Mid-term bariatric surgery outcomes for obese patients: does weight matter?

INTRODUCTION: Studies have attempted to identify prognostic indicators for successful outcomes following bariatric surgery for obesity. The aim of this study was to determine whether the degree of obesity affects outcomes in patients who are morbidly obese (basal metabolic index, BMI, 40-49.9 kg/m2), super-obese (BMI 50-59.9 kg/m2) and super-super-obese (BMI greater than 60 kg/m2) undergoing restrictive or malabsorptive bypass procedures. MATERIAL AND METHODS: Retrospective analysis of a prospectively maintained database was undertaken to include all consecutive laparoscopic adjustable gastric bands (LAGB), laparoscopic sleeve gastrectomies (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures since 2010. Patients with at least two years of follow-up were included. At each visit, the patient's weight, BMI, excess weight loss and comorbidity status were recorded. RESULTS: A total of 353 patients (75% women) were included in the analysis; 65 (18.4%) underwent LAGB; 70 (19.8%) LSG and 218 (61.8%) LRYGB. At presentation, the median BMI for the morbidly obese sub-group was 47.2 kg/m2 for LAGB, 46.4 kg/m2 for LSG and 46.6 kg/m2 for LRYGB (P = 0.625); for the super-obese sub-group it was 53.2 kg/m2 for LAGB, 52.9 kg/m2 for LSG and 52.4 kg/m2 for LRYGB (P = 0.481); and for the super-super-obese sub-group 66.9 kg/m2 for (LAGB, 66.7 kg/m2 for LSG and 61.5 kg/m2 for LRYGB (P = 0.169). Percentage of excess weight loss at the end of two years was significantly higher in the morbidly obese and super-morbidly obese sub-groups undergoing LRYGB (median 68.5% and 69.5%, respectively; P < 0.001) than in the sub-groups undergoing LAGB and LSG. This was also reflected in the reduction of BMI achieved with bypass in the two sub-groups (P < 0.001). Complete diabetes remission was significantly higher in the morbidly obese and super-morbidly obese sub-groups undergoing LRYGB treatment (P < 0.05). Sleep apnoea, asthma and exercise tolerance had significantly improved in the super-morbidly obese undergoing LRYGB (P < 0.05). There was no significant difference between the three treatment groups in remission of hypertension; dyslipidaemia; gastro-oesophageal reflux disease and depression in all three BMI sub-groups. CONCLUSION: The mid-term results for weight loss and resolution of obesity-related comorbidities is best achieved in super-obese patients undergoing LRYGB, without any significant increase in complications with this procedure as compared with LAGB and LSG.

Retrospective cohort study of 925 OAGB procedures. The UK MGB/OAGB collaborative group.

BACKGROUND: Mini-One Anastomosis Gastric Bypass is a new operation that provides comparable outcomes to the common bariatric procedures. Revisional surgery is still needed after a number of MGB-OAGB procedures. The aim of this study is to report the causes and management of these revisions. METHODS: From 2010 to 2018, 925 MGB-OAGB operations were performed at 7 bariatric units across the United Kingdom and included in this retrospective cohort study. The data was retrospectively collected and analysed. The primary end point was the identification of the causes and management of revisions. Follow up ranged from 6 months to 3 years. RESULTS: Twenty-two patients [2.3%] required revisional surgery after MGB-OAGB. Five patients [0.5%] developed severe diarrhoea managed by shortening the bilio-pancreatic limb to 150 cm. Four patients [0.4%] developed afferent loop syndrome and bile reflux was reported in another 3 [0.3%] cases; all were managed by either conversion to Roux en Y Gastric Bypass or a Braun anastomosis. Postoperative bleeding was controlled laparoscopically in 3 patients [0.3%]. Liver decompensation that was reported in 2 patients [0.2%] was treated by shortening the BPL in one patient and a reversal to normal anatomy in another. The liver failure resolved in both patients. Other indications for revision included two gastro-jejunal stenosis [0.2%], one perforated ulcer [0.1%], one patient [0.1%] with excessive weight loss and one case [0.1%] of protein malnutrition. None of the 22 patients undergoing revisional surgery after MGB-OAGB died. Lost to follow up rate was 0.2%. CONCLUSION: Complications requiring revisional surgery after MGB-OAGB are uncommon [2.3%] and the majority can be managed by bilio-pancreatic limb shortening, the addition of a Braun side-to-side anastomosis or conversion to RYGB. Bilio-pancreatic limb length of 200 cm or more resulted in serious complications of liver failure, protein malnutrition, excessive weight loss and diarrhoea.

Influence of Patient Choice on Outcome of Bariatric Surgery.

BACKGROUND: The "perfect" bariatric procedure remains the topic of debate. The aim of this study is to compare the safety and outcome of laparoscopic Roux-en-Y gastric bypass (LRYGB) to those of laparoscopic sleeve gastrectomy (LSG) and adjustable gastric band (AGB) in a single centre, amongst those patients who made their own choice of which procedure they prefer. METHODS: After the multi-disciplinary team's assessment, the patients could make their own choice of procedures (self-selected, SS), unless medical/surgical conditions limited this (medically restricted, MR). All consecutive primary bariatric procedures were involved and reviewed between June 2010 and September 2014. The primary outcomes included 30-day complication and readmission rates, excess weight loss (%EWL) and co-morbidity resolution at 24 months postoperatively. RESULTS: A total of 303 patients were included and 271 of them made their own choice (SS 90%). One hundred eighty-three chose LRYGB (60.4%), and 57 underwent LSG (SS 45 and MR 12; overall 18.8%), with the initial BMI of 50.7 and 52.5 kg/m2, respectively. Sixty-two patients (SS 43, MR 19, overall 20%) underwent AGB, with a BMI of 52.1 kg/m2. Thirty-day complication rates for LRYGB and LSG were 10.2 and 2.9% (p < 0.05), and the readmission rates were 4.7 and 2.9%, respectively. %EWL for LRYGB was significantly higher than that of other procedures at 24 months (67.8 vs SS-sleeve 43.9%, MR-sleeve 47%, SS-band 33.8% and MR-band 36%; FU rate 94%). Diabetes remission was achieved in 31/50 patients in the LRYGB group (62%) and 2/9 patients (22%) in the LSG group. CONCLUSIONS: Self-selected bariatric procedures yield excellent weight loss and metabolic outcome. Providing an information-dense environment augments the choice of the right operation and could improve patients' compliance with weight loss surgery programmes.

Initial experience of treating anal fistula with the Surgisis anal fistula plug.

BACKGROUND: Complex anal fistulas remain a challenge for the colorectal surgeon. The anal fistula plug has been developed as a simple treatment for fistula-in-ano. We present and evaluate our experience with the Surgisis anal fistula plug from two centres. METHODS: Data were prospectively collected and analysed from consecutive patients undergoing insertion of a fistula plug between January 2007 and October 2009. Fistula plugs were inserted according to a standard protocol. Data collected included patient demographics, fistula characteristics and postoperative outcome. RESULTS: Forty-four patients underwent insertion of 62 plugs (27 males, mean age 45.6 years), 25 of whom had prior fistula surgery. Mean follow-up was 10.5 months Twenty-two patients (50%) had successful healing following the insertion of plug with an overall success rate of 23 out of 62 plugs inserted (35%). Nineteen out of 29 patients healed following first-time plug placement, whereas repeated plug placement was successful in 3 out of 15 patients (20%; p = 0.0097). There was a statistically significant difference in the healing rate between patients who had one or less operations prior to plug insertion (i.e. simple fistulas) compared with patients who needed multiple operations (18 out of 24 patients vs. 4 out of 20 patients; p = 0.0007). CONCLUSIONS: Success of treatment with the Surgisis anal fistula plug relies on the eradication of sepsis prior to plug placement. Plugs inserted into simple tracts have a higher success rate, and recurrent insertion of plugs following previous plug failure is less likely to be successful. We suggest the fistula plug should remain a first-line treatment for primary surgery and simple tracts.