Laparoscopic Roux-en-Y Gastric Bypass Patients Research Articles

Early postoperative weight loss predicts nadir weight and weight regain after laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass.

Weight regain (WR) post bariatric surgery affects almost 20% of patients. It has been theorized that a complex interplay between physiologic adaptations and epigenetic mechanisms promotes WR in obesity, however, reliable predictors have not been identified. Our study examines the relationship between early postoperative weight loss (WL), nadir weight (NW), and WR following laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG). A retrospective review of prospectively collected data was conducted for LRYGB or LSG patients from 2012 to 2016. Demographics, preoperative BMI, procedure type, and postoperative weight at 6, 12, 24, 36, and 48 months were recorded. WR was defined as > 20% increase from NW. Univariate and multivariate linear and logistic regression models were used to determine the association between early postoperative WL with NW and WR at 4years. Thousand twenty-six adults were included (76.8% female, mean age 44.9 ± 11.9years, preoperative BMI 46.1 ± 8); 74.6% had LRYGB and 25.3% had LSG. Multivariable linear regression models showed that greater WL was associated with lower NW at 6months (Coef -2.16; 95% CI -2.51, -1.81), 1year (Coef -2.33; 95% CI -2.58, -2.08), 2years (Coef -2.04; 95% CI -2.25, -1.83), 3years (Coef -1.95; 95% CI -2.14, -1.76), and 4years (Coef -1.89; 95% CI -2.10, -1.68), p≤0.001. WR was independently associated with increased WL between 6months and 1year (Coef 1.59; 95% CI 1.05,2.14; p≤0.001) and at 1year (Coef 1.24; 95% CI 0.84,1.63;p≤0.001) postoperatively. The multivariable logistic regression model showed significantly increased risk of WR at 4years for patients with greater WL at 6months (OR 1.20, 95% CI 1.08,1.33; p = 0.001) and 1year (OR 1.14; 95% CI 1.06,1.23; p≤0.001). Our findings demonstrate that higher WL at 6 and 12months post bariatric surgery may be risk factors for WR at 4years. Surgeons may need to follow patients with high early weight loss more closely and provide additional treatment options to maximize their long-term success.

Beyond 5 years: a matched cohort of sleeve gastrectomy versus gastric bypass.

Laparoscopic sleeve gastrectomy (LSG) has demonstrated excellent short-term outcomes. However, existing studies suffer from loss to follow-up, and most long-term data focus on laparoscopic Roux-en-Y gastric bypass (LRYGB). This study compares weight loss in patients ≥5 years from LSG with that in matched patients who underwent LRYGB. The purpose of this study was to compare long-term weight loss in patients undergoing LRYGB and LSG. University hospital, United States. We retrospectively evaluated patients who underwent LSG before August 2012 with follow-up data ≥5 years. LSG patients were matched 1:1 with LRYGB patients by sex, age at surgery, and preoperative body mass index. Univariate and multivariate analyses were performed with weight loss at the longest duration the primary outcome. One-hundred and sixty-five patients underwent LSG during the study period. Long-term follow-up data (≥5 years) were available for 85 patients (52%). There were no preoperative differences between those with and without follow-up data. Six LSG patients (7%) were excluded because they underwent reoperation that altered intestinal anatomy. Of the 79 patients remaining, 75 were matched with post-LRYGB patients. The average follow-up period was 6.4 years for LSG patients and 6.5 years for LRYGB patients (P = .08, not significant). Change in body mass index was 6.81 kg/m2 for LSG patients and 13.11 kg/m2 for LRYGB patients. Percentage of total body weight loss was 15.25% for LSG patients and 28.73% for LRYGB patients. Percentage of excess body weight loss was 37% for LSG patients and 67% for LRYGB patients (P < .0001). Weight loss for LSG patient follow-up in clinic versus outside the clinic was 46% versus 34% (P = .18, not significant). LSG is now the most common bariatric surgery in the United States. Long-term data are needed to confirm that observed short-term favorable outcomes are maintained. Recent studies have produced divergent results. We observed significantly less weight loss at ≥5 years in LSG patients compared with matched LRYGB patients.

Mid-Term Outcomes of Laparoscopic Gastric Greater Curvature Plication versus Roux-en-Y Gastric Bypass: Weight Loss, Gastrointestinal Symptoms, and Health-Related Quality of Life.

Background and Objectives: Laparoscopic gastric greater curvature plication (LGGCP) is considered to be less invasive, technically simpler, and less costly. Few studies have compared LGGCP to gastric bypass. The aim of this prospective study was to evaluate the mid-term outcomes of LGGCP such as weight loss, gastrointestinal symptoms, and health-related quality of life (HRQoL) in comparison to laparoscopic Roux-en-Y gastric bypass (LRYGB). Materials and Methods: Between 2017 April and 2018 December, 112 patients were included in the study. Fifty patients had LGGCP, and sixty-two patients underwent LRYGB. Demographics, comorbidities, complications, percentage of excess body mass index loss (%EBMIL), gastrointestinal symptoms (GSRS questionnaire), and HRQoL (EQ-5D-3L questionnaire) were analysed. Gastrointestinal symptoms and HRQoL data are presented as the mean and median with the interquartile range (25th–75th percentile). Follow-up at 1 year and 3 year was performed. Results: The follow-up rate was 96.4% and 92.9%, 1 year and 3 year after surgery, respectively. Mean (SD) %EBMIL 1 year after surgery was 59.05 (25.34) in the LGGCP group and 82.40 (19.03) in the LRYGB group (p < 0.001) and 3 year after was 41.44 (26.74) and 75.59 (19.14), respectively (p < 0.001). The scores of all gastrointestinal symptoms measured by the GSRS questionnaire significantly decreased 3 year after both procedures, except reflux after LGGCP. Patients 3 year after LGGCP had a significantly lower abdominal pain score as compared to patients after LRYGB (1.01; 1.0 (1.0–1.0) and 1.20; 1.0 (1.0–1.33), respectively (p < 0.001); however, LGGCP resulted in significantly more GERD symptoms (1.79; 1.25 (1.0–2.5) and 1.18; 1.0 (1.0–1.0), respectively (p < 0.001)). Three years after surgery, the quality of life was significantly lower in the LGGCP group (0.762; 0.779 (0.690–0.794) and 0.898; 1.000 (0.783–1.000), respectively (p < 0.001)). Conclusions: Three years after surgery, LGGCP patients lost significantly less weight, had less abdominal pain and more reflux symptoms, and a lower quality of life as compared to LRYGB patients.

The Influence of Mesenteric Defects Closure on the Use of Computed Tomography for Abdominal Pain 5 Years After Laparoscopic Gastric Bypass\u2014a Post Hoc Analysis of a Randomized Clinical Trial

BackgroundAbdominal pain after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a common and unwanted complication that typically leads to further exploration through radiology. Concerns have been raised regarding the consequences of this radiation exposure and its correlation with the lifetime risk of cancer. The aim of this study was to evaluate the differences in computed tomography (CT) use between LRYGB patients with open and closed mesenteric defects and to assess the radiological findings and radiation doses.MethodsThis subgroup analysis included 300 patients randomized to either closure (n = 150) or nonclosure (n = 150) of mesenteric defects during LRYGB. The total number of CT scans performed due to abdominal pain in the first 5 postoperative years was recorded together with the radiological findings and radiation doses.ResultsA total of 132 patients (44%) underwent 281 abdominal CT scans, including 133 scans for 67 patients with open mesenteric defects (45%) and 148 scans for 65 patients with closed mesenteric defects (43%). Radiological findings consistent with small bowel obstruction or internal hernia were found in 31 (23%) of the scans for patients with open defects and in 18 (12%) of the scans for patients with closed defects (p = 0.014). The other pathological and radiological findings were infrequent and not significantly different between groups. At the 5-year follow-up, the total radiation dose was 82,400 mGy cm in the nonclosure group and 85,800 mGy cm in the closure group.ConclusionClosure of mesenteric defects did not influence the use of CT to assess abdominal pain.Graphical abstract

Impact of Self-Monitoring on Weight Loss After Bariatric Surgery.

Weight loss after bariatric surgery varies among patients. Patients who do not comply with self-monitoring are predicted to lose less weight than those who comply with self-monitoring. To assess the effect of compliance with self-monitoring behavior on long-term %excess weight loss (%EWL) and %total weight loss (%TWL) among patients receiving laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). We used retrospective analysis to evaluate the self-monitoring behavior of patients and their weight changes throughout a 2-year follow-up. The participants were divided into two groups: group 1 consisted of participants who kept self-monitoring behavior records for all follow-ups and group 2 consisted of participants who kept self-monitoring behavior records for only six months of follow-up. Our investigators used telephone interviews to collect the data. By comparing %EWL and %TWL, we assessed the possible relationship between the long-term self-monitoring behavior, weight loss outcome, and operation type. There were 384 included samples. %EWL was significantly different between group 1 and group 2, and group 1 participants had better outcomes regardless of operational method. In group 2, LRYGB patients had better %EWL outcomes than LSG patients. Patients with long-term self-monitoring behaviors have better %EWL and %TWL. Patients in LRYGB group had better weight loss outcomes than the LSG group.

Small bowel obstruction following laparoscopic Roux-en-Y gastric bypass: is it always necessary to operate? A 5-year, high volume center experience.

This study aims to describe the incidence, associated factors, etiology, and management of small bowel obstructions following laparoscopic Roux-en-Y gastric bypass (LRYGB). A retrospective analysis was conducted between January 15 and December 19 using the surgery database of our hospital. Included LRYGB patients were those that evolved with a prolonged length of stay; readmission; emergency room consult; and re-intervention due to small bowel obstruction (SBO) related symptoms with compatible radiological or intraoperative findings. The LRYGB technique implied an antecolic alimentary limb reconstruction and systematic closure of mesenteric defects. Descriptive and analytical statistics were carried out, using a parametric or non-parametric approach as needed. Nine hundred forty-one LRYGB were performed. 9.9% were revisional surgeries of patients with a laparoscopic sleeve gastrectomy. During the study period, 36 SBOs occurred, representing 3.8% of operated patients, with no mortality. 58.3% had successful non-operative management, while 41.7% required surgical exploration, of which 73.3% were treated laparoscopically and 20% needed conversion to open surgery. Etiologies of SBO were jejuno-jejunostomy (JJO) related stenosis (22, 61.1%), internal hernias (6, 16.7%), adherences (3, 8.3%), and other diagnoses (5, 13.9%). Regarding JJO stenosis and internal hernias, median time to diagnosis was 8days (IQR 7-11) and 12months (IQR 8.7-16) respectively. Previous sleeve gastrectomy, age, or sex was not associated to the incidence of small bowel obstruction. LRYGB is safe when performed by experienced surgeons. SBO due to internal hernias were scarce in this series. JJO stenosis could explain most cases of SBO; under this diagnosis, non-surgical management was successful frequently.

The Impact of Combined Bariatric Interventions on the Course of Non-Alcoholic Fatty Liver Disease

Background. Obesity is widely recognized as a disease that acquires the scale of an epidemic and is accompanied by a number of comorbidities, one of which is non-alcoholic fatty liver disease (NAFLD), while the issue of the impact of bariatric interventions on its course remains a subject of discussion, which determines the relevance of this study.Aims. Тo evaluate the impact of combined bariatric interventions - laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic mini-gastric bypass (LMGB-OAGB), - on the course of NAFLD and to determine the criteria that affect the dynamics of NAFLD after thеsе bariatric interventions.Materials and methods. The study included 56 patients who had one of 2 types of bariatric interventions performed between 2014 and 2017: LRYGB (26 (46,4%) patients) and LMGB-OAGB (30 (53,6%) patients). All patients underwent intraoperative liver biopsy, a range of laboratory and instrumental studies, FibroTest were calculated in dynamics. The frequency of complications in the postoperative period was estimated. The period of observation was 2 years. Results. In the group of laparoscopic Roux-en-Y gastric bypass 12 (46.2%) patients showed signs of liver fibrosis according to histological research, and 8 (30.8%) - signs of non - alcoholic steatohepatitis (NASH). There was an increase in transaminases in 5(19,2%), gamma-glutamyltranspeptidase (GGTP) in 19 (73.1%), and total bilirubin in 8 (30.8%) subjects. 20 (76.9%) participants had increased alkaline phosphatase (ALP), 22 (84.6%) had reduced high density lipoproteins (HDL) and increased triglycerides (TG). According to the results of ultrasound examination of the liver, 19 (73.1%) patients had enlarged liver size, 26 (100%) - diffuse heterogeneity, and 25 (96.2%) - hyperechogenicity. In the group of laparoscopic mini-gastric bypass, there were signs of liver fibrosis in 14 (46.7%) and NASH - in 14 (46.7%) patients. An increase in tranasminases was observed in 8 (26.7%), GGTP in 22 (73.3%), and total bilirubin in 6 (20%) patients. 9 (30%) of participants had increased ALP, 26 (86.7%) patients had reduced HDL and increased TG. 21 (70%) patients had enlarged liver size, 29 (96.7%) - diffuse heterogeneity, and 28 (93.3%) - hyperechogenicity.6 months after both types of interventions, there was a decrease in the clinical and biochemical characteristics of non-alcoholic fatty liver disease, which was transient and regressed by 1 year after surgery.After laparoscopic Roux-en-Y gastric bypass %EBMIL in 1 year was 75.25 [65.85-84.36] %. Normalization of transaminases was observed in 84.6%, cholestasis indicators in 87.2%, and FibroTest -in 46.2% of cases. % EBMIL 1 year after laparoscopic mini-gastric bypass was 74.77 [67.28-78.89] %. Normalization of transaminases was observed in 83.3%, cholestasis indicators in 78.9%, and FibroTest -in 43.3% of cases.Combined bariatric interventions were shown to be more effective in participants under 45 years of age compared to those over 45 years of age and in patients with initial stages of fibrosis F0-F2 by METAVIR compared to participants with stages F3-F4 by METAVIR. Patients with a BMI of more than 40 kg / m2 achieved higher FibroTest values after six months compared to subjects with a BMI of up to 40 kg/m2 and in fewer cases - FibroTest normalization by 1 year after surgery, respectively. The effectiveness of operations on the course of NAFLD was comparable.The results of the intervention on signs of non-alcoholic fatty liver disease were preserved for 2 years of postoperative follow-up. The mortality rate during the entire follow-up period was 0%. 47 (83,9%) patients were followed up to 2 years.Conclusion. Тhere was a high efficiency of RYGB and MGB-OAGB in patients with non-alcoholic fatty liver disease, while a transient aggravation of the course of non-alcoholic fatty liver disease was detected 6 months after the operation.Keywords: non-alcoholic fatty liver disease; obesity; metabolic syndrome; bariatric surgery; LRYGB; LMGB-OAGB; FibroTest; surgical intervention

Clinical symptoms are correlated with gastrojejunal anastomosis complications only during the first year after laparoscopic Roux-en-Y gastric bypass.

Introduction: after laparoscopic Roux-en-Y gastric bypass (LRYGBP) many patients complain of epigastric pain or food intolerance, leading to the performance of upper gastrointestinal (UGI) endoscopy. Objective: this study aims to assess which symptomatology as reported by LRYGBP patients during follow-up suggested correlation with pathological findings of endoscopy, and which factors might play a role, taking the timing of symptom presentation into account. Materials and methods: a retrospective cohort study was performed identifying LRYGBP patients presenting with food intolerance and/or epigastric pain who had undergone endoscopy. Primary outcomes were endoscopy findings, their association with patient characteristics, and timing of symptom presentation. Results: of the 514 patients complaining of epigastric pain and/or food intolerance, 81 (15.6 %) underwent endoscopy. A gastrojejunostomy complication was found in 58 % of cases. All patients who complained about food intolerance and epigastric pain presented pathological findings. The only preoperative factor associated with a gastrojejunostomy complication was being a smoker (p = 0.021). Time between surgery and endoscopy was also a predictive factor for endoscopic pathological findings (p = 0.007); in cases of epigastric pain, symptom onset during the first year (median: 10 months) was related to increased risk of gastrojejunal complications (p < 0.05). Conclusions: endoscopies performed within one year of surgery were significantly more likely to reveal pathological findings than endoscopies performed after the first postoperative year, especially in patients experiencing epigastric pain.

Long-Term Effects of Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass on Body Composition and Bone Mass Density

Background: Currently, the two most common bariatric procedures are laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). Long-term data comparing the two interventions in terms of their effect on body composition and bone mass density (BMD) are scarce. Objective: The aim of this study was to assess body composition and BMD at least 5 years after LSG and LRYGB. Setting: Department of Endocrinology and Nutrition, St. Claraspital Basel and St. Clara Research Ltd., Basel, Switzerland. Methods:Bariatric patients at least 5 years after surgery (LSG or LRYGB) were recruited, and body composition and BMD were measured by means of dual-energy X-ray absorptiometry. Data from body composition before surgery were included in the analysis. Blood samples were taken for determination of plasma calcium, parathyroid hormone, vitamin D₃, alkaline phosphatase, and C-terminal telopeptide, and the individual risk for osteoporotic fracture assessed by the Fracture Risk Assessment Tool score was calculated. After surgery, all patients received multivitamins, vitamin D₃, and zinc. In addition, LRYGB patients were prescribed calcium. Results: A total of 142 patients were included, 72 LSG and 70 LRYGB, before surgery: median body mass index 43.1, median age 45.5 years, 62.7% females. Follow-up after a median of 6.7 years. For LRYGB, the percentage total weight loss at follow-up was 26.3% and for LSG 24.1% (p = 0.243). LRYGB led to a slightly lower fat percentage in body composition. At follow-up, 45% of both groups had a T score at the femoral neck below –1, indicating osteopenia. No clinically relevant difference in BMD was found between the groups. Conclusions:At 6.7 years after surgery, no difference in body composition and BMD between LRYGB and LSG was found. Deficiencies and bone loss remain an issue after both interventions and should be monitored.

Higher Edmonton Obesity Staging System scores are independently associated with postoperative complications and mortality following bariatric surgery: an analysis of the MBSAQIP.

Bariatric surgery is an evidence-based approach for sustained weight loss in patients with severe obesity. The most common procedures in North America are the laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). The Edmonton Obesity Staging System (EOSS) is a tool that assigns patients a score of 0 to 4 according to their obesity-related comorbidities and functional status. Previous research demonstrates that increasing EOSS score is associated with overall non-operative mortality risk. We sought to assess the association of the EOSS with major 30-day postoperative complications following LSG or LRYGB. Primary LSG or LRYGB patients were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. Patients were assigned EOSS scores according to their comorbidities and functional limitations extracted from the database. Multivariable logistic regression analysis was conducted to evaluate the relationship between EOSS score, age, sex, BMI, type of procedure, or operative time with 30-day major complications. From 2015 to 2017, 430,238 patients (79.4% female) who underwent primary LSG or LRYGB were identified. The relative frequencies of patients by EOSS score were: 0 and 1 (23.9%), 2 (62.8%), 3 (10.5%), and 4 (2.9%). Mean preoperative BMI was 45.4 (SD 7.9) kg/m2 and mean age was 44.6 (SD 12.0) years. The overall 30-day major complication rate was 3.5%. EOSS 2, 3, and 4 were significantly associated with major complications. The strongest associations with major complications were EOSS 4 (OR 2.30; 95% CI 2.11-2.51, p < 0.001) and LRYGB versus LSG (OR 2.03; 95% CI 1.97-2.11, p < 0.001). EOSS 3 and 4 were most strongly associated with death. Higher EOSS scores are independently associated with 30-day major postoperative complications and mortality. The EOSS provides utility in staging patients and identifying those at greater risk of postoperative complications.

Endoscopy Used as Provocative Testing in Bariatric Surgery: An Analysis of the Texas Public Use Data File

Background:Many bariatric surgeons test the anastomosis and staple lines with some sort of provocative test. This can take the form of an air leak test with a nasogastric tube with methylene blue dye or with an endoscopy. The State Department of Health Statistics in Texas tracks outcomes using the Texas Public Use Data File (PUDF).Methods:We queried the Texas Inpatient and Outpatient PUDFs for 2013 to 2017 to examine the number of bariatric surgeries with endoscopy performed at the same time. We used the International Classification of Diseases Clinical Modification Version 9 (ICD-9-CM) and ICD-10 procedure codes and Current Procedural Terminology for Sleeve Gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) and endoscopy, and the ICD-9-CM and ICD-10 diagnosis codes for morbid obesity.Results:There were 74,075 SG reported in the Texas Inpatient and Outpatient PUDF for the years 2013–2017. Of the SG performed, 5,521 (7.4%) had an intraoperative endoscopy. For the 19,192 LRYGB reported, 1640 (8.6%) underwent LRYGB + endoscopy. This was broken down by SG only vs SG + endoscopy and LRYGB only vs LRYGB + endoscopy. Overall, SG + endoscopy had a significantly shorter length of stay (LOS) vs LRYGB + endoscopy at 1.74 d vs 2.34 d (P < .001) and a significantly less cost of $71,685 vs $91,093 (P < .001).Conclusions:A small percentage of SG and LRYGB patients underwent endoscopy for provocative testing over the study period. Provocative testing with endoscopy costs more for SG and LRYGB and was associated with a shorter LOS.

A Step in the Right Direction: Trends over Time in Bariatric Procedures for Patients with Gastroesophageal Reflux Disease.

While laparoscopic sleeve gastrectomy (LSG) has recently emerged as the predominant surgery type for the national bariatric cohort, the literature suggests that laparoscopic Roux-en-Y gastric bypass (LRYGB) may be more effective in normalizing gastroesophageal physiology for the subset of patients with GERD. This study explored practice patterns over time for patients with GERD or hiatal hernia, a related comorbidity, undergoing bariatric surgery. Data for LSG and LRYGB were extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) datasets for 2015-2018. Multivariable logistic regression analyses were performed to determine the effects of pre-existing GERD or concomitant hiatal hernia repair on surgery type. A total of 130,772 patients underwent LRYGB (30.5%) or LSG (69.5%) in 2015, which increased year-to-year to 161,275 patients in 2018 (74.61% LSG). A total of 38.4% LRYGB patients had pre-existing GERD vs. 27.55% LSG patients. Patients with pre-existing GERD were increasingly likely to undergo LRYGB vs. those without GERD (OR 1.205 [95% CI 1.17-1.24] in 2015 vs. OR 1.510 [95% CI 1.47-1.55] in 2018, p < 0.0001 across years). Concomitant hiatal hernia repair was less common among LRYGB patients across all years (OR 0.413 [95% CI 0.4-0.43] for 2015; OR 0.381 [95% CI 0.37-0.4] for 2016; OR 0.403 [95% CI 0.39-0.42] for 2017, OR 0.464 [95% CI 0.45-0.48] for 2018, p < 0.0001). Bariatric patients with pre-existing GERD are increasingly likely to undergo LRYGB, consistent with the literature. LSG is presently more common in the overall cohort and among those undergoing concomitant hiatal hernia repair. Despite the growing recognition of GERD in bariatric patients, a significant discrepancy persists in hiatal hernia management per bariatric procedure type.

Improvement in glycated hemoglobin A1C after laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in an ethnically diverse population with diabetes.

Obesity is a well-known risk factor for the development of type 2 diabetes. The efficacy of bariatric surgery in reducing weight with resulting improvement in type 2 diabetes has been reliably demonstrated. We investigated and compared the effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) on glycated hemoglobin (HbA1C) levels in a predominantly Hispanic and black population. Community Hospital in New York, New York, United States. This is a retrospective review of a 5-year data from a single center where patients with diabetes who underwent LRYGB or LSG were included. HbA1C levels and body mass index were analyzed preoperatively and then annually postoperatively for up to 5 years. Improvements in HbA1C were compared between the 2 groups after adjusting for age, sex, race, and hypertension with linear mixed-effects or logistic regression models. Of the 676 included patients, 84.8% were females and the mean age was 47 years. HbA1C levels decreased significantly (P < .05) in the entire group at 1 (21%), 2 (20%), 3 (20%), 4 (18%), and 5 (14%) years. Compared with LSG, LRYGB patients displayed greater improvement in HbA1C levels at 1 year (25% versus 17%, P = .001). The differences in the reduction of HbA1C between LRYGB and LSG for the other time intervals were not significant (P > .05), 24% versus 17% (2 yr), 22% versus 16% (3 yr), 22% versus 13% (4 yr), and 17% versus 10% (5 yr). Changes in body mass index were not correlated to changes in HbA1C at various study points. Both LRYGB and LSG resulted in significant decreases in HbA1C levels and are correlated with changes in body mass index. LRYGB had the greatest effect at 1 year postoperatively. There was no significant difference in HbA1C reduction for LRYGB and LSG after 1 year postoperatively in this predominantly Hispanic and black cohort.

Bariatric surgery in the elderly: a randomized prospective study comparing safety of sleeve gastrectomy and Roux-en-Y gastric bypass (BASE Trial).

The aging population along with the obesity epidemic has increased the number of older patients undergoing bariatric surgery. Nevertheless, there is still conflicting data regarding surgical safety in this population. The aim of this study was to compare the surgical morbidity of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) for older patients. University hospital, São Paulo, Brazil. We performed a prospective randomized clinical trial from September 2017 to May 2019. Obese patients aged ≥65 years were randomized to LSG or LRYGB. Data collection included demographic information, body mass index (BMI), and co-morbidities. We assessed readmission, postoperative complications, and mortality. Complications were scored according to Clavien-Dindo classification. A total of 36 patients, with a BMI between 35.5 and 52.8 kg/m2 were randomized to either LSG (18 patients) or LRYGB (18 patients). The overall complication rate was similar between LSG and LRYGB (3 versus 7, P = .13). Severe complication was more prevalent in LRYGB patients but had no statistically significant difference (0 versus 3, P = .07). Each group had 1 readmission and there was no mortality in 90-day follow-up. Morbidity and mortality rates of bariatric surgery are low in elderly obese patients. Despite not statistically significant, LSG had a lower rate of severe complications compared withLRYGB in this population setting.

Laparoscopic Roux-En-Y gastric bypass versus one anastomosis (loop) gastric bypass for obesity: A prospective comparative study of weight loss and complications

IntroductionMost Bariatric units perform Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) and One Anastomosis Gastric Bypass (OAGB) for weight loss and metabolic purposes with satisfactory results and low complication profile. ObjectivesThis study compares LRYGB and OAGB outcomes in a high volume single bariatric unit. MethodsData was collected prospectively and analysed retrospectively for all LRYGB and OAGB performed between Jan 2014 to Dec 2016. The follow up period was for 2 years. Patients who were lost to follow up or had prior bariatric procedure were excluded. Excess weight loss percentage (EWL %), total weight loss percentage (TWL %) and post-operative complications were compared in both groups. Results1268 procedures performed. 113 patients were excluded. At 2 years, for LRYGB and OAGB groups mean TWL % was 31% and 35.4% respectively (P < 0.0001); and mean EWL % was 70.1% and 74.8% respectively (P = 0.0119). Gastroesophageal reflux symptoms were higher in OAGB group 17 (8.5%), with 7 patients needing further surgery, versus 26 (2.7%) in LRYGB (P = 0.0003). There was no difference in incidence of marginal ulcers between LRYGB and OAGB 2.7% vs 5% respectively (P = 0.1115). Internal hernia was seen only in LRYGB patients, 22 (2.2%). There was no significant difference in the re-operation rates following LRYGB 52 (5.4%) and OAGB 16 (8%) (P = 0.1824). ConclusionOAGB had superior short-term weight loss and low complications profile. Both procedures demonstrated no difference in either marginal ulcers or re-operation rates. Reflux symptoms have remained a major side effect of OAGB.

Outcome of revisional bariatric surgery for insufficient weight loss after laparoscopic Roux-en-Y gastric bypass: an observational study.

Insufficient weight loss or secondary weight regain with or without recurrence of comorbidity can occur years after laparoscopic Roux en Y gastric bypass (LRYGB). In selected patients, increasing restriction or adding malabsorption may be a surgical option after conservative measures failed. Evaluation of short and long term results of revisional surgery for insufficient weight loss or weight regain after LRYGB. Tertiary hospital. Retrospective analysis of prospectively collected data from a cohort of 1150 LRYGB patients. Included were patients, who underwent revisional bariatric surgery after LRYGB for insufficient weight loss with a follow-up of minimal 1 year. Fifty-four patients were included in the analysis. After an interdisciplinary evaluation, patients with insufficient weight loss, signs of dumping syndrome, and lacking restriction were offered a nonadjustable band around the pouch (banded group, n = 34) and patients with sufficient restriction, excellent compliance, and adherence were offered a revision to laparoscopic biliopancreatic diversion (BPD group, n = 20). The revisional procedure was performed 3.3 ± 2.3 years after LRYGB in the banded-group and after 6.4 ± 4.3 years in the BPD group (P = .001). Mean body mass index at the time of the primary bariatric procedure was 41.7 ± 6.2 kg/m2 in the banded group and 45.2 ± 8.2 kg/m2 in the BPD group (P = .08); minimal body mass index between both operations was 29.1 ± 4.7 kg/m2 in the banded group and 36.5 ± 9.4 kg/m2 in the BPD group, and, at the time of revisional surgery, 31.4 ± 5.5 kg/m2 in the banded group and 40.8 ± 6.7 kg/m2 in the BPD group (P = .0001). The mean body mass index difference 1 year after revisional surgery was 1.3 ± 3.0 kg/m2 in the banded group and 6.7 ± 4.5 kg/m2 in the BPD group (P = .01). In the banded group, 11 patients (32.4%) needed removal of the band, 4 patients (11.8%) needed an adjustment, and 4 patients (11.8%) were later converted to BPD. In the BPD group, 2 (10.0%) patients needed revision for severe protein malabsorption. Insufficient weight loss or secondary weight regain after LRYGB is a rare indication for revisional surgery. Banded bypass has modest results for additional weight loss but can help patients suffering from dumping. In very carefully selected cases, BPD can achieve additional weight loss with acceptable complication rate but higher risk for reoperation. Future "adjuvant medical treatments," such as glucagon-like peptide 1 analogues and other pharmacologic treatment options could be an alternative for achievingadditional weight loss and better metabolic response.

Vertical Banded Gastroplasty Revision to Gastric Bypass Leads to Effective Weight Loss and Comorbidity and Dysphagia Symptom Resolution.

Up to 50% of patients with vertical banded gastroplasty (VBG) experience failure or complications in the mid- and long-term and present for revisional bariatric surgery. This study aimed to review our experience for patient outcomes after VBG revisions and compare their benefits to those of primary laparoscopic Roux-en-Y gastric bypass (LRYGB) operations. Data from patients who underwent VBG revision between 2009 and 2015 at a center of excellence were reviewed. Patient demographics, symptoms, comorbidities, weight loss, reinterventions, reoperations, and hospital stay were analyzed and compared with those of primary LRYGB patients (control group). Fifty-two patients (88.5% female, 55 ± 9.6years old) underwent revisional surgery during the study period (86.5% LRYGB, 11.5% VBG reversal, and 2% sleeve gastrectomy). Patients presented 17.3 ± 7.2years after their VBG for weight regain (55.8%), dysphagia (19.2%), or both (25%). Patients who underwent conversion to LRYGB for weight regain and for mix-symptoms had similar weight loss to the control group (38.2 ± 11.8 vs 35.6 ± 7.7, p = 0.108), along with similar comorbidity resolution. However, even though the early (< 30days) complication rate was similar between the two groups, the conversion group had higher 4-year reoperation rate (29% vs 9.5%, p < 0.001) and length of stay (5.4 ± 5.3 vs 2.6 ± 3.1, p < 0.001). Additionally, dysphagia resolved in all the patients of our cohort. VBG conversion to LRYGB leads to significant weight loss, resolution of dysphagia, and comorbidities similarly to the primary LRYGB operations. However, higher mid-term complication rates should be expected.

Cardiovascular Benefits and Lipid Profile Changes 5 Years After Bariatric Surgery: A Comparative Study Between Sleeve Gastrectomy and Roux-en-Y Gastric Bypass

IntroductionVisceral adipose tissue has been linked with cardiovascular events. Visceral adiposity index (VAI) is a routinely applicable tool for evaluation of visceral adipose dysfunction and linked to 10 year-cardiovascular risk. No previous studies have evaluated the changes over time of the VAI in patients who underwent different types of bariatric surgery. Materials and MethodsWe reviewed data of 42 patients who underwent laparoscopic sleeve gastrectomy (LSG) and 61 patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB). VAI, lipid profile, and several anthropometric variables were measured before and after 5 years following surgery. ResultsDuring the studied time period, the BMI was similar between LSG and LRYGB patients (34.1 vs 31.6; p = 0.191), but the percentage of total weight loss (%TWL) for LRYGB was significantly higher than LSG (31.3% vs 23.0%; p < 0.001). LRYGB patients had a significant improvement of all lipid parameters evaluated over time, while LSG patients experienced only a reduction in triglycerides (TG) levels and an increase in HDL cholesterol (HDL-C). VAI values were similar in the two groups at baseline as well at the last follow-up point (5-year VAI, LSG: 0.93, RYGB: 0.93; p = 0.951). At multivariate regression analysis, 5-year-%TWL was the only independent predictor of a greater amount of VAI reduction over time. ConclusionBariatric surgery, independent of the type of surgical procedure, decreases the cardiovascular disease (CVD) risks due to weight loss and improvement of lipid parameters. VAI could be a useful tool to better identify eligible patients for bariatric surgery and to determine the success of surgery.

Trends in Drain Utilization in Bariatric Surgery: an Analysis of the MBSAQIP Database 2015-2017.

BackgroundLaparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (SG) are the two most common bariatric operations. With the implementation of enhanced recovery protocols, the use of drains should decrease.MethodsThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was queried for the years 2015–2017. Our inclusion criteria included all patients undergoing a primary LRYGB, SG, and revisions. We examined demographics, operative characteristics, the use of drains, and postoperative complications. Continuous variables were summarized using means and standard deviations (SD). Categorical variables were summarized using frequencies and proportions. Student’s T test (Wilcoxon sum rank test in the case of skewed data) and chi-squared analysis were used to assess the baseline differences in drain utilization.ResultsFrom 2015 to 2017, there were 388,239 bariatric cases performed without drains and 100,221 performed with drains. Twenty-nine percent of LRYGB patients had a drain placed but only 16.7% of SG patients. The percentage of LRYGB that had a drain dropped from 33.1 to 24.6% during the study period and that of SG dropped from 20.3 to 13.6%. Patients that had drains placed were more likely to have a provocative test at the time of surgery (prevalence ratio (PR) 2.24) and to have a postoperative swallow study (PR 1.93).ConclusionsDrains are still commonly used in bariatric patients. Over the study period, there was a decrease in the use of drains in both bypass and sleeve patients. Patients with a drain were more likely to have had a provocative test and a swallow study and have a higher rate of complications and mortality.Electronic supplementary materialThe online version of this article (10.1007/s11695-019-04215-6) contains supplementary material, which is available to authorized users.

Perioperative outcomes of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in super-obese and super-super-obese patients: a national database analysis

BackgroundEvidence remains contradictory for perioperative outcomes of super-obese (SO) and super-super-obese (SSO) patients undergoing bariatric surgery. ObjectiveTo identify national 30-day morbidity and mortality of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in SO and SSO patients. SettingThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. MethodsAll LSG and LRYGB patients from 2015 through 2017 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database were grouped based on body mass index (BMI) as follows: morbidly obese (MO; BMI 35.0–49.9 kg/m2), SO (BMI 50.0–59.9 kg/m2), and SSO (BMI ≥60.0 kg/m2). Complications and mortality within 30 days were compared between BMI groups using Pearson X2 or Fischer’s exact tests. Multivariate logistic regression was used to adjust for demographic characteristics and co-morbidities, and adjusted odds ratio (AOR) was reported for each outcome. ResultsOf 356,621 patients, 71.6% had LSG and 28.4% LRYGB. A total of 272,195 patients were in the MO group, 65,565 in the SO group, and 18,861 in the SSO group. Higher BMI was associated with increased overall morbidity and mortality. The overall complication rate was significantly higher for SO (AOR = 1.20, 95% confidence interval [CI] 1.13–1.28 for LSG; AOR = 1.08, 95% CI 1.01–1.15 for LRYGB) and SSO (AOR = 1.44, 95% CI 1.31–1.58 for LSG; AOR = 1.31, 95% CI 1.19–1.45 for LRYGB) compared with the MO group. Mortality was also significantly higher for SO (AOR = 1.65, 95% CI 1.10–2.48 for LSG; AOR = 1.85, 95% CI 1.23–2.80 for LRYGB) and SSO (AOR = 3.30, 95% CI 1.98–5.48 for LSG; AOR = 3.32, 95% CI 1.93–5.73 for LRYGB) compared with the MO group. ConclusionsSO and SSO patients are at increased risk of 30-day morbidity and mortality compared with MO patients. Despite this elevated perioperative risk, the overall risk of these procedures remains low and acceptable especially as bariatric surgery is the durable treatment option for obesity.