Daniel W. Birch

Sleeve gastrectomy and type 2 diabetes mellitus: a systematic review

BACKGROUND Existing evidence has suggested that bariatric surgery produces sustainable weight loss and remission or cure of type 2 diabetes mellitus (DM). Laparoscopic sleeve gastrectomy (LSG) has garnered considerable interest as a low morbidity bariatric surgical procedure that leads to effective weight loss and control of co-morbid disease. The objective of the present study was to systematically review the effect of LSG on type 2 DM. METHODS An electronic data search of MEDLINE, PubMed, Embase, Scopus, Dare, Clinical Evidence, TRIP, Health Technology Database, Conference abstracts, clinical trials, and the Cochrane Library database was completed. The search terms used included LSG, vertical gastrectomy, bariatric surgery, metabolic surgery, and diabetes (DM), type 2 DM, or co-morbidities. All human studies, not limited to those in the English language, that had been reported from 2000 to April 2010 were included. RESULTS After an initial screen of 3621 titles, 289 abstracts were reviewed, and 28 studies met the inclusion criteria and the full report was assessed. One study was excluded after a careful assessment because the investigators had combined LSG with ileal interposition. A total of 27 studies and 673 patients were analyzed. The baseline mean body mass index for the 673 patients was 47.4 kg/m(2) (range 31.0-53.5). The mean percentage of excess weight loss was 47.3% (range 6.3-74.6%), with a mean follow-up of 13.1 months (range 3-36). DM had resolved in 66.2% of the patients, improved in 26.9%, and remained stable in 13.1%. The mean decrease in blood glucose and hemoglobin A1c after sleeve gastrectomy was -88.2 mg/dL and -1.7%, respectively. CONCLUSION Most patients with type 2 DM experienced resolution or improvement in DM markers after LSG. LSG might play an important role as a metabolic therapy for patients with type 2 DM.

Weight Recidivism Post-Bariatric Surgery: A Systematic Review

Obesity is considered a worldwide health problem of epidemic proportions. Bariatric surgery remains the most effective treatment for patients with severe obesity, resulting in improved obesity-related co-morbidities and increased overall life expectancy. However, weight recidivism has been observed in a subset of patients post-bariatric surgery. Weight recidivism has significant medical, societal and economic ramifications. Unfortunately, there is a very limited understanding of how to predict which bariatric surgical patients are more likely to regain weight following surgery and how to appropriately treat patients who have regained weight. The objective of this paper is to systematically review the existing literature to assess the incidence and causative factors associated with weight regain following bariatric surgery. An electronic literature search was performed of the Medline, Embase and Cochrane library databases along with the PubMed US national library from January 1950 to December 2012 to identify relevant articles. Following an initial screen of 2,204 titles, 1,437 abstracts were reviewed and 1,421 met exclusion criteria. Sixteen studies were included in this analysis: seven case series, five surveys and four non-randomized controlled trials, with a total of 4,864 patients for analysis. Weight regain in these patients appeared to be multi-factorial and overlapping. Aetiologies were categorized as patient specific (psychiatric, physical inactivity, endocrinopathies/metabolic and dietary non-compliance) and operation specific. Weight regain following bariatric surgery varies according to duration of follow-up and the bariatric surgical procedure performed. The underlying causes leading to weight regain are multi-factorial and related to patient- and procedure-specific factors. Addressing post-surgical weight regain requires a systematic approach to patient assessment focusing on contributory dietary, psychologic, medical and surgical factors.

Bariatric surgery: a systematic review of the clinical and economic evidence.

CONTEXTUse of bariatric surgery for severe obesity has increased dramatically.OBJECTIVETo systematically review 1. the clinical efficacy and safety, 2. cost-effectiveness of bariatric surgery, and 3. the association between number of surgeries performed (surgical volume) and outcomes.DATA SOURCESMEDLINE (from 1950), EMBASE (from 1980), CENTRAL, EconLit, EURON EED, Harvard Center for Risk Analysis, trial registries and HTA websites were searched to January 2011.STUDY SELECTION1. Randomized controlled trials (RCTs) and 2. cost-utility and cost-minimisation studies comparing a contemporary bariatric surgery (i.e., adjustable gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy) to another contemporary surgical comparator or a non-surgical treatment or 3. Any study reporting the association between surgical volume and outcome.DATA EXTRACTIONOutcomes included changes in weight and obesity-related comorbidity, quality of life and mortality, surgical complications, resource utilization, and incremental cost-utility.RESULTSRCT data evaluating mortality and obesity-related comorbidity endpoints were lacking. A small RCT of 16 patients reported that adjustable gastric banding reduced weight by 27% (p < 0.01) compared to diet-treated controls over 40 weeks. Six small RCTs reported comparisons of commonly used, contemporary procedures. Gastric banding reduced weight to a lower extent than gastric bypass and sleeve gastrectomy and resulted in shorter operating times, fewer serious complications, lower weight loss efficacy, and more frequent reoperations compared to gastric bypass. Sleeve gastrectomy and gastric bypass reduced weight to a similar extent. A 2-year RCT in 50 adolescents reported that gastric banding substantially reduced weight compared to lifestyle modification (35 kg vs. 3 kg; p <0.001). Based on findings of 14 observational studies, higher volume centers and surgeons had lower mortality and complication rates. Surgery resulted in long-term incremental cost–utility ratios of

Robotic-assisted laparoscopic colorectal surgery.

<1.000–

Effect of preoperative weight loss in bariatric surgical patients: a systematic review

40,000 (2009 USD) per quality-adjusted-life-year compared with non-surgical treatment.CONCLUSIONSContemporary bariatric surgery appears to result in sustained weight reduction with acceptable costs but rigorous, longer-term (≥5 year) data are needed and a paucity of RCT data on mortality and obesity related comorbidity is evident. Procedure-specific variations in efficacy and risks exist and require further study to clarify the specific indications for and advantages of different procedures.

The impact of latency on surgical precision and task completion during robotic-assisted remote telepresence surgery

Robotic assistance provides a number of potential benefits for laparoscopic surgery by addressing several inherent limitations. However, its utility in colorectal surgery has not been determined. This is a report of our initial experience with robot-assisted colon resections. We prospectively followed 10 patients who underwent robotic-assisted laparoscopic colorectal surgery using Zeus Microwrist System. Surgical outcomes were compared with those of 10 consecutive patients who underwent laparoscopic colorectal surgery in the same institution for similar indications prior to the start of robotic-assisted surgery. Six patients in each group had surgery for colorectal malignancy. All 10 robotic-assisted procedures were completed with no intraoperative complications, conversions, or mortality. The average blood loss was less than 150 mL in all cases. Morbidity and hospital stay were comparable to those for the patients undergoing standard laparoscopic procedures. Robotic surgery was associated with a significant increase in operative time of almost 1 hour. This time was reduced significantly after the first 4 cases. The value of robotic assistance in colorectal surgery needs to be further evaluated in a larger comparative study.

Medical tourism in bariatric surgery

BACKGROUND The potential benefit of preoperative weight loss in patients undergoing bariatric surgery has led many bariatric surgeons to recommend an aggressive weight reduction regimen to their patients. Some surgeons might withhold bariatric procedures if a certain threshold of preoperative weight loss is not achieved. It is unclear whether this practice has any scientific evidence supporting it. Our study aimed to examine the current evidence surrounding this issue in a systematic review. The setting was a university hospital. METHODS A systematic search of multiple databases, including MEDLINE, Google Scholar, EMBASE, the Cochrane Library, and conference proceedings were reviewed, yielding a final total of 27 studies. Of the 27 studies, 7 were prospective studies (2 randomized controlled trials from the same patient population), 14 were retrospective studies (2 chart reviews from the same patient population), 1 was an editorial, and a number were conference presentations. RESULTS A total of 17 trials, including approximately 4611 patients, deemed preoperative weight loss beneficial, and 10 studies, including 2075 patients, deemed preoperative weight loss to be of no benefit. The operative time was 12.5 minutes shorter for the preoperative weight loss patients undergoing laparoscopic Roux-en-Y gastric bypass. With regard to the effects of preoperative weight loss on postoperative weight loss, 9 studies (39%) reported a positive correlation, and 15 (62.5%) reported no benefit. Nine studies reporting perioperative complications (852 patients) revealed no difference in the complication rates, and 2 studies (1234 patients) suggested a significant decrease was associated with preoperative weight loss. CONCLUSION This systematic review suggests little evidence is available to support or refute the routine use of preoperative weight reduction in bariatric surgery. Clearly, a large-scale, multicenter, randomized, controlled trial with sufficient power is necessary to clarify this significant aspect of preoperative care.

Weight loss required by the severely obese to achieve clinically important differences in health-related quality of life: two-year prospective cohort study

Objective: It has been suggested that robotic-assisted remote telepresence surgery with a signal transmission latency of greater than 300 ms may not be possible. Methods: We evaluated the impact of four different latencies of up to 500 ms on task completion and error rate in five surgeons after completion of three different surgical tasks. Results: The surgeons were able to complete all tasks with a latency of 500 ms. However, higher latency was associated with higher error rates and task completion time (TCT). There were significant variations between surgeons and different tasks. Conclusion: Surgeons are able to complete tasks with a signal transmission latency of up to 500 ms. The clinical impact of slower TCT and increased error rates encountered at higher latency needs to be established.

Does preoperative weight loss predict success following surgery for morbid obesity

BACKGROUND The number of Canadians who self-refer for bariatric surgery outside of Canada or to private clinics within Canada remains undefined. The outcomes from this questionable practice have not been evaluated systematically to date. METHODS We completed a chart review of known cases referred to our center for complications related to medical tourism and bariatric surgery. RESULTS We present a series of patients who have experienced complications because of medical tourism for bariatric surgery and required urgent surgical management at a tertiary care center within Canada. Complications have resulted from 3 commonly used procedures: adjustable gastric banding, gastric sleeve resection, and Roux-en-Y gastric bypass. CONCLUSIONS Because of this review, we propose that a medical tourism approach to the surgical management of obesity-a chronic disease-is inappropriate and raises clear ethical and moral issues.

Sleeve Gastrectomy and Gastroesophageal Reflux Disease

BackgroundGuidelines and experts describe 5% to 10% reductions in body weight as `clinically important’; however, it is not clear if 5% to 10% weight reductions correspond to clinically important improvements in health-related quality of life (HRQL). Our objective was to calculate the amount of weight loss required to attain established minimal clinically important differences (MCIDs) in HRQL, measured using three validated instruments.MethodsData from the Alberta Population-based Prospective Evaluation of Quality of Life Outcomes and Economic Impact of Bariatric Surgery (APPLES) study, a population-based, prospective Canadian cohort including 150 wait-listed, 200 medically managed and 150 surgically treated patients were examined. Two-year changes in weight and HRQL measures (Short-Form (SF)-12 physical (PCS; MCID = 5) and mental (MCS; MCID = 5) component summary score, EQ-5D Index (MCID = 0.03) and Visual Analog Scale (VAS; MCID = 10), Impact of Weight on Quality of Life (IWQOL)-Lite total score (MCID = 12)) were calculated. Separate multivariable linear regression models were constructed within medically and surgically treated patients to determine if weight changes achieved HRQL MCIDs. Pooled analysis in all 500 patients was performed to estimate the weight reductions required to achieve the pre-defined MCID for each HRQL instrument.ResultsMean age was 43.7 (SD 9.6) years, 88% were women, 92% were white, and mean initial body mass index was 47.9 (SD 8.1) kg/m2. In surgically treated patients (two-year weight loss = 16%), HRQL MCIDs were reached for all instruments except the SF-12 MCS. In medically managed patients (two-year weight loss = 3%), MCIDs were attained in the EQ-index but not the other instruments. In all patients, percent weight reductions to achieve MCIDs were: 23% (95% confidence interval (CI): 17.5, 32.5) for PCS, 25% (17.5, 40.2) for MCS, 9% (6.2, 15.0) for EQ-Index, 23% (17.3, 36.1) for EQ-VAS, and 17% (14.1, 20.4) for IWQOL-Lite total score.ConclusionsWeight reductions to achieve MCIDs for most HRQL instruments are markedly higher than the conventional threshold of 5% to 10%. Surgical, but not medical treatment, consistently led to clinically important improvements in HRQL over two years.Trial registrationClinicaltrials.gov NCT00850356.