The resulted anterior 180° Dor fundoplication is usually sufficient to relieve or to avoid reflux symptomatic. DISCUSSION: Based on our preliminary and literature experiences, the SG with anterior Dor fundoplication (Sleeve-Dor) procedure could provide favorable safety profile, satisfactory reflux control and good bariatric outcomes. The complication rate is lower compared to published for Nissen Sleeve or Sleeve-Rossetti technique, with no leaks or major complications recorded to date. Sleeve-Dor procedure may be a potential primary and standard surgery for morbidly obese patients, especially for patients with preoperative GERD symptoms without major findings at endoscopy.

Single- Versus Double-Anastomosis Duodenal Switch: Outcomes Stratified by Preoperative BMI.

PURPOSE: Describe and analyze the safety and weight loss performance of biliopancreatic diversion and duodenal switch (BPD-DS) and single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S), verifying any possible superiority according to preoperative BMI. METHODS: Retrospective review of patients who underwent primary SADI-S or BPD-DS in three bariatric centers. Study groups were further stratified according to preoperative BMI (subgroup 1: BMI < 50; subgroup 2: 50 ≤ BMI < 55; subgroup 3: BMI ≥ 55). RESULTS: Four hundred and sixty patients underwent BPD-DS (n = 220) or SADI-S (n = 240). The mean LOS was 3.48 ± 3.7 and 3.13 ± 2.3 days for BPD-DS and SADI-S respectively (p = 0.235). The mean operative time was shorter in the SADI-S group (167.25 ± 33.6 vs 140.85 ± 56.7 min) (p < 0.00). The mean %EWL was 44.2, 62.4, and 69.4 for the BPD-DS group and 48.4, 64.5, and 67.1 for the SADI-S group at 6, 12, and 24 months respectively. The mean %TBWL was 25, 35.9, and 40.3 for the BPD-DS group, and 26.2, 35, and 36.9 for the SADI-S group at 6, 12, and 24 months respectively. Overall complication rates were comparable between BPD-DS and SADI-S groups (14% vs 18%) (p = 0.219). SADI-S showed greater emergency department visits (17% vs 7%) (p = 0.005); similar readmission rates (6% vs 7%) (p = 0.80); similar reoperation rates (3% vs 7%) (p = 0.102); and similar mortality rate (0.9% vs 0.4%), after BPD-DS and SADI-S respectively. CONCLUSION: BPD-DS achieved greater %TBWL at 2 years, but no superiority was perceived among study subgroups. SADI-S and BPD-DS showed similar overall complication rates.

Duodenal Switch Conversion in Non-responders or Weight Recurrence Patients.

INTRODUCTION: Several modalities have been proposed to tackle insufficient weight loss and weight regain after bariatric surgery; we aimed to evaluate efficacy and safety of duodenal switch conversion as a salvage procedure. MATERIAL AND METHODS: Data from patients who underwent duodenal switch conversions (n = 50) were retrospectively studied. Excess weight loss % and total body weight loss % were compared between primary procedure and duodenal switch conversion. Overall complication, emergency department visits, readmissions, reoperation, and mortality rates were described, analyzed, and compared to the current literature. RESULTS: Every excess weight loss % and total body weight loss % comparison at 6, 12, and 24 months, demonstrated a statistically significant superiority in weight loss after duodenal switch conversion (p < 0.05). The mean operative time of adjustable gastric band, sleeve gastrectomy, Roux-en-Y gastric bypass (1 and 2 stages) conversions to duodenal switch were 208, 146, 187, and 152 min, respectively, while the mean length of stay was 3.38 days. No statistically significant differences were perceived regarding the primary procedure. The overall complication rate was 18% (9 patients); 3 patients (6%) had 1 emergency department visit; readmissions accounted for 12% of cases (6 patients); the reoperation rate was 10% (5 patients); no fatal outcomes were recorded. CONCLUSION: Duodenal switch conversions are an effective salvage procedure for insufficient weight loss and/or weight regain after adjustable gastric band, sleeve gastrectomy, and Roux-en-Y gastric bypass; it is also safe, associated to low readmission, reoperation, and mortality rates.

Analysis of the sharpening effect in gyromagnetic nonlinear transmission lines using the unidimensional form of the Landau-Lifshitz-Gilbert equation.

Continuous nonlinear transmission lines (NLTLs), also known as gyromagnetic lines, consist of ferrite-based magnetic cores biased by an external magnetic field. Over the past years, many analytical and experimental studies have predicted the rise time reduction of the input pulse to the range of a few nanoseconds or even hundreds of ps experimentally observed in such gyromagnetic lines. This effect, known as pulse sharpening, is investigated in this paper built on a model based on a periodic structure of inductive-capacitive cells in series with magnetization-driven voltage sources expressed by the one-dimensional form (1D) of the Landau-Lifshitz-Gilbert (LLG) gyromagnetic equation. We explore the model through parametric study under various input-pulse parameters to understand the physics behind the ferrimagnetic material responses. Moreover, the numerical results obtained from computational simulations using Mathematica (v. 12.1) show how the line parameters (input voltage, damping constant, saturation magnetization, and length) affect the sharpening effect, which is quantified by the switching time. Our results on ferrite-loaded coaxial lines have confirmed many results found in the literature. We validated with a good agreement the proposed model with the result obtained by Dolan in 1993 using the same 1D form of the LLG equation, thus showing that the model proposed here is suitable to quantify the sharpening effect produced by a gyromagnetic NLTL.

Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): a prospective, multicentre, randomised trial.

BACKGROUND: Endoscopic sleeve gastroplasty (ESG) is an endolumenal, organ-sparing therapy for obesity, with wide global adoption. We aimed to explore the efficacy and safety of ESG with lifestyle modifications compared with lifestyle modifications alone. METHODS: We conducted a randomised clinical trial at nine US centres, enrolling individuals aged 21-65 years with class 1 or class 2 obesity and who agreed to comply with lifelong dietary restrictions. Participants were randomly assigned (1:1·5; with stratified permuted blocks) to ESG with lifestyle modifications (ESG group) or lifestyle modifications alone (control group), with potential retightening or crossover to ESG, respectively, at 52 weeks. Lifestyle modifications included a low-calorie diet and physical activity. Participants in the primary ESG group were followed up for 104 weeks. The primary endpoint at 52 weeks was the percentage of excess weight loss (EWL), with excess weight being that over the ideal weight for a BMI of 25 kg/m2. Secondary endpoints included change in metabolic comorbidities between the groups. We used multiple imputed intention-to-treat analyses with mixed-effects models. Our analyses were done on a per-protocol basis and a modified intention-to-treat basis. The safety population was defined as all participants who underwent ESG (both primary and crossover ESG) up to 52 weeks. FINDINGS: Between Dec 20, 2017, and June 14, 2019, 209 participants were randomly assigned to ESG (n=85) or to control (n=124). At 52 weeks, the primary endpoint of mean percentage of EWL was 49·2% (SD 32·0) for the ESG group and 3·2% (18·6) for the control group (p<0·0001). Mean percentage of total bodyweight loss was 13·6% (8·0) for the ESG group and 0·8% (5·0) for the control group (p<0·0001), and 59 (77%) of 77 participants in the ESG group reached 25% or more of EWL at 52 weeks compared with 13 (12%) of 110 in the control group (p<0·0001). At 52 weeks, 41 (80%) of 51 participants in the ESG group had an improvement in one or more metabolic comorbidities, whereas six (12%) worsened, compared with the control group in which 28 (45%) of 62 participants had similar improvement, whereas 31 (50%) worsened. At 104 weeks, 41 (68%) of 60 participants in the ESG group maintained 25% or more of EWL. ESG-related serious adverse events occurred in three (2%) of 131 participants, without mortality or need for intensive care or surgery. INTERPRETATION: ESG is a safe intervention that resulted in significant weight loss, maintained at 104 weeks, with important improvements in metabolic comorbidities. ESG should be considered as a synergistic weight loss intervention for patients with class 1 or class 2 obesity. This trial is registered with ClinicalTrials.gov, NCT03406975. FUNDING: Apollo Endosurgery, Mayo Clinic.

ANTI-REFLUX PROCEDURES AFTER ROUX-EN-Y GASTRIC BYPASS.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) has been the choice of bariatric procedure for patients with symptomatic reflux - and is known to be effective in reducing the need for anti-reflux medication postoperatively. However, a small number of RYGB patients can still develop severe reflux symptoms that require a surgical intervention. AIM: To examine and describe the patient population that requires an anti-reflux procedure after RYGB evaluating demographics, characteristics, symptoms and diagnosis. METHODS: A retrospective chart review was performed on 32 patients who underwent a hiatal hernia repair and/or Nissen fundoplication after RYGB Jul 1st, 2014 and Dec 31st, 2019. Patients were identified using the MBSAQIP database and their electronic medical records were reviewed. RESULTS: Most patients were female (n=29, 90.6%). The mean age was 52.8 years and the mean body mass index (BMI) was 34.1 kg/m2 at the time of anti-reflux procedure. Patients underwent the anti-reflux procedure at a mean of 7.9 years after the RYGB procedure. The mean percentage of excess BMI loss during the time between RYGB and anti-reflux procedure was 63.4%. CONCLUSIONS: Female patients with a significant weight loss may develop a severe reflux symptoms years after RYGB. Complaints of reflux after RYGB should not be overlooked. Careful follow-up and appropriate treatment (including surgical intervention) is needed for this population.

To oversew or not to oversew in robotic sleeve gastrectomy: a case against oversewing the staple line.

BACKGROUND: The benefits of oversewing the staple lines during laparoscopic sleeve gastrectomy have been controversial. No study examined the benefit of oversewing the staple lines in robotic sleeve gastrectomy (RSG). This retrospective study aims to examine the difference in immediate postoperative complications, readmissions, reoperations, and emergency room visits between RSG patients with and without oversewn staple lines at a single, large-volume, bariatric center. METHODS: A retrospective chart review was conducted on 623 patients who underwent RSG between November 1, 2017, and November 1, 2019. Of these, 316 had their staple line oversewn between November 1, 2017, and November 12, 2018, and 307 did not have their staple line oversewn between November 13, 2018, and November 1, 2019. RESULTS: A total of 623 patients underwent RSG, of which 50.7% (n = 316) had their staple line oversewn. The mean length of hospital stay was similar between the two groups. However, the mean operative time was significantly longer in the "oversew" group than "no oversew" group by 7.4 minutes (p < 0.001). Readmission, reoperation, and intervention rates during the 30-day postoperative period were similar between the two groups. However, the percentage of patients requiring outpatient emergency room visits during the 30 days after RSG was significantly higher in the "oversew" group than that of the "no oversew" group. CONCLUSIONS: No significant difference in major complications was found between RSG patients with and without oversewn staple lines. Oversewing of the staple line may be associated with increased emergency room visits.

Brazilian Consensus on Endoscopic Sleeve Gastroplasty.

PURPOSE: Bariatric endoscopy is a less invasive approach for obesity management, with better efficacy than pharmacological treatment and low morbidity. Endoscopic sleeve gastroplasty (ESG) is the remodeling of the stomach using a suturing device showing technical feasibility, safety, and sustained weight loss. With growing numbers of procedures worldwide, there is a need to standardize the procedure. MATERIALS AND METHODS: A consensus meeting was held in São Caetano do Sul-SP, Brazil, in June 2019, bringing together 47 Brazilian endoscopists with experience in ESG from all regions of the country. Topics on indications and contraindications of the procedure, pre-procedure evaluation and multidisciplinary follow-up, technique and post-procedure follow-up, and training requirements were discussed. An electronic voting was carried, and a consensus was defined as ≥ 70% agreement. RESULTS: The panel's experience consisted of 1828 procedures, with a mean percentage total body weight loss (TBWL) of 18.2% in 1 year. Adverse events happened in 0.8% of the cases, the most common being hematemesis. The selected experts discussed and reached a consensus on several questions concerning patient selection, contraindications for the procedure, technical details such as patient preparation, procedure technique, and patient follow-up. CONCLUSIONS: This consensus establishes practical guidelines for performance of ESG. The experience of 1828 procedures shows the expertise of the selected specialists participating in this consensus statement. The group's experience has a satisfactory weight loss with low adverse events rate. The main points discussed in this paper may serve as a guide for endoscopists performing ESG. Practical recommendations and technique standardization are described.

Anti-reflux procedures after roux-en-y gastric bypass / Procedimentos anti-refluxo após bypass gástrico em y-de roux

ABSTRACT Background: Roux-en-Y gastric bypass (RYGB) has been the choice of bariatric procedure for patients with symptomatic reflux - and is known to be effective in reducing the need for anti-reflux medication postoperatively. However, a small number of RYGB patients can still develop severe reflux symptoms that require a surgical intervention. Aim: To examine and describe the patient population that requires an anti-reflux procedure after RYGB evaluating demographics, characteristics, symptoms and diagnosis Methods: A retrospective chart review was performed on 32 patients who underwent a hiatal hernia repair and/or Nissen fundoplication after RYGB Jul 1st, 2014 and Dec 31st, 2019. Patients were identified using the MBSAQIP database and their electronic medical records were reviewed. Results: Most patients were female (n=29, 90.6%). The mean age was 52.8 years and the mean body mass index (BMI) was 34.1 kg/m2 at the time of anti-reflux procedure. Patients underwent the anti-reflux procedure at a mean of 7.9 years after the RYGB procedure. The mean percentage of excess BMI loss during the time between RYGB and anti-reflux procedure was 63.4%. Conclusions: Female patients with a significant weight loss may develop a severe reflux symptoms years after RYGB. Complaints of reflux after RYGB should not be overlooked. Careful follow-up and appropriate treatment (including surgical intervention) is needed for this population.

RESUMO Racional: O bypass gástrico em Y-de-Roux (RYGB) tem sido o procedimento bariátrico de escolha para pacientes com refluxo sintomático - e é conhecido por ser eficaz na redução da necessidade de medicação anti-refluxo no pós-operatório. No entanto, um pequeno número de pacientes com RYGB ainda pode desenvolver sintomas de refluxo graves que requerem uma intervenção cirúrgica. Objetivo: Examinar e descrever a população de pacientes que requer procedimento anti-refluxo após RYGB avaliando dados demográficos, características, sintomas e diagnóstico. Métodos: Revisão retrospectiva de prontuários foi realizada em 32 pacientes submetidos a hérnia hiatal e / ou fundoplicatura Nissen após RYGB em 1º de julho de 2014 a 31 de dezembro de 2019. Os pacientes foram identificados por meio do banco de dados MBSAQIP e seus prontuários eletrônicos foram revisados. Resultados: A maioria dos pacientes era do sexo feminino (n = 29 - 90,6%). A média de idade foi de 52,8 anos e o índice de massa corporea (IMC) médio de 34,1 kg / m2 na época do procedimento anti-refluxo. Os pacientes foram submetidos ao procedimento anti-refluxo em média 7,9 anos após o procedimento do BGYR. A porcentagem média de perda do excesso de IMC durante o tempo entre o BGYR e o procedimento anti-refluxo foi de 63,4%. Conclusões: Pacientes do sexo feminino com perda de peso significativa podem desenvolver sintomas graves de refluxo anos após o BGYR. Sintomas de refluxo após RYGB não devem ser negligenciadas. Acompanhamento cuidadoso e tratamento adequado (incluindo intervenção cirúrgica) são necessários para essa população.

Cardiopexy at the Time of Sleeve Gastrectomy as a Preventive Measure for Reflux.

BACKGROUND: One of the most significant concerns after laparoscopic sleeve gastrectomy (LSG) is the new-onset or worsening of gastroesophageal reflux disease (GERD). Some patients with LSG undergo a conversion to Roux-en-Y gastric bypass (RYGB) because of severe GERD. Cardiopexy at the time of LSG may help prevent GERD. This study aims to examine the safety and effectiveness of cardiopexy at the time of LSG. METHODS: A retrospective chart review was performed on 161 consecutive patients who underwent LSG between May 1, 2017 and April 30, 2018. Of these, 79 underwent cardiopexy at the time of LSG. Weight, comorbidities, and complications were recorded at 6 months after LSG. RESULTS: Baseline characteristics were similar between the cardiopexy and noncardiopexy groups of patients. In the cardiopexy group, 8 (10.1%) patients reported having GERD at the time of LSG, whereas 12 (14.6%) patients did in the noncardiopexy group. At 6 months after the procedure, 5 (8.9%) patients in the cardiopexy group reported symptoms of GERD, whereas 14 (17.7%) patients did in the noncardiopexy group (P=0.15). One (1.3%) patient in the cardiopexy group and 2 (2.4%) patients in the noncardiopexy group were converted to an RYGB because of severe reflux (P=0.58). The percentage of excess body mass index loss and the percentage of total weight loss were similar between the 2 groups. CONCLUSION: Cardiopexy was not associated with a reduced rate of symptomatic GERD and conversion to RYGB after 6 months.