Andrea Lazzati

Bariatric surgery trends in France: 2005–2011

BACKGROUND Bariatric surgery underwent a dramatic change in the past decade in France. The objective of this study was to examine elective bariatric surgical procedures from 2005 to 2011 in France and to determine trends in the use of the procedure. METHODS Data were extracted from the National Hospital Database. All admissions involving a bariatric surgery procedure were included. Procedures authorized by the Public Health Authority for the treatment of morbid obesity, including the adjustable gastric banding (AGB), vertical banded gastroplasty (VBG), gastric bypass (GB), sleeve gastrectomy (SG), and biliopancreatic diversion (BPD), either by laparotomic or laparoscopic approach, were retrieved. Revisional procedures, such as band removal or repositioning, band changing, and access device revisions, were also evaluated. RESULTS We observed a 2.5-fold increase in bariatric procedures, from 12,800 in 2005 to 31,000 in 2011. Sleeve gastrectomy and gastric bypass became the most common bariatric procedures in France in 2011, whereas adjustable gastric banding has been decreasing since 2007. During the analysis period, about 50,000 revisional procedures were performed. The number of hospitals (private or public) providing bariatric surgery has considerably increased. However, most of the activity remains confined to a small number of centers, as 50% of all bariatric surgeries are carried out in 12% of hospitals. Bariatric procedures are predominantly performed in private hospitals. CONCLUSIONS In France the number of bariatric procedures increased considerably between 2005 and 2011. The type of procedures changed, with a constant decrease of AGB and an important increase of SG and GB. Most bariatric procedures are still performed in low volume activity hospitals and in private hospitals.

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

BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSION 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.

Natural History of Adjustable Gastric Banding: Lifespan and Revisional Rate: A Nationwide Study on Administrative Data on 53,000 Patients.

Objective: The aim of this study was to analyze the adjustable gastric banding (AGB) natural history on a national basis. Background: Adjustable gastric banding represented the most common bariatric procedure in France until 2010. Since then, the number of AGBs has decreased and the rate of band removal and revisional surgeries has progressively increased. Methods: For analysis, we included all adult patients operated on with AGB in France between 2007 and 2013. Data were extracted from a national administrative database (“Programme De Médicalisation des Systèmes d’Information,” PMSI), which is an exhaustive source of all surgical procedures performed in France. The Cox proportional hazard model was used to test univariate and multivariate associations with band survival and revisional rate. To control for center-specific effects, we performed a frailty analysis, in which each center was assumed to have a random effect indicating the possibility of different baseline risks for patients at different centers. Results: During the study period, 52,868 patients underwent AGB, and 10,815 bands were removed. The removal rate at 5, 6, and 7 years was 28%, 34%, and 40%, respectively. Female sex, body mass index >50 kg/m2, type 2 diabetes, hypertension, dyslipidemia, and sleep apnea were found to be significantly associated with band removal by multivariate analysis. A significant center effect was also found, but this did not change the impact of the highly significant factors already identified. After band removal, the median time to revisional surgery was 1 year (95% confidence interval 1.0–1.1) and the conversion rate at 7 years was 71%. Conclusions: With a removal rate of about 6% annually and the need for revisional surgery for more than two-thirds of patients after removal, AGB does not appear to provide a long-term solution for obesity.

Conversion of sleeve gastrectomy to Roux-en-Y gastric bypass: an audit of 34 patients

BACKGROUND Weight loss failure and proton pomp inhibitor (PPI)-resistant gastroesophageal reflux diseases (GERD) after sleeve gastrectomy (SG) are frequently encountered. OBJECTIVES The aim of this study was to evaluate the efficacy and risks of SG conversion to Roux-en-Y gastric bypass (RYGB) in the case of weight loss failure or severe GERD. SETTING University hospitals. METHODS Between March 2007 and December 2014, 34 patients with history of SG underwent RYGP. A retrospective analysis of a prospectively collected database was undertaken. RESULTS Among 34 patients, 31 underwent revisional surgery for weight loss failure and 3 for PPI-resistant GERD. Six patients in the weight loss failure group had symptomatic GERD that was effectively treated with PPIs. The average body mass index (BMI) was 53±11 kg/m2 before SG. A laparoscopic approach was performed in 94% of patients. There was no postoperative mortality. Major adverse events (<90 days) occurred in 4 patients (11.7%). The mean length of stay was 6.7±2.8 days. At the time of revisional surgery, the mean BMI, percentage excess weight loss, and percentage weight loss were 44.7±9.8 kg/m2, 33.6±27.1%, and 16±9.7%, respectively, compared with 40.9±8.5 kg/m2, 63.1±36.2%, and 23.8±14% at 3 years. The GERD was resolved in all patients, allowing the cessation of PPI medication. CONCLUSION Laparoscopic conversion of SG to RYGB is feasible and it allows improvement in secondary weight loss and GERD, but at the cost of high morbidity.

Single-Anastomosis Pylorus-Preserving Bariatric Procedures: Review of the Literature

Single-anastomosis pylorus-preserving procedures (SAPPP) were recently introduced into bariatric surgery in order to combine the physiologic advantages of a post-pyloric reconstruction with the technical advantages of an omega loop. Surgery consists of a sleeve gastrectomy that is performed first, followed by a duodeno-enterostomy. Two main variants exist: proximal and distal SAPPP, with duodeno-jejunostomy and duodeno-ileostomy, respectively. This review describes the SAPPP reported in the literature and analyzes their outcomes in comparison with the most frequently performed bariatric techniques. Preliminary results appear as promising in terms of both safety and effectiveness on weight loss and comorbidities improvement.

One or two steps for laparoscopic conversion of failed adjustable gastric banding to sleeve gastrectomy: a nationwide French study on 3357 morbidly obese patients.

BACKGROUND Adjustable gastric banding (AGB) has been a very common bariatric procedure, but long-term AGB related complications have led to an increased number of second procedures. Sleeve gastrectomy (SG) is one option and can be done as a 1- or 2-step procedure. OBJECTIVES To compare the 1-step and 2-step approachs of conversion of AGB to SG with respect to postoperative mortality and morbidity. SETTING Nationwide study, France. METHODS All morbidly obese patients who underwent AGB followed by SG in France between 2007 and 2012 were included. Multivariate analyses were conducted using the French National Health Service Database data to ascertain predictive factors for 90-day postoperative mortality and morbidity. RESULTS There were 2061 and 1296 patients in the 1-step and 2-step conversion groups, respectively. The readmission rate was 22.8% and 16.5% in the 1- and 2-step groups, respectively (P<.001). More patients required an intensive care unit stay in the 1-step group (11.7 % versus 6.7%; P<.001). The 90-day mortality was .1%, with no difference between the 2 groups (1% versus .08%). The complication rate was 14.7% (1-step 15.9% versus 2-step 12.7%; P = .009). The timing of AGB removal (P = .02), patient age 50-60 years (P = .004), hypertension (P = .01), surgical approach (P = .002), and hospital status (P = .015) were significantly associated with the complication rate. CONCLUSION This study indicates that the 2-step conversion of failed AGB to SG results in a significantly reduced rate of postoperative staple line leaks, gastric tube stricture, respiratory complication, and need for intensive care unit stay.

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

PurposeThe 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.MethodsThe 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.ResultsA 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.ConclusionAcademic 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.

Mortalité après chirurgie bariatrique sur 140 000 patients

Contexte Le taux de mortalite de la chirurgie bariatrique en France n’est connu que par des etudes monocentriques. Methodes Les donnees ont ete extraites de la base de donnees nationale du Programme de medicalisation des systemes d’information (PMSI). Tous les sejours des patients ayant eu un acte de chirurgie bariatrique entre 2007–2012 ont ete retenus pour analyse. Nous avons analyse la mortalite a 30, 90 jours et a 1 an. Resultats Dans la periode analysee, 143 449 patients ont eu une procedure de chirurgie bariatrique. La duree moyenne de suivi etait de 29,7 mois (1–71). L’intervention la plus realisee etait la sleeve gastrectomy (SG), suivie par l’anneau gastrique ajustable (AGA) et le bypass gastrique (BPG) avec 45 600, 43 600, 38 500 actes respectivement. La mortalite operatoire etait de 0,09 %, 0,14 % et 0,2 % respectivement a 1,6 et 12 mois, la mortalite par type d’intervention etait de 0,20 % pour la SG, de 0,03 % pour l’AGA et de 0,35 % pour le BPG (a 1 an). En analyse multivariee les facteurs associes significativement a la mortalite etaient : le sexe masculin, l’âge, le volume d’actes par centre, le type d’intervention, la conversion en une autre technique, la voie d’abord, le diabete, l’insuffisance cardiaque et l’indice de masse corporelle. Conclusion La mortalite apres chirurgie bariatrique est faible. Ce modele fournit des informations utiles pour la selection des candidats a la chirurgie, pour une correcte information des patients et pour le choix de la technique.