Bariatric Surgery In France Research Articles

Evaluating the impact and costs of conversional or revisional metabolic bariatric surgery on obstructive sleep apnea: Insights from a French nationwide cohort

BackgroundThis study assesses the effectiveness of 5 main conversional or revisional metabolic bariatric surgery sequences after sleeve gastrectomy, adjustable gastric banding and gastric bypass on reimbursement and cost of continuous positive airway pressure therapy, the first line treatment for obstructive sleep apnea, in France. MethodsThis nationwide observational population-based cohort study analyzed data from the French National Health Insurance database. It included all patients who had undergone primary metabolic bariatric surgery in France between January 1, 2012, and December 31, 2014, and followed until December 31, 2020. The study assessed continuous positive airway pressure therapy reimbursement discontinuation and costs of reimbursed continuous positive airway pressure therapy across 5 different conversional or revisional metabolic bariatric surgery sequences. ResultsDuring follow-up, 6,396 patients underwent the following sequences: sleeve gastrectomy–gastric bypass (n = 2,400), adjustable gastric banding–sleeve gastrectomy (n = 2,277), adjustable gastric banding–gastric bypass (n = 1,173), sleeve gastrectomy–sleeve gastrectomy (n = 546), and gastric bypass–others (n =332), with a rate of obstructive sleep apnea of 15.2%, 12.4%, 15.5% 12.8%, and 9.9% in the year before conversional or revisional metabolic bariatric surgery. The rates of patients who had a discontinuation of continuous positive airway pressure were at 2 and 4 years: 41.1%, 41.9%, 46.4%, 29.3%, and 33.3%; 62.3%, 57.0%, 78.2%; 57.5%, and 44.4%, respectively. At 4 years, the mean annual costs (euros) of obstructive sleep apnea treatment per patient were significantly lower (P < .01) than the costs in the year before conversional or revisional metabolic bariatric surgery for each sequence: 526.9 ± 414.4 vs 257.4 ± 349.7; 368.0 ± 247.5 vs 230.9 ± 288.4; 433.7 ± 326.0 vs 116.8 ± 238.3; 540.7 ± 275.3 vs 248.0 ± 308.4 and 501.2 ± 254.0 vs 281.1 ± 287.0, respectively. ConclusionsOur study underscore the effectiveness of conversional or revisional metabolic bariatric surgery in significantly reducing the need and associated costs of continuous positive airway pressure therapy for patients with obstructive sleep apnea postprimary metabolic bariatric surgery over a 4-year period.

Guideline compliance in bariatric surgery: a French nationwide study.

Strict adherence to guidelines with a comprehensive preoperative assessment and rigorous follow-up are essential to improve postoperative and long-term outcomes of bariatric surgery (BS). To investigate the trends in BS in France and to assess the compliance to guidelines in people with obesity before and after BS. University Hospital of Bordeaux, France. Data on patients who were admitted for a primary BS procedure in France between January 1 and April 1, 2014, were extracted from the French national health insurance system database. Data on patients' characteristics, preoperative assessment, hospitalization, and postoperative follow-up, including medical consultations, laboratory tests, and drug consumption, during the year preceding and the 2 years after BS were collected. Most of the 11,824 patients (60.4%) had sleeve gastrectomy. Rates of reimbursement for preoperative consultations with general practitioners, digestive surgeons, and endocrinologists or internists were 94.5%, 89.2%, and 63%, respectively. Laboratory tests for nutritional and obesity-related co-morbidity evaluations were performed in 94.3% and 91.4%, respectively. Rates of consultation with general practitioners, digestive surgeons, and endocrinologists or internists dropped from 93.1%, 91.2%, and 29.2%, respectively, the first year to 88.4%, 50.3%, and 20%, respectively, the second year after BS (P < .001). Reimbursements for vitamin, iron, and calcium supplementation dropped from 66.6%, 24.9%, and 21%, respectively, the first year to 52.1%, 19.3%, and 11.7%, respectively, the second year after BS (P < .001). Overall compliance with guidelines is improving. While preoperative medical assessment is nearly optimal, efforts still should be made in order to improve long-term follow-up in general and patient adherence to micronutrient supplementation in particular.

POSA392 Opera Study: Observatory of a Population Eligible to a Reintervention of a Bariatric Surgery in France- Impact of the Different Revisional Bariatric Surgeries on Diabetes Mellitus and Its Treatments.

POSA392 Opera Study: Observatory of a Population Eligible to a Reintervention of a Bariatric Surgery in France- Impact of the Different Revisional Bariatric Surgeries on Diabetes Mellitus and Its Treatments.

POSA97 Assessment of the Economic IMPACT in Relation with the Use of Sugammadex in the French Hospitals Setting

This study aims to estimate the impact of sugammadex administration as neuromuscular reversal agents on time spent in the operating room (OR) and post-acute care unit (PACU) and the potential economic impact of faster recovery in patients undergoing colectomy, hysterectomy, or bariatric surgery in France.

Self-harm hospitalization following bariatric surgery in adolescents and young adults

While bariatric surgery has demonstrated physical and psychological benefits, a risk of suicide and non-fatal self-harm has also been shown. The aim of this study was to compared the rate of hospitalization for self-harm during a three-year observational follow-up period between adolescents/young adults who underwent bariatric surgery in France in 2013-2014 and two control groups. All individuals aged 12-25 years old who underwent bariatric surgery in France between January 1st, 2013, and December 31st, 2014, were identified with a validated algorithm from the French national hospital database, and compared to a healthy sample of the general population matched for age and gender. Information relative to hospitalizations, including for self-harm (ICD-10 codes X60-84), were extracted i) between 2008 and the surgery, and ii) for a three-year follow-up period. A second unmatched control group with obesity but no bariatric surgery was also identified. Survival analyses with adjustments for confounding variables were used. In 2013-2014, 1984 youths had bariatric surgery in France. During follow-up, 1.5% were hospitalized for self-harm vs. 0.3% for controls (p<0.0001). After adjustment, subsequent hospitalization for self-harm was associated with bariatric surgery (HR 3.64, 95% CI 1.70-7.81), prior psychiatric disorders (HR 7.76, 95% CI 3.76-16.01), and prior self-harm (HR 4.43, 95% CI 1.75-11.24). When compared to non-operated youths with obesity, bariatric surgery was not associated with self-harm while prior mental disorders and self-harm were. Mortality reached 0.3% after surgery. Bariatric surgery is associated with an increased risk of self-harm, mainly in relation to preexisting psychological conditions. Vigilance and appropriate care are thus warranted in vulnerable individuals.

Change in Birth Rate Before and After Bariatric Surgery in France.

Bariatric surgery worldwide has grown significantly over the past years and is performed, in a vast majority, in women of childbearing age. The impact of these procedures on birth rates remains largely unknown. The main objective was to study the evolution of the birth rates in these women, before and after bariatric surgery and in comparison with women from the general population. The secondary objectives were to compare the birth rates before and after surgery according to the Body Mass Index (BMI) (BMI 40-50 versus >50 kg/m2). Our analyses are based on a national medico-administrative database. All women of childbearing age and who had bariatric surgery between 2012 and 2016 were included, and we included all deliveries between 2012 and 2018 in this population. We compared the birth rates before and after bariatric surgery. National statistics (INSEE, Institut National de la Statistique et des Etudes Economiques) were used for comparison with women from the general population. A total of 69,932 women were included between 2012 and 2016, with a median age at surgery of 33 years [27; 39]. Among them, 9391 (13%) had a BMI over 50 kg/m2 before surgery, 46,818 (67%) benefited from a sleeve gastrectomy (SG), and 23,376 (33%) from a gastric bypass (GBP). Birth rates tend to be smaller after surgery compared to before surgery for women under 27 years (OR: 0.92, CI95% [0.88; 0.96]), while being not different after 27 in both groups (OR: 1.00, CI95% [0.97; 1.03]). Birth rates of obese women who have benefited or will benefit from the bariatric surgery were higher than the general population, with a peak at a younger age, and then decline earlier than the general population. Trends were different according to BMI class. Birth rates were higher for women with BMI between 40 and 50 kg/m2 compared to women with BMI greater than 50 kg/m2 (OR=1.28, CI95% [1.21; 1.36]) before surgery while slightly lower after surgery (OR=0.95, CI95% [0.91; 0.99]). We showed that birth rates after bariatric surgery were not different before and after bariatric surgery except for women under 27 years old who had a smaller birth rate. Interestingly, we observed an improvement of birth rates after surgery for women with a BMI of 50 kg/m2 or more.

Study on a New Energy Device in Bariatric Surgery in France, the Sound Reach™ System

Current laparoscopic bariatric operations (e.g. gastric bypass and sleeve gastrectomies) require systematically the use of an energy device, meant for dissection and coagulation. Several companies make them, the US Medtronic and Ethicon being dominant, with published favorable results. A trial has been conducted with devices created by the company REACH Surgical Inc (Beijin, China): Sound Reach device in two centers in France (Lyon, Saint-Etienne) and three different surgeons. Thirty interventions have been carried out (21 sleeve gastrectomies, 1 bypass, and 8 gastric band removals), 27 F and 3 H, mean age 40, mean weight 99 kg, and mean BMI 40,4. From 0 to 5, the average note for ergonomics has been 3.5, and 4.5 for safety. There was no intra-operative incidents, but a post-operative hematoma treated by surveillance only at D2. The overall impression has been that this device was safe and effective.

A series of severe neurologic complications after bariatric surgery in France: the NEUROBAR Study.

Neurologic complications after bariatric surgery are rare, but can have dramatic consequences. Little data are available on this topic. The aim of the Neurologic complications after BARiatric surgery (NEUROBAR) study was to define, which factors (anthropometric, nutritional, surgical, etc.) were frequently associated with neurologic complications after bariatric surgery. Data were collected by the French Centers of Obesity Care Management hosted in University Hospitals. An online standardized questionnaire was designed and submitted to the 37 French Centers of Obesity Management. This questionnaire included items about patient characteristics, bariatric surgery, neurologic complications, nutritional status, and management. Patients were retrospectively included from January 2010 to November2018. Thirteen centers included 38 patients (34 females and 4 males) with neurologic complications after bariatric surgery. The 2 main bariatric procedures were gastric bypass and sleeve gastrectomy. More than half of the patients with neurologic complications had a surgical complication after bariatric surgery (53%) and gastrointestinal symptoms, including vomiting (53%). Vitamin B deficiencies were frequent (74%) including at least 47% of cases with deficiency in Vitamin B1. Early identification of patients with surgical complications and gastrointestinal symptoms after bariatric surgery could help prevent neurologic complications related to nutritional deficiencies.

A French National Study on Gastropleural and Gastrobronchial Fistulas After Bariatric Surgery: the Impact of Therapeutic Strategy on Healing.

Gastropleural and gastrobronchial fistulas (GPF/GBFs) are serious but rare complications after bariatric surgery whose management is not consensual. The aim was to establish a cohort and evaluate different clinical presentations and therapeutic options. A multicenter and retrospective study analyzing GPF/GBFs after bariatric surgery in France between 2007 and 2018, via a questionnaire sent to digestive and thoracic surgery departments. The study included 24 patients from 9 surgical departments after initial bariatric surgery (21 sleeve gastrectomies; 3 gastric bypass) for morbid obesity (mean BMI = 42 ± 8kg/m2). The GPF/GBFs occurred, on average, 124days after bariatric surgery, complicating an initial post-operative gastric fistula (POGF) in 66% of cases. Endoscopic digestive treatment was performed in 79% of cases (n= 19) associated in 25% of cases (n= 6) with thoracic endoscopy. Surgical treatment was performed in 83% of cases (n= 20): thoracic surgery (n= 5), digestive surgery (n= 8), and combined surgery (n= 7). No patient died. Overall morbidity was 42%. The overall success rate of the initial and secondary strategies was 58.5% and 90%, respectively. The average healing time was approximately 7months. Patients who had undergone thoracic surgery (n= 12) had more initial management failures (n= 9/12) than patients who had not (n= 3/12), p= 0.001. Complex and life-threatening fistulas that are revealed late require a multidisciplinary strategy. Thoracic surgery should be reserved once the abdominal leak heals; otherwise, it is associated with a higher risk of failure.

Bariatric Surgery in France from 1997 to 2018.

Bariatric surgery is 1 of the major treatments of obesity. This study describes the development of the bariatric surgery in France and look at some factors of this evolution. It concerns the activity of all the French hospitals over a 22-year period. Hospitalization databases from 1997 to 2018 have been used to study the evolution of the number of bariatric operations, their types, the characteristics of both patients and hospitals performing this surgery. The number of operations grew from 2800 in 1997 to 52,500 in 2018, with 2 interruptions in this growth, in 2002 and from 2017 to date. The rate of operations is 4 times higher for women than for men, with a peak in the 35-44 age group. The adjustable gastric banding was the most popular operation until 2010, then replaced by sleeve gastrectomy since 2010. Private for-profit hospitals carried out the majority of these operations, even if the public hospitals activity progressed regularly during the past 2 decades. Compared to other countries, the rate of bariatric operations in France is rather high whereas the obesity rate is medium to low. Easy accessibility to bariatric surgery should play a role in the high rate, but specific studies are necessary to evaluate if the operations are delivered adequately to the obese population.

Medico-legal claims in bariatric surgery in France between 2010 and 2015.

The practice of bariatric surgery has multiplied 3.5 times in France in the last ten years. The purpose of the study is to analyze medico-legal claims in this area in order to identify lessons to improve patient care. Two visceral surgeons analyzed 358 independent claim files. Age, gender, socio-economic origin, body mass index, surgical history, depression, smoking, anticoagulants, and pre-operative assessment of patients were recorded. The operative indication, the type and date of occurrence of the event, the existence and causes of intra-operative incidents, re-interventions, inter-hospital transfers and deaths were noted. Any anomaly of care, whether noted by the expert or the court, was considered a fault. The types of bariatric procedures included sleeve gastrectomy in 52.1% of cases and gastric bypass in 33.2% of cases. A third of patients (31.2%) had a history of previous abdominal surgery. The main complications were anastomotic leak (48.6%), followed by vomiting, wounds of neighboring organs, and infections. Fault was found in 30.4% of cases: for delay of care (36.8%), surgical clumsiness or ineptitude (15.5%), incorrect indications, lack of patient information. In 6.4% of cases, metabolic deficiencies with encephalopathy developed. The indications of the French High Authority of Health [Haute autorité de santé (HAS)] must be respected and intra-operative difficulties should not be underestimated in patients who have undergone previous surgery. Post-operatively, clinical signs of severity take precedence over complementary examinations, even when negative. Close monitoring is necessary to quickly detect complications that occur outside the facility, whether it is a surgical complication or vitamin deficiency.

Readmissions After Bariatric Surgery in France, 2013-2016: a Nationwide Study on Administrative Data.

Readmission rate is considered an indicator of quality of care, which is already used in some countries to impose financial penalties on hospital with readmissions in excess of the national average. Nevertheless, this indicator presents some controversial drawbacks. The objective of this study was the assessment of readmission rate after bariatric surgery. This is a retrospective observational study on a national administrative claims database, the Information Systems Medicalization Program, PMSI, which is a nationwide billing tool collecting information on all hospital discharges in France. All adult patients operated of bariatric surgery from January 1, 2013, through December 31, 2016, were included. The main outcome was unplanned 30-day readmission rate. Secondary outcome was the analysis of reasons for readmission. During the study period, out of 187,000 bariatric interventions, the unplanned readmission rate was 4.7%. A significant difference was found between bariatric procedures (gastric banding 3.1%, sleeve gastrectomy 4.5%, gastric bypass 5.7%, p < 0.001). The most important risk factors are the Charlson comorbidity index, the occurrence of a complication after the initial intervention, and the bariatric technique type itself. The main causes of return to the hospital are abdominal pain, peritonitis, nausea/vomiting, and bleeding. After adjustment for confounders, the rate of rehospitalization varies between 1.0% and 16.0% among all French hospitals. Approximately 5 % of patients undergoing bariatric surgery suffered a readmission within 30days. We identified common causes and identified patients at high risk for such an event. These information could be useful for developing strategies to improve in- and outpatient care in bariatric population.

Cost-effectiveness of an educational healthcare circuit for bariatric surgery in France

ObjectivesAn educational healthcare circuit (EHC) is proposed with the objective of preventing weight recovery of patients after bariatric surgery through education and lifestyle change. The objective of this study was to measure the viability of the EHC (shared medical appointments [SMAs] combined with bariatric surgery) through cost-effectiveness analysis. The EHC presented in this study is innovative because it offers a multidisciplinary approach based on medical, psychological and dietetic expertise to combat obesity. The strategy is to give the patient a diagnosis and then a personalised follow-up. Study designA mathematical model based on a decision tree (1 year) and a Markov model (10 years) to measure the efficiency and cost of an EHC in comparison with the customary care offered in France were built. MethodsThe effects of the EHC were observed for the prevalence of type 2 diabetes and the risk of cardiovascular disease. The chosen financial perspective is from the point of view of the French social security system. ResultsThe EHC records an incremental cost-effective ratio (ICER) of € 48,315.43 per quality-adjusted life year (QALY) over a 1-year horizon and € 28,283.77 per QALY over 10 years (with discount rate of 8%: € 25,362.85 per QALY). ConclusionThe results suggest that an EHC is more expensive yet more effective than usual care. That is, in the short term, the costs are high, but at 10 years, the treatment is cost-effective, representing a feasible alternative for those patients who qualify for bariatric surgery in France.

Association Between Bariatric Surgery and Rates of Continuation, Discontinuation, or Initiation of Antidiabetes Treatment 6 Years Later

Few large-scale long-term prospective cohort studies have assessed changes in antidiabetes treatment after bariatric surgery. To describe the association between bariatric surgery and rates of continuation, discontinuation, or initiation of antidiabetes treatment 6 years after bariatric surgery compared with a matched control obese group. This nationwide observational population-based cohort study extracted health care reimbursement data from the French national health insurance database from January 1, 2008, to December 31, 2015. All patients undergoing primary bariatric surgery in France between January 1 and December 31, 2009, were matched on age, sex, body mass index category, and antidiabetes treatment with control patients hospitalized for obesity in 2009 with no bariatric surgery between 2005 and 2015. Bariatric surgery, including adjustable gastric banding (AGB), gastric bypass (GBP), and sleeve gastrectomy (SG). Reimbursement for antidiabetes drugs. Mixed-effects logistic regression models estimated factors of discontinuation or initiation of antidiabetes treatment over a period of 6 years. In 2009, a total of 15 650 patients (mean [SD] age, 38.9 [11.2] years; 84.6% female; 1633 receiving antidiabetes treatment) underwent primary bariatric surgery, with 48.5% undergoing AGB, 27.7% undergoing GBP, and 22.0% undergoing SG. Among patients receiving antidiabetes treatment at baseline, the antidiabetes treatment discontinuation rate was higher 6 years after bariatric surgery than in controls (-49.9% vs -9.0%, P < .001). In multivariable analysis, the main predictive factors for discontinuation were the following: GBP (odds ratio [OR], 16.7; 95% CI, 13.0-21.4), SG (OR, 7.30; 95% CI, 5.50-9.50), and AGB (OR, 4.30; 95% CI, 3.30-5.60) compared with no bariatric surgery, as well as insulin use (OR, 0.17; 95% CI, 0.13-0.22), dual therapy without insulin (OR, 0.38; 95% CI, 0.32-0.45) vs monotherapy, lipid-lowering treatment (OR, 0.76; 95% CI, 0.63-0.91), antidepressant treatment (OR, 0.67; 95% CI, 0.55-0.81), and age (OR, 0.96; 95% CI, 0.95-0.97) per year. For patients without antidiabetes treatment at baseline, the 6-year antidiabetes treatment initiation rate was much lower after bariatric surgery than in controls (1.4% vs 12.0%, P < .001). In multivariable analysis, protective factors were GBP (OR, 0.06; 95% CI, 0.04-0.09), SG (OR, 0.08; 95% CI, 0.06-0.11), and AGB (OR, 0.16; 95% CI, 0.14-0.20) vs controls, and risk factors were as follows: body mass index category (OR, 2.04; 95% CI, 1.68-2.47 for ≥50.0 vs 30.0-39.9 and OR, 1.68; 95% CI, 1.49-1.90 for 40.0-49.9 vs 30.0-39.9), antihypertensive treatment (OR, 1.49; 95% CI, 1.33-1.67), low income (OR, 1.43; 95 % CI, 1.26-1.62), and age (OR, 1.04; 95 % CI, 1.03-1.05) per year. Bariatric surgery was associated with a significantly higher 6-year postoperative antidiabetes treatment discontinuation rate compared with baseline and with an obese control group without bariatric surgery.

Plastic surgery in bariatric patients: a nationwide study of 17,000 patients on the national administrative database

BackgroundBariatric patients are often candidates for plastic surgery. However, the rate of postbariatric procedures is not known. ObjectivesThe aim of this study was to analyze the rate of plastic surgery, and factors related to surgery, in bariatric patients. SettingUniversity hospital, France. MethodsThis was a cohort study based on administrative data. All adult patients who received bariatric surgery in France between 2007 and 2013 were included to estimate the rate of plastic surgery and related predictive factors. Data are reported according to the reporting of studies conducted using observational routinely collected data guidelines for observational studies on administrative data. ResultsAmong the 183,514 patients who underwent bariatric surgery in the study period, 23,120 plastic surgeries were performed on 17,695 patients, including abdominoplasty (62%), dermolipectomy of the upper or lower limbs (25%), and reconstruction of the breast (14%). The rates of plastic surgery were 13%, 18%, and 21% at 3, 5, and 7 years post–bariatric surgery, respectively. Multivariate analysis revealed that patients who had a biliopancreatic diversion or a gastric bypass had a hazard ratio of 2.67 and 2.67 for subsequent plastic surgery, respectively, compared with patients who had adjustable gastric banding. Women had a 2-fold probability of surgery compared with men (hazard ratio 2.02). Important variability in the rate of surgery was found among different hospitals; rates ranged from 6.1% to 41.3% at 5 years. ConclusionsThis study showed that 21% of bariatric patients undergo plastic surgery. Large variability exists among hospitals, suggesting that several unmeasured factors may limit access to contouring surgery.

General Practitioners and Bariatric Surgery in France: Are They Ready to Face the Challenge?

The epidemic of obesity has determined an important rise in popularity for bariatric surgery (BS) in France. The role of general practitioners (GPs) in the decision-making process of candidates to BS as well as in their life-long follow-up after surgery is therefore destined to grow up. The aim of this survey was to provide a picture of the actual knowledge of GPs about BS. The link to an e-questionnaire composed of 20 multiple choice questions was sent to all the 101 Departmental Councils of the French Medical Board, accompanied by a letter explaining the objectives of the study. Councils were asked to distribute the e-questionnaire to GPs in their department. A total of 2224 GPs were solicited by e-mail in six departments and 288 surveys were completed, representing a 12.9% response rate. A proportion as high as 97.2% of GPs reported taking care of at least one patient operated on for BS and 88.5% declared having referred at least one patient for BS. Nevertheless, a considerable proportion of GPs declared not to have sufficient knowledge to manage BS patients. Moreover, 86.1% wished to receive more education and 83.7% declared to be available for participating in follow-up. Academic institutions, scientific societies, and all physicians involved in obesity care should actively participate in the correction of the educational gap of GPs in order to obtain an effective help in the complex challenge of facing the obesity epidemic.

Occurrence or Remission of Antidiabetic Treatment Six Years after Bariatric Surgery: A Nationwide Matched Cohort Study

Few large long-term prospective cohorts have assessed the evolution of antidiabetic treatment after bariatric surgery (BS). The aim of our study was to study, under real life conditions and at a national level, remission and occurrence of antidiabetic treatment over 6 post-operative years after BS, compared to a matched control group, using the French national health insurance database. Each patient undergoing primary BS in France in 2009 was matched on age, sex, BMI categories and antidiabetic treatment with one control patient hospitalised for obesity in 2009 who had no BS between 2005-2015. Reimbursements of antidiabetic treatment were extracted from the French National Health Insurance database (SNIIRAM) between 2008-2015. Mixed-effects logistic regression models analysed factors of remission or occurrence of antidiabetic treatment over 6 years. In 2009, 15,650 patients (85% female; 1,633 with antidiabetic treatment) had undergone primary BS: gastric banding (AGB) 48%, gastric bypass (GBP) 28%, sleeve gastrectomy (SG) 24%. For patients with antidiabetic treatment at baseline, discontinuation of treatment at 6 years was more frequent after BS than in controls (50% vs. 9%; P<0.001). In multivariate analysis, the main predictive factors of discontinuation were overall (OR; 95%CI): GBP=16.7 (13.0-21.4); SG= 7.3 (5.5-9.5), AGB=4.3 (3.3-5.6), no baseline insulin (5.9 (4.5-7.7)) and no hypolipidemic treatment (1.5 (1.1-1.6)). For patients without antidiabetic treatment at baseline, occurrence of treatment at 6 years was much less frequent after BS than in controls (1% vs. 12%; P<0.001). All types of procedures were protective factors: GBP=0.06 (0.04-0.09), SG=0.08 (0.06-0.1), AGA=0.16 (0.14-0.19). Our large study confirms that BS leads to a significant discontinuation rate of antidiabetic treatment compared to baseline and to non-surgical obese controls over 6 post-operative years, as well as to a lower occurrence rate of antidiabetic treatment, with GBP being the most effective procedure.

Why Would a Patient Complain of Dysphagia and Heartburn After Multiple Bariatric Surgeries?

Question: A 43-year-old woman presented for management of a complication of her bariatric surgery. The history goes back to September 2000 when the patient presented with a body mass index (BMI) of 45 (120 kg to 1.63 m). An adjustable gastric band was placed. One year postoperatively, the band migrated, which resulted in removal of the band. In 2003, the patient regained weight and reached a BMI of 47 kg/m2. She underwent a Roux-en-Y gastric bypass. The Roux-en-Y gastric bypass failed in the long term; the patient regained weight and reached a BMI of 45. A supportive band was also placed on the gastric pouch and failed to result in significant weight loss, which necessitated its removal. Currently, the patient has a BMI of 55 and she complains of heartburn accompanied by intermittent abdominal epigastric pain and dysphagia for solid food for the last few months. A 3-dimensional thoracoabdominal computed tomography (CT) scan was done (Figure A–C). What is the diagnosis and how it should be managed? Look on page 654 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. A 3-dimensional thoracoabdominal CT scan was done that showed herniation of the gastric pouch, the gastrojejunal anastomosis, the alimentary limb, and the residual excluded stomach into the thoracic cavity through the hiatal orifice (Figure A–C). The patient underwent laparoscopic reduction of the intrathoracic contents into the abdominal cavity and repair of the hiatal orifice. Mesh repair of the hiatal defect was preferred. The postoperative course was uneventful. She was doing well at follow-up 6 months after surgery. Bariatric surgery is booming in all countries.1Debs T. Petrucciani N. Kassir R. et al.Trends of bariatric surgery in France during the last 10 years: analysis of 267,466 procedures from 2005–2014.Surg Obes Relat Dis. 2016; 12: 1602-1609Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar However, hiatal hernia is an uncommon pathology after bariatric surgery. The patient underwent multiple bariatric surgeries, with repeated dissection of the angle of His and the diaphragmatic crura, which might have increased the risk of herniation, owing to enlargement of natural orifices such as the hiatal orifice. The reduced formation of adhesions owing to the laparoscopic approach could also play a role. Morbid obesity itself is an independent risk factor for development of hiatal hernia. The intra-abdominal and visceral fat in obese patient leads to a higher intragastric pressure. In addition, obesity reduces the inferior esophageal sphincter pressure and causes esophageal motility problems. Abnormal changes in the collagen and reduced elastin in the diaphragmatic crura after bariatric surgery predispose these patients to hiatal hernias.2Pandolfino J.E. El-Serag H.B. Zhang Q. et al.Obesity: a challenge to esophagogastric junction integrity.Gastroenterology. 2006; 30: 639-649Abstract Full Text Full Text PDF Scopus (395) Google Scholar, 3Curci J.A. Melman L.M. Thompson R.W. et al.Elastic fiber depletion in the supporting ligaments of the gastroesophageal junction: a structural basis for the development of hiatal hernia.J Am Coll Surg. 2008; 207: 191-196Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar Management of hiatal hernia after bariatric surgery consists of reduction of the contents into the abdominal cavity, closure of the hiatal orifice and mesh repair.

Trends of bariatric surgery in France during the last 10 years: analysis of 267,466 procedures from 2005–2014

BackgroundDuring the past decade, the field of bariatric surgery has changed dramatically. ObjectivesThe study aims to summarize and perform a periodic assessment of the current trends in the use of bariatric surgery in France and review findings on the long-term progression of bariatric surgery. The data were extracted from the national registry Programme de Médicalisation des Systèmes d׳Information from 2005 to 2014. SettingNational health system and private practice in France. MethodsWe identified all hospitalizations during which a bariatric procedure was performed for the treatment of morbid obesity from 2005 to 2014 in France. Data were reviewed for patient characteristics and the number and types of bariatric procedures. We also analyzed the setting and the characteristics of the centers and the difference of the activity between the public and private sector. ResultsBetween 2005 and 2014, the number of bariatric operations increased fourfold. Sleeve gastrectomy became the most performed bariatric intervention, representing 60.7% of bariatric activity in 2014. There was a concomitant steep increase in sleeve gastrectomy, with Roux-en-Y gastric bypass increasing slightly overall and a substantial decrease in adjustable gastric banding. In 2014, 481 centers performed bariatric surgery. Among them, one third performed<30 operations/yr. We observed an overall in-hospital mortality ranging from .038% to .05% during the last 3 years. ConclusionBariatric surgery is increasing in France, with a fourfold augmentation of interventions in the last 10 years. The number of sleeve gastrectomies has increased considerably. This activity is performed in numerous centers, one third of them performing<30 interventions/yr.

Reduction in early mortality outcomes after bariatric surgery in France between 2007 and 2012: A nationwide study of 133,000 obese patients

Early postoperative mortality after bariatric surgery has been reported in large national studies before sleeve gastrectomy (SG) was introduced as a stand-alone procedure. The aim of this study was to investigate the 90-day postoperative mortality rates after bariatric surgery in France on a nationwide basis. All morbidly obese patients who underwent adjustable gastric banding (AGB), gastric bypass (GBP), or SG in France between 2007 and 2012 were included in this study. Multivariate analyses were conducted using the French National Health Service Database data to ascertain predictive factors for 90-day postoperative mortality. Data from 133,804 patients were analyzed. SG was performed in 36.5% of cases, GBP in 31.2%, AGB in 32.3%, and revisional surgery in 5.1%. The postoperative mortality rate (POM) for the 3 procedures was 0.12%. The rate of POM remained stable for AGB (0.01%), and it decreased from 0.25 to 0.08% and from 0.36 to 0.11% for SG and GBP, respectively. POM was greater among male patients and was associated with age, type-2 diabetes, high blood pressure, body mass index, open surgery, and hospital procedural volume. The rate of early mortality after bariatric surgery was low, and has decreased greatly during the past few years. AGB presents a mortality rate close to nil and SG has a risk of early mortality that is about half that of GBP.