Laparoscopic Gastric Bypass Procedures Research Articles

Can robotic gastric bypass be considered a valid alternative to laparoscopy? Our early experience and literature review.

Robotic bariatric surgery serves as an alternative to laparoscopy. The technology provides the surgeon with an accurate three-dimensional view, allowing complex maneuvers while maintaining full control of the operating room. We report our experience with this innovative surgery compared with laparoscopy during Roux-en-Y gastric bypass to demonstrate its safety and feasibility. The aim of this study is to evaluate potential differences between the robotic and laparoscopic techniques. Our study retrospectively identified 153 consecutive obese patients who underwent either laparoscopic or robotic gastric bypass (RGB) procedures over a 2-year period at the Department of Medical and Surgical Sciences, University of Foggia. Data on demographics, operative time, conversion rate, length of hospital stay, and mortality were collected and compared between two groups of patients: 82 patients who underwent laparoscopic procedures and 71 who underwent robotic procedures. We analyzed 153 patients who underwent gastric bypass with a mean age of 42.58 years, of whom 74 were female; 71 were treated with a robotic approach and 82 with a laparoscopic approach. The mean operative time was 224.75 ± 10.4 min for RGB (including docking time) and 101.22 min for laparoscopic gastric bypass (LGB) (p < 0.05), which is statistically significant. The median length of stay was 4.1 days for the RGB group and 3.9 days for the LGB group (p = 0.89). There is only one conversion to laparoscopy in the RGB group. We observed only one case of postoperative complications, specifically one episode of endoluminal bleeding in the laparoscopic group, which was successfully managed with medical treatment. No mortality was observed in either group. The statistical analysis shows to support the robotic approach that had a lower incidence of complications but a longer operative duration. Based on our experience, the laparoscopic approach remains a technique with more haptic feedback than the robotic approach, making surgeons feel more confident.This study has been registered on ClinicalTrial.gov Protocol Registration and Results System with this ID: NCT05746936 for the Organization UFoggia (https://clinicaltrials.gov/ct2/show/NCT05746936).

Weakly Supervised Temporal Convolutional Networks for Fine-Grained Surgical Activity Recognition.

Automatic recognition of fine-grained surgical activities, called steps, is a challenging but crucial task for intelligent intra-operative computer assistance. The development of current vision-based activity recognition methods relies heavily on a high volume of manually annotated data. This data is difficult and time-consuming to generate and requires domain-specific knowledge. In this work, we propose to use coarser and easier-to-annotate activity labels, namely phases, as weak supervision to learn step recognition with fewer step annotated videos. We introduce a step-phase dependency loss to exploit the weak supervision signal. We then employ a Single-Stage Temporal Convolutional Network (SS-TCN) with a ResNet-50 backbone, trained in an end-to-end fashion from weakly annotated videos, for temporal activity segmentation and recognition. We extensively evaluate and show the effectiveness of the proposed method on a large video dataset consisting of 40 laparoscopic gastric bypass procedures and the public benchmark CATARACTS containing 50 cataract surgeries.

Delayed diagnosis of Petersen hernia in the third trimester of pregnancy: case presentation and literature review

Petersen’s Hernia, a type of internal hernia that occurs posterior to a gastrojejunostomy, is a known late complication of gastric bypass surgery, particularly prevalent in laparoscopic Roux-en-Y procedures (LRYGB). The rise in laparoscopic gastric bypass procedures has coincided with a resurgence of Petersen’s Hernia cases.1 LRYGB surgeries performed on women of reproductive age improve fertility and pregnancy outcomes.2 However, pregnancy predisposes these patients to Petersen’s hernia due to the increased intraabdominal pressure and anatomical distortion.3 We present a case of Petersen’s hernia that occurred in a 29-year-old at 30 weeks gestation who had previously undergone LRYGB, notable for a delay in diagnosis. Pregnant patients with a history of bariatric surgery should be considered at high-risk for internal hernias. Abdominal or back pain associated with nausea and vomiting should prompt consideration of internal hernia and the need for imaging and surgical evaluation.

Linear or circular: Anastomotic ulcer after gastric bypass surgery

BackgroundAfter laparoscopic Gastric Bypass Procedure (GBP), anastomotic ulcers (AU) at the gastrojejunostomy (GJ) occur in up to 16% of the patients. Surgical techniques seem to influence the development of AU, but this is still a matter of discussion. This study aims to compare the incidence of AU in circular-stapled (CS) versus linear-stapled (LS) gastrojejunostomy.MethodsSingle-centre retrospective analysis of 241 (m 77 /f 164) consecutive patients (126 CS, 115 LS) with primary or revisional GBP including Roux-Y-Gastric Bypass (RYGB) and One-Anastomosis Gastric Bypass (OAGB) between 01/2014 and 01/2018. Follow-up with oesophagogastroduodenoscopy was only performed in symptomatic patients. Age, body mass index (BMI), comorbidities, smoking and medication were analyzed in both groups. The data are reported as total numbers (%) and mean ± standard deviation.ResultsAU occurred significantly more often in the CS group than in the LS group (p = 0.0034). Moreover, refractory AU and the need for revisional surgery were higher in the CS group. Smoking correlates significantly with the development of AU, whereas other risk factors had no impact on its incidence.ConclusionLinear-stapled gastrojejunostomy with a long and narrow pouch should be the preferable procedure for reducing AU development risk. Smoking cessation minimizes the risk for AU and is a necessary part of the treatment.

Retrocolic retrogastric ROUX-EN-Y gastric bypass: how I do it.

Technical variations of the laparoscopic Roux-en-Y gastric bypass may influence the incidence of complications such as fistulas, marginal ulcers, stenosis, and internal hernias. We described the technical aspects of a retrocolic, retrogastric, laparoscopic gastric bypass procedure with manual gastrojejunostomy and the closure technique for the three mesenteric defects generated by the Roux-en-Y limb reconstruction. We summarized the data from 587 patients concerning complications directly related to the surgical technique. There were no internal hernias in patients followed, and in only 2 cases, small bowel obstruction related to defect closure occurred. The retrocolic, retrogastric gastric bypass performed with a meticulous closure of all three mesenteric defects reflects a low incidence of internal hernias and low complication rates related to the closure itself. The technique also allows less tension at the gastrojejunostomy.

Multi-task temporal convolutional networks for joint recognition of surgical phases and steps in gastric bypass procedures

PurposeAutomatic segmentation and classification of surgical activity is crucial for providing advanced support in computer-assisted interventions and autonomous functionalities in robot-assisted surgeries. Prior works have focused on recognizing either coarse activities, such as phases, or fine-grained activities, such as gestures. This work aims at jointly recognizing two complementary levels of granularity directly from videos, namely phases and steps.MethodsWe introduce two correlated surgical activities, phases and steps, for the laparoscopic gastric bypass procedure. We propose a multi-task multi-stage temporal convolutional network (MTMS-TCN) along with a multi-task convolutional neural network (CNN) training setup to jointly predict the phases and steps and benefit from their complementarity to better evaluate the execution of the procedure. We evaluate the proposed method on a large video dataset consisting of 40 surgical procedures (Bypass40).ResultsWe present experimental results from several baseline models for both phase and step recognition on the Bypass40. The proposed MTMS-TCN method outperforms single-task methods in both phase and step recognition by 1-2% in accuracy, precision and recall. Furthermore, for step recognition, MTMS-TCN achieves a superior performance of 3-6% compared to LSTM-based models on all metrics.ConclusionIn this work, we present a multi-task multi-stage temporal convolutional network for surgical activity recognition, which shows improved results compared to single-task models on a gastric bypass dataset with multi-level annotations. The proposed method shows that the joint modeling of phases and steps is beneficial to improve the overall recognition of each type of activity.

Low Health Literate State Does Not Negatively Affect Final Weight Loss After a Laparoscopic Gastric Bypass Procedure

Weight loss surgery is an effective treatment in patients with morbid obesity, but its benefit depends on self-care management afterwards Self-care management is partly influenced by individual’s health literacy. The level of individual’s health literate state (HLS) could determine the person’s health behavior with a subsequent effect on final weight loss We therefore hypothesized that a low HLS may result in a worse post-bariatric surgery outcome (final weight loss) compared to them with a high HLS. A retrospective study was performed including 78 patients (male vs female: 23% vs 77%, respectively; mean age 43 years (SD 12)) who underwent a laparoscopic gastric bypass (LGB) procedure. All patients were invited to perform in a review in which HLS was estimated using Rapid Estimate of Adult Literacy in Medicine- Dutch (REALM-D) and Newest Vital Sign- Dutch (NVS-D) questionnaires. Anthropometric information, such as weight at 0, 3, 6 9 and 12 months after surgery, was collected. Mean preoperative weight was 128.0 kg (SD 21.1) and patients had an average weight loss of 42.2 kg (SD 12.0) after 12 months. Almost half of the population (49%) was low educated, 38% had medium education and 13% was high educated. Of all patients, 22% had an inadequate HLS, according to the REALM-D. Following the NVS-D, 14% was characterized with an inadequate HLS. Patients with an inadequate HLS had an average weight loss of 40.2 kg (SD 13.8) or 31.5% (SD 8.1), while patients with an adequate HLS had an average weight loss of 42.8 kg (SD 11.4 or 33.3 % (SD 6.6). Following the NVS-D, preoperative weight was 123.6 (SD 20.5) for patients with an inadequate HLS and 128.7 (SD 21.1) for patients with an adequate HLS. Patients with an inadequate HLS had an average weight loss of 39.8 kg (SD 14.2) or 31.5% (SD 8.5), patients with an adequate HLS had an average weight loss of 42.6 kg (SD 11.6) or 33.1 % (SD 6.7). This reduce after 12 months did not significantly differ between patients with an inadequate and adequate HLS according to the REALM-D (B = - 1.806, P = 0.350) and NVS-D (B= -0.357, P = 0.885) after correction for age, gender and preoperative weightWeight reduction did not significantly differ between patients with inadequate or adequate health literacy levels, one year after LGB.

PSU4 COMPARISON OF OBESITY CLASSIFICATIONS AT 1, 3, AND 5 YEARS AFTER GASTRIC BYPASS AND GASTRIC SLEEVE SURGERY USING A FEDERATED ELECTRONIC MEDICAL RECORD (EMR) NETWORK

Few published studies have reported body mass index (BMI) following different bariatric surgical procedures. This real-world study compared the rates of obesity and severe obesity at multiple time points following laparoscopic gastric bypass (LGB) or laparoscopic gastric sleeve (LGS) procedures. This retrospective study utilized the TriNetX EMR Research Data Network and Platform. Patients ≥20 years old undergoing LGB or LGS between January 2009 and March 2018 were identified and then excluded if they ever underwent any alternative surgical treatment for obesity. Demographic and clinical characteristics one-year pre-surgery were used for 1:1 propensity-score matching. Outcomes at 1, 3, and 5 years post-surgery included BMI <30 (non-obese) and <40 (non-super obese), using the most recent measurement or diagnosis code, were compared using standard bivariate statistics. Initially 14,482 LGB and 20,890 LGS patients of similar mean age (46±12 years), proportion female (79%) and mean BMI (45±9) met the study criteria. LGB patients had significantly higher rates of comorbidity but lower rates of select medication use. Post-match (n=13,450 each) standardized differences were all <10%. At each time point significantly greater rates of LGB compared to LGS patients attained BMIs <30 (Year 1: 21.6% vs 11.6%; Year 3: 32.2% vs 16.0%; Year 5: 34.0% vs 16.7%) and <40 (Year 1: 57.2% vs 49.3%; Year 3: 66.3% vs 54.6%; Year 5: 68.6% vs 55.7%), all P<0.001. The 5-year odds ratios were BMI<40: 2.50 (CI 2.44, 2.74) and BMI<30: 1.70 (1.66, 1.83). In this real-world setting, LGB patients were more likely than LGS patients to not be obese or severely obese up to 5 years following surgery. While more than half the patients in each cohort could not be classified as severely obese by year 1, the proportion of the LGB cohort to not be obese was 2-fold greater at each time point post-surgery.

Same-day discharge on laparoscopic Roux-en-Y gastric bypass patients: an outcomes review.

The objective of this research was to study safety and outcomes in patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) on an ambulatory outpatient basis. As the prevalence of morbid obesity increases, more patients are opting for surgical weight loss as a means to combat their chronic disease. There are several studies demonstrating the safety and feasibility of select patients undergoing LRYGB on a 23-h outpatient basis, but few studies exist regarding the safety and efficacy of these procedures being performed on an ambulatory outpatient basis. A retrospective review was completed on all patients who underwent a laparoscopic gastric bypass procedure from 2008 to 2018 at a single outpatient ambulatory surgery center. Median BMI was 46.7kg/m2. Inclusion criteria included age > 18 and < 65, ASA class less than 3, completion of a bariatric surgery preparation program, no history of major cardiovascular events, and no prior major open abdominal operations. Exclusion criteria included males > 55years, BMI > 55 for men, and BMI > 60 for women. Operations included primary LRYGB procedures. We determined 30-day post-operative morbidity and mortality for all patients. There were 398 patients who underwent a LRYGB on an ambulatory basis. After thorough chart review, a total of 362 patients were included. The majority were women (315, 87%). The median age was 42 (range 19-65). Seven (1.93%) patients were directly admitted to the hospital, while 13 (3.59%) patients were admitted to the hospital after initial discharge. There were 3 (0.83%) leaks, 4 (1.11%) bleeds requiring transfusion, no wound infections, 1 (0.28%) obstruction, one (0.28%) venous thrombotic event and/or pulmonary embolism, and 9 (2.49%) reoperations. There were zero deaths. This study demonstrates that laparoscopic Roux-en-Y gastric bypass is both feasible and safe when performed on select patients on an ambulatory outpatient basis.

Pancreatitis following bariatric surgery

BackgroundThe laparoscopic Roux-en-Y gastric bypass (LRYGBP) is the second most performed bariatric surgical procedure. With the increasing number of patients undergoing bariatric surgery, the number of complications is also growing. Early diagnosis and treatment of the complications is crucial.Case presentationA very unusual complication was met after an uneventful laparoscopic gastric bypass (LGBP) procedure due to an obstructing blood clot in the biliairy limb resulting in an acute pancreatitis and gastric distention, accompanied by an obstructing blood clot in the distal ileum causing small bowel obstruction. A review of the occurrence of these complications and the diagnosis and treatment is presented.ConclusionPost-bariatric acute pancreatitis is uncommon, but could be fatal. Blood clots should be considered as possible causes of small bowel obstruction, ileus or pancreatitis.

The Influence of Socioeconomic Factors on Quality-of-Life After Laparoscopic Gastric Bypass Surgery

IntroductionPatients with low socioeconomic status have been reported to experience poorer outcome after several types of surgery. The influence of socioeconomic factors on health-related quality-of-life (HRQoL) after bariatric surgery is unclear.Materials and MethodsPatients operated with a primary laparoscopic gastric bypass procedure in Sweden between 2007 and 2015 were identified in the Scandinavian Obesity Surgery Register. Patients with a completed assessment of health-related quality-of-life based on the Obesity-related Problem Scale (OP Scale) were included in the study. Socioeconomic status was based on data from Statistics Sweden.ResultsA total of 13,723 patients (32% of the 43,096 operated during the same period), with complete OP scores at baseline and two years after surgery, were included in the study. Age, lower preoperative BMI, male gender, higher education, professional status and disposable income as well as not receiving social benefits (not including retirement pension), and not a first- or second-generation immigrant, were associated with a higher postoperative HRQoL. Patients aged 30–60 years, with lower BMI, higher socioeconomic status, women and those born in Sweden by Swedish parents experienced a higher degree of improvement in HRQoL. Postoperative weight-loss was associated with higher HRQoL (unadjusted B 16.3, 95%CI 14.72–17.93, p < 0.0001).ConclusionAt 2 years, a strong association between weight loss and improvement in HRQoL was seen, though several factors influenced the degree of improvement. Age, sex, preoperative BMI and socioeconomic status all influence the postoperative HRQoL as well as the improvement in HRQoL after laparoscopic gastric bypass surgery.

The impact of socioeconomic factors on the early postoperative complication rate after laparoscopic gastric bypass surgery: A register-based cohort study

BackgroundSocioeconomic factors may influence the outcome of certain surgical procedures, but it is not known whether such factors influence the risk for postoperative complication after bariatric surgery. ObjectivesDetermining whether different socioeconomic factors influence the risk for postoperative complication after laparoscopic gastric bypass surgery. SettingNationwide in Sweden. MethodsRetrospective register-based cohort study that includes all primary laparoscopic gastric bypass procedures in Sweden between 2010 and 2016, using data from the Scandinavian Obesity Surgery Registry, Statistics Sweden, and the Swedish Population Register. Main outcome measures were occurrence and severity of early postoperative complications. ResultsIncluded in this study were 41,537 patients with 30-day follow-up percentage of 96.7%. Study groups with increased risk for postoperative complication (age, sex, body mass index, and co-morbidity adjusted–odds ratio with 95% confidence intervals) were as follows: being divorced, a widow, or a widower (1.14 [1.03–1.23]); receiving disability pension (1.37 [1.23–1.53]) or social assistance (1.22 [1.07–1.40]); and being first- (1.22 [1.04–1.44]) or second-generation (1.20 [1.09–1.32]) immigrant. In contrast, being single (.90 [.83–.99]), having higher disposable income (50th–80th percentile: .84 [.76–.93]; >80th percentile: .84 [.72–.98]), and living in a medium (.90 [.83–.98]) or small (.84 [.76–.92]) town were associated with lower risk. Increased risk for severe postoperative complication was seen for divorced, widowm, or widower (1.30 [1.12–1.52]) and those receiving disability pension (1.37 [1.16–1.61]) or social assistance (1.32 [1.08–1.62]), while higher disposable income (50th–80th percentile: .79 [.68–.92]; >80th percentile .57 [.46–.72]) was associated with lower risk. ConclusionSocioeconomic factors influence the risk for early postoperative complication after laparoscopic gastric bypass surgery. The impact is not enough to exclude patients from surgery, but they must be taken into account in preoperative risk assessment.

Comparing Techniques for Mesenteric Defects Closure in Laparoscopic Gastric Bypass Surgery\u2014a Register-Based Cohort Study

BackgroundRoutine closure of mesenteric defects is generally considered standard part of laparoscopic gastric bypass surgery today. Controversy still exists regarding the optimal method for mesenteric defects closure. The objective was to compare different methods for mesenteric defects handling in laparoscopic gastric bypass surgery.MethodsPrimary laparoscopic gastric bypass procedures from 2010 until 2015 reported to the Scandinavian Obesity Surgery Registry (SOReg), where the mesenteric defects closure method was identifiable, were included. Main outcome measures were serious postoperative complication within 30 days after surgery, and reoperation for small bowel obstruction within 5 years after surgery. Quality-of-life before and after surgery, duration of surgery, and risk factors for complication were also analyzed. Information on operation for small bowel obstruction was based on data from the SOReg, the Swedish National Patient Register and reviews of hospital charts.ResultsIn all, 34,707 patients were included. Serious postoperative complication occurred in 174 (2.9%) patients with sutures, in 592 (3.1%, adjusted p = 0.079) with clips, and 278 (3.1%; adjusted p = 0.658) in the non-closure group. Reoperation for small bowel obstruction within 5 years after surgery was lower with sutures (cumulative incidence 6.9%) and clips (cumulative incidence 7.3%; adjusted HR 1.16, 95% CI 1.02–1.32, p = 0.026), compared to non-closure (cumulative incidence 11.2%; adjusted HR 1.63, 95% CI 1.44–1.84, p < 0.0001).ConclusionClosure of the mesenteric defects using either non-absorbable metal clips or non-absorbable running sutures is a safe and effective measure to reduce the risk for small bowel obstruction after laparoscopic gastric bypass surgery. Sutures appear slightly more effective and should remain gold standard for mesenteric defects closure.

Pregnancy As a Risk Factor for Small Bowel Obstruction After Laparoscopic Gastric Bypass Surgery.

To evaluate whether pregnancy is associated with increased risk for small bowel obstruction after laparoscopic gastric bypass surgery. Small bowel obstruction is a common and feared long-term complication to laparoscopic gastric bypass surgery that may be more common during pregnancy. It is unclear if the risk truly increases during pregnancy. Women, 18 to 55 years, operated with a primary laparoscopic gastric bypass procedure from 2010 until 2015 were identified through the Scandinavian Obesity Surgery Registry (n = 25,853). Through record-linkage to the Medical Birth Registry, the National Patient Registry, and review of hospital charts, information on pregnancy periods and outcome were obtained. The main outcome was operation due to small bowel obstruction after the laparoscopic gastric bypass procedure. Pregnancy was associated with increased risk for small bowel obstruction following laparoscopic gastric bypass surgery (incidence rates 46.5, 95% CI 38.0-56.9/1000 person-years, vs 20.9 95% CI 19.9-22.0; adjusted-HR 1.72, 95% CI 1.39-2.12, P < 0.001). While no excess risk was observed during the first trimester, the second (adjusted-HR 1.67, 95% CI 1.17-2.39, P = 0.005) and third (adjusted-HR 2.69, 95% CI 2.02-3.59, P < 0.001) conferred increased risk. The incidence rate of small bowel obstruction during pregnancy was 42.9 (95% CI 32.4-57.0/1000 person-years) among women for whom the mesenteric defects had been closed during the primary procedure, and 53.2 (95% CI 38.9-72.8/1000 person-years) for women in whom they had been left open. Pregnancy is associated with increased risk for small bowel obstruction after laparoscopic gastric bypass surgery during the second and third trimesters.

Impact of mesenteric defect closure technique on complications after gastric bypass

BackgroundClosure of mesenteric defects during laparoscopic gastric bypass surgery markedly reduces the risk for small bowel obstruction due to internal hernia. However, this procedure is associated with an increased risk for early small bowel obstruction and pulmonary complication. The purpose of the present study was to evaluate whether the learning curve and subsequent adaptions made to the technique have had an effect on the risk for complications.MethodsThe results of patients operated with a primary laparoscopic gastric bypass procedure, including closure of the mesenteric defects with sutures, during a period soon after introduction (January 1, 2010–December 31, 2011) were compared to those of patients operated recently (January 1, 2014–June 30, 2017). Data were retrieved from the Scandinavian Obesity Surgery Registry (SOReg). The main outcome was reoperation for small bowel obstruction within 30 days after surgery.ResultsA total of 5444 patients were included in the first group (period 1), and 1908 in the second group (period 2). Thirty-day follow-up rates were 97.1 and 97.5% respectively. The risk for early (within 30 days) small bowel obstruction was lower in period 2 than in period 1 (13/1860, 0.7% vs. 67/5285, 1.3%, OR 0.55 (0.30–0.99), p = 0.045). The risk for pulmonary complication was also reduced (5/1860, 0.3%, vs. 41/5285, 0.8%, OR 0.34 (0.14–0.87), p = 0.019).ConclusionClosure of mesenteric defects during laparoscopic gastric bypass surgery can be performed safely and should be viewed as a routine part of that operation.

Surgical skill in bariatric surgery: Does skill in one procedure predict outcomes for another?

Recent data establish a strong link between peer video ratings of surgical skill and clinical outcomes with laparoscopic gastric bypass. Whether skill for one bariatric procedure can predict outcomes for another related procedure is unknown. Twenty surgeons voluntarily submitted videos of a standard laparoscopic gastric bypass procedure, which was blindly rated by 10 or more peers using a modified version of the Objective Structured Assessment of Technical Skills. Surgeons were divided into quartiles for skill in performing gastric bypass, and within 30days of sleeve gastrectomy, their outcomes were compared. Multivariate logistic regression analysis was utilized to adjust for patient risk factors. Surgeons with skill ratings in the top (n=5), middle (n=10, middle 2 combined), and bottom (n=5) quartiles for laparoscopic gastric bypass saw similar rates of surgical and medical complications after laparoscopic sleeve gastrectomy (top 5.7%, middle 6.4%, bottom 5.5%, P=.13). Furthermore, surgeons' skill ratings did not correlate with rates of reoperation, readmission, and emergency department visits. Top-rated surgeons had significantly faster operating room times for sleeve gastrectomy (top 76minutes, middle 90minutes, bottom 88minutes; P<.001) and a higher annual volume of bariatric cases per year (top 240, middle 147, bottom 105; P=.001). Video ratings of surgical skill with laparoscopic gastric bypass do not predict outcomes of laparoscopic sleeve gastrectomy. Evaluation of surgical skill with one procedure may not apply to other related procedures and may require independent assessment of surgical technical proficiency.

Excess Weight Loss and Cardiometabolic Parameter Reduction Diminished among Hispanics Undergoing Bariatric Surgery: Outcomes in More than 2,000 Consecutive Hispanic Patients at a Single Institution

Bariatric surgery has been established as the most effective long-term treatment for morbid obesity and obesity-related comorbidities. Despite its success, there is a paucity of data on the outcomes of bariatric surgery on Hispanic patients. We performed a retrospective review of obese patients treated at our institute between 2008 and 2014. We identified self-reported Hispanic patients who underwent a laparoscopic gastric bypass (LGBP), sleeve gastrectomy (LSG), or gastric band (LGB) procedure. The primary end point was excess weight loss (EWL) at 6, 12, 24, and 36 months. Secondary end points included improvement of obesity-related metabolic parameters at 1 year. We performed a repeated measures analysis of variance to calculate statistical significance throughout our study time period. We identified 2002 Hispanic patients who underwent bariatric surgery (1,235 LGBP, 600 LSG, 167 LGB) at our institute from 2008 to 2014. Follow-ups at 6, 12, 24, and 36 months were 62.2%, 54.5%, 36.2%, and 19.8%, respectively. Mean preoperative BMIs were 47.0 ± 7.2 kg/m2, 46.1 ± 7.8 kg/m2, and 44.9 ± 6.0 kg/m2 for the LGBP, LSG, and LGB cohorts, respectively. Excess weight loss was significantly more pronounced in the LGBP and the LSG groups than in the LGB group; this difference was accentuated over time (p < 0.0001). Obesity-related metabolic parameters and the need for comorbidity medical therapy decreased in all 3 surgical groups. Bariatric surgery is highly successful in Hispanic obese patients. In the largest series to date, LGBP and LSG seem to yield more effective EWL and reduction of cardiometabolic parameters than LGB among Hispanics; however, outcomes are still markedly reduced when compared with those in non-Hispanic populations.

Are we operating too late? Mortality Analysis and Stochastic Simulation of Costs Associated with Bariatric Surgery: Reconsidering the BMI Threshold.

Present guidelines recommend bariatric surgery at BMI ≥ 40 kg/m2 or BMI ≥ 35 kg/m2 with obesity-related morbidity. Evidence for cost and mortality/morbidity risk of bariatric surgery and obesity-related diseases was evaluated determining equivalency point of absolute incremental mortality risk by BMI and risks associated with bariatric surgery. A stochastic model was developed evaluating costs related to surgical procedure at a given BMI. Bariatric surgery produces significant lifetime cost savings associated with diabetes, gallstones, hypertension, high cholesterol, colon cancer, heart disease, and stroke in men at BMI 30 kg/m2 for laparoscopic gastric bypass. For women, laparoscopic gastric bypass saves cost at BMI 32 kg/m2 and laparoscopic gastric banding at BMI 37 kg/m2. In white men, relative to single-year mortality risks by BMI, surgical intervention becomes risk-beneficial at BMI 25 kg/m2 for laparoscopic gastric banding, BMI 27 kg/m2 for laparoscopic gastric bypass procedure and open gastric banding, and BMI 37 kg/m2 for open gastric bypass. Risk benefit for African-American men by procedure occurs at BMI <25 kg/m2, BMI 27 kg/m2, and BMI 42 kg/m2, respectively. In white women, surgical intervention is beneficial at BMI 25.5 kg/m2 (laparoscopic gastric banding), BMI 28.5 kg/m2 (laparoscopic gastric bypass procedure), and BMI 45 kg/m2 (open gastric banding). Risk benefit for black women by procedure occurs at BMI 27.5 kg/m2, BMI 33.5 kg/m2, and BMI 50+ kg/m2, respectively. Risk and cost benefit suggest surgical guidelines should be reconsidered. Threshold for bariatric surgery should be redefined to BMI 35 kg/m2 or BMI 30 kg/m2 with comorbidities.

Does Bariatric Surgery Reduce Health Care Costs?: Weighing the Evidence.

Bariatric surgery is by far themost effective therapy formorbid obesity and obesity-related conditions, especially type 2 diabetesmellitus.Numerouswell-designedobservational studies and randomized clinical trials showprofoundweight loss, high rates of comorbidity resolution, improvedquality of life, and decreased mortality after bariatric surgery.1-3 Despite these well-known clinical benefits, there is debate about the impact of bariatric surgery on health care expenditures. Bariatric surgery itself is a relatively expensive intervention.Besides the surgical episode itself, there are substantial preoperative costs fromtesting and referrals to specialists, as well as increased postsurgical costs owing to shortand longer-term complications. Studies evaluating the longer-term health care costs have shownmixed results.4-6 The study in this issue of JAMA Surgery by Lewis et al7 brings important newdata to this debate. Using a uniquedata source, privatepayer claims fromacross theUnitedStates, the authorswere able tomeasure health care expenditures (from thepayer perspective) over time for patients undergoing laparoscopic adjustable gastric banding and laparoscopic gastric bypass procedures. Importantly, theauthorsusedarigorous longitudinal study design—evaluatinghealth care costs over time inpatientswho had surgery—that allows patients to serve as their own controls. Inmanyways, this is superior to using a nonsurgical cohort of control individuals, as there is no way of knowing whether patientswho do not have surgery are truly similar to those who do have surgery. The study design used by Lewis et al7 assumes that an individual’s health care spending trend will continue on a similar trajectory (a slow upward trend) if they do not have surgery, which seems quite reasonable. This study has 2 very important findings.7 First, at 3 years after surgery, there was a significant change in trajectory of health care expenditures,with a flatteningof the trend in total health care costs and prescription drug costs. Without surgery, it is most likely that this trend would have followed the upward trend demonstrated in the preoperative period. This finding implies that bariatric surgery is certainly not increasing costs as many worry about, and it very well may result in net cost savings in the long term. Second, this studyprovides important informationon the comparative effectiveness of the laparoscopic band vs laparoscopic gastric bypass. Although the laparoscopic band was associated with lower costs and fewer emergency department visits early postoperatively (which has clinical face validity), by 3 years, the laparoscopic gastric bypass was associatedwith lower total andprescription costs. This conclusively demonstrates that the superior clinical efficacy of laparoscopic gastric bypass demonstrated in clinical trials translates into greater longer-term health care cost savings. This study does leave some important questions to answer. Namely, what happens to health care expenditures beyond 3 years? As the authors pointed out, if this flattening of the cost trend continues, bariatric surgery may be a costsaving procedure,7 which has important implications for expanding insurance coverage.Moreover, howdo expenditures for laparoscopic sleeve gastrectomy comparewith gastric bypass? Because laparoscopic sleeve gastrectomy is rapidly becoming the most common bariatric procedure subsequent evaluations of this procedure will be essential.

Long-Term Follow-Up of Gastric Banding 10 Years and Beyond.

This investigation assessed the long-term outcome of patients with gastric banding implanted more than 10 years ago. A total of 73 patients undergoing laparoscopic gastric banding between 1997 and 2003 were identified. Patients who had their band removed were converted to a laparoscopic gastric bypass procedure. The mean preoperative body mass index (BMI) was 44.4 (SD 5.3). The mean follow-up was 11.6 (SD 2.1) years. The reasons for reoperation were leakage (N = 16, 21.9 %), slipping (N = 15, 20.5 %), and insufficient weight loss (N = 9, 12.3 %). The band was left in situ in 33 patients (45.2 %). The 5- and 10-year survival rates for the banding were 82.2 % (95 %CI 73.9-91.5 %) and 53.4 % (95 %CI 43.1-66.2 %). Best results were observed in male patients (10-year survival rate 76.5 %, 95 %CI 58.7-99.5 %, HR = 0.44, P = 0.043) and patients older than 50 years (10-year survival rate 63.8 %, 95 %CI 51.5-79.2 %, HR = 0.41, P = 0.006). Overall, the BMI was 31.0 (SD 6.3) at follow-up, excess weight loss was 68.1 % (SD 26.4), and the score for the Moorehead-Ardelt Questionnaire was 1.6 (SD 1.0). Similar results were obtained for patients with and without banding failure. The present investigation provides evidence that gastric banding remains effective after more than 10 years in less than 50 % of initially operated patients. Older (>50 years) and male patients seemed to maintain the banding as long-time carriers with good results, and these patients subjectively profited from this method. Good results can be achieved if patients are followed thoroughly, and alternative surgical options for patients who fail may be offered with longstanding success.