Michał R. Janik

Present status of bariatric surgery in Poland

Introduction The first survey of bariatric surgery in Poland was published in 2007. New trends are observed worldwide, and there is a current need to investigate the status of bariatric surgery in Polish institutions. This survey was initiated to gain an overview of Polish bariatric surgery during 2007–2014. Aim To analyze the number and types of bariatric procedures performed in Polish institutions in 2014 and to perform a trend analysis from 2007 to 2014. Material and methods A questionnaire regarding the numbers and types of bariatric procedures performed between 2007 and 2014 was e-mailed to all members of the Bariatric Society (a branch of the Association of Polish Surgeons) and to 28 surgical departments. Trend analyses from 2007 to 2014 were performed. Results Among the surgical departments, 16 (57%) responded. The results showed that 1499 bariatric procedures were performed in Poland in 2014, with 96.4% done laparoscopically. The highest number was from Masovian Voivodeship. The most commonly reported procedures were laparoscopic sleeve gastrectomy (LSG) (60.7%), followed by laparoscopic Roux-en-Y gastric bypass (19.2%), mini gastric bypass (11.1%), and adjustable gastric banding (7.6%). Most significant was the rise in prevalence of LSG from 8.0% to 60.4% of the total bariatric procedures from 2007 to 2014. Conclusions Laparoscopic sleeve gastrectomy is currently the most frequently performed bariatric procedure in Poland. The accuracy of the national survey of procedures would be enhanced if we could create a national registry.

Cross-sectional study of male sexual function in bariatric patients

Introduction Obesity is associated with numerous comorbidities and affects various aspects of life, including sexual functioning. Bariatric surgery is an effective treatment for obese people. Male sexual function after bariatric surgery is not well known. Aim To compare male sexual function and sexual quality of life after surgical weight loss with controls seeking bariatric surgery. Material and methods International Index of Erectile Function and Sexual Quality of Life-Male (SQoL-M) questionnaires were administered by e-mail to 152 men who had undergone weight-loss surgery. The control group consisted of 44 obese men who completed the questionnaires during their preoperative evaluation. Results Fifty-six percent of men in the control group and 20% of men in the postoperative group reported erectile dysfunction (ED) (OR = 5.1; 95% CI: 1.6–16.0, p = 0.005). The median (Q1, Q3) total International Index of Erectile Function (IIEF) score did not show a significant difference between the control (62.0 (37.5, 66.5)) and postoperative groups (67.0 (57.0, 70.0)). However, median scores in domains of erectile function (EF), sexual desire (SD), and overall satisfaction (OS) were significantly higher in the postoperative group. The median SQoL-M was significantly higher (81.8 (51.5, 89.4) vs. 88.6 (84.8, 90.9); p < 0.05) in the postoperative group. Conclusions A lower prevalence of erectile dysfunction and better sexual quality of life were observed in the patients after surgical weight loss. The improvement in male sexual function may be considered as an advantage of bariatric surgery.

Usefulness of the Obesity Surgery Mortality Risk Score (OR-MRS) in choosing the laparoscopic bariatric procedure

Introduction The most popular scale to stratify the postoperative risk is the Obesity Surgery Mortality Risk Score (OS-MRS). The design and ease of interpretation make the scale a potential tool for clinical use. Aim To evaluate the usefulness of the OS-MRS scale in the enrollment of patients for laparoscopic bariatric procedures, including laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). Material and methods The medical records of patients who underwent LSG or LRYGB due to obesity between January 2010 and December 2010 were reviewed retrospectively. The decision of choosing the surgical procedure was made on the basis of OS-MRS risk category. The primary endpoint of this study was the 90-day mortality, and the secondary endpoint was the presence of major complications. Results There were 107 patients including 66 women and 41 men. The OS-MRS classes were A (48%), B (47%) and C (5%). The LSG was applied to patients with higher body mass index and to patients of class C. The secondary endpoints occurred in 6 patients, distributed in 10% of class A, 2% of class B and 0% of class C patients (p < 0.05). In 5 of 6 cases the endpoint was observed after LRYGB. Fatal cases were not observed. Conclusions The OS-MRS can be a useful clinical tool for choosing the appropriate laparoscopic bariatric procedure, depending on the risk of postoperative complications. Low risk of postoperative complications should not lower the watchfulness of the surgeon.

Safety of laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass in elderly patients – analysis of the MBSAQIP

BACKGROUND An increase in the prevalence of obesity and longer life expectancy has resulted in an increased number of candidates over the age of 60 who are pursuing a bariatric procedure. OBJECTIVE The aim of this study was to assess the safety of laparoscopic Roux-Y gastric bypass (LRYGB) compared to laparoscopic sleeve gastrectomy (LSG) in patients aged 60 years or older. SETTING University Hospital, United States METHODS: Preoperative characteristics and 30-day outcomes from the MBSAQIP 2015 were selected for all patients aged 60 years or older who underwent a LSG or LRYGB. LRYGB cases were closely matched (1:1) with LSG patients by age (±1 year), BMI (±1 kg/m2), gender, preoperative steroid or immunosuppressant use, preoperative functional health status and comorbidities including: diabetes, gastroesophageal reflux disease, hypertension, hyperlipidemia, venous stasis, sleep apnea and history of severe chronic obstructive pulmonary disease. RESULTS A 3371 matched pairs were included in the study. The mean operative time in LRYGB was significantly longer in comparison to LSG patients (122 vs 84 min., P<0.001). Patients after LRYGB had a significantly increased anastomotic leakage rate (1.01% vs 0.47 %, p = 0.011), 30-day readmission rate (6.08% vs 3.74%, p < 0.001) and 30-day reoperation rate (2.49% vs 0.89%, p < 0.001) The length of hospital stay was longer in LRYGB. Mortality and bleed rate was comparable. CONCLUSIONS LRYGB and LSG in patients aged 60 years or older are relatively safe in the short term with an acceptable complication rate and low mortality. However, LRYGB is more challenging and is associated with significantly increased rates of leakage events, 30-day reoperation, 30-day readmission, longer operative time and longer hospital stay.

Histopathological examination of tissue resected during bariatric procedures – to be done or not to be done?

Introduction Obesity is one of the major lifestyle diseases and provokes various comorbidities, such as hypertension, type 2 diabetes mellitus, obstructive sleep apnea, and even neoplasms. Bariatric surgery is the most effective treatment of obesity. Since cost-effectiveness has become a major concern, there is a tendency to avoid general histological evaluation of surgical specimens during routine procedures. Aim To evaluate the necessity of histopathological investigation of tissue excised during bariatric surgery and to verify whether the operation should be continued in the case of suspicious macroscopic findings. Material and methods From January 2013 to December 2016, 1252 patients with obesity were qualified for bariatric procedures. The qualification was performed according to the current European recommendations. Every operation started with an inspection of the peritoneal cavity performed once the abdomen was insufflated. If a macroscopic pathology was found, the specimen was secured for histopathological investigation. Results Out of 81 (6.47%) patients from whom histopathological samples were collected, 39% (n = 32) showed negative results, and 61% (n = 49) cases showed abnormalities. Conclusions As it is impossible to exclude the existence of gastric tumors only in preoperative gastroscopy and ultrasonography, especially as there is a higher risk in obese patients, routine histological examination of tissue excised during bariatric procedures should be considered. Since most of the neoplasms were found to be benign, there is no need to abandon the bariatric procedure if a pathology is found and resected. Bariatric surgeons should always focus on thorough examination of the abdominal and the pelvic cavity, especially in female patients.

Comparison of circular- and linear-stapled gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass: a multicenter study

Introduction Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a common, well-established procedure, but no consensus regarding selection of the gastrojejunostomy (GJ) technique has been reached, and standardization of this precise technique is far from being achieved. Aim To compare circular-stapled and linear-stapled GJ in LRYGB in terms of operative time and postoperative complications. Material and methods This retrospective case-control study compared the perioperative and postoperative outcomes of LRYGB with a circular-stapled (LRYGB-CS) versus linear-stapled (LRYGB-LS) gastrojejunostomy. All patients, operated on in two academic referral care centers for bariatric surgery, were enrolled from April 2013 to June 2016. 457 patients were included (255 and 202 respectively in the LRYGB-CS and LRYGB-LS groups). After matching the groups for age, sex, body mass index, arterial hypertension, and presence of type 2 diabetes in a 1 : 1 ratio, 99 patients were enrolled in each. Results The total operative time was longer in the LRYGB-LS group (140 vs. 85 min, p < 0.001). The postoperative hemorrhage and wound infection rates were lower in the LRYGB-LS group (2.1% vs. 10.3%, p = 0.021, and 1.0% vs. 9.3%, p = 0.011). The readmission rates were comparable (8.2% vs. 6.1%, p = 0.593). There was no significant difference in the incidence of gastrojejunostomy leakage, stricture, port-site hernia, or marginal ulcer. Conclusions Both anastomosis types for LRYGB are safe and have low and comparable risks of postoperative complications. After LRYGB-CS, postoperative bleeding and wound infections are slightly more frequent; however, the operative time is shorter.

Bariatric surgery and incidental gastrointestinal stromal tumors – a single-center study

Introduction Gastrointestinal stromal tumors (GISTs), originating from Cajal cells, are most commonly located in the stomach; therefore they can be found in the specimens excised during bariatric operations. The global prevalence of GISTs is about 130 cases per million population. Morbidity differs depending on geographical latitude. Although surgery is the treatment of choice for GISTs, 40–50% of patients after radical surgical treatment will have a relapse or metastases. Aim To analyze the incidence of GISTs in patients undergoing bariatric surgery and to verify whether an operation performed according to the bariatric protocol is oncologically radical in case of GIST. Material and methods A single-center retrospective study. The study group comprised 1252 obese patients qualified for bariatric procedures, with no upper gastrointestinal tract neoplasms found during preoperative diagnostic examinations. In case of suspicious macroscopic pathologies (n = 81) present during the operation, tissue specimens underwent histopathological examination with further investigation performed if GISTs were found, including tumor size and localization, mitotic index and immunohistochemical analysis. Results Gastrointestinal stromal tumors were found in 16 cases, and benign tumors of various histological origin in 33 cases. All cases of GIST found came from stomach specimens, 7 from the gastric corpus vs. 9 from the fundus. Fourteen GISTs were found during laparoscopic sleeve gastrectomies (LSGs) vs. 2 during laparoscopic Roux-en-Y gastric bypasses (LRYGBs). Conclusions In case of incidental findings of GISTs during bariatric surgery, tumor resection with negative margins of incision may be considered as complete oncological treatment if there was very low/low risk stratification of GIST’s recurrence after surgery.

The effect of oversewing the staple line in laparoscopic sleeve gastrectomy: randomized control trial

Introduction Laparoscopic sleeve gastrectomy (LSG) is one of the most popular bariatric procedures. The procedure is associated with serious staple-line complications such as bleeding, leaks, and stenosis. Aim To determine whether oversewing the staple line, compared with clipping, in LSG reduces the incidence of postoperative bleeding. Material and methods We conducted a parallel-group, prospective, randomized controlled trial (RCT) of 100 patients who underwent LSG for obesity at a single institution between May 2014 and August 2015. Patients were assigned to one of two groups for reinforcement of the staple line: the oversewing group (staple line oversewn) or the clipping group (staple line clipped). The primary outcome was reoperation for hemodynamic instability caused by staple-line bleeding within 72 h postoperatively. The secondary outcomes were operative duration, length of hospital stay, postoperative leaks, and postoperative stenosis. Results Mean operative duration was longer in the oversewing group (78.2 ±20.5 min) than in the clipping group (64.1 ±16.5 min, p < 0.001). Mean length of hospital stay was comparable in both groups. Postoperatively, there was no significant between-group difference in bleeding (oversewing, n = 0 vs. clipping, n = 2 (4.6%); p = 0.21) or in stenosis and leakage (both outcomes: oversewing, n = 0, vs. clipping, n = 1 (2.3%); p = 0.46). Conclusions Oversewing the staple line prolongs operative duration. No conclusions can be drawn regarding the effects of oversewing on staple-line bleeding, postoperative leakage and stenosis, or length of hospital stay.

Present trends in bariatric surgery in Poland

Introduction As obesity has become a major health problem in Poland and bariatric procedures are the best way of treatment, an increasing trend has been observed in Polish bariatric surgery for the last decade. Aim Our purpose was to provide an updated overview of the bariatric surgical procedures performed in Polish institutions in comparison to the situation in Europe as well as to analyze the trends in Polish bariatric surgery over the last decades. Material and methods A questionnaire about the number and type of bariatric procedures performed in 2016 was sent to all Polish surgical departments. Two hundred and sixty surgical departments returned the questionnaires. Results Twenty-seven departments reported having performed bariatric operative or endoscopic procedures in 2016. The total number of procedures reported was 1958, the most popular being the laparoscopic sleeve gastrectomy (LSG). More than 99% of procedures were performed using laparoscopic techniques. The most common operations were: LSG (64.6%, n = 1032) and laparoscopic Roux-en-Y gastric bypass (LRYGB) (18.2%; n = 291), followed by one anastomosis gastric bypass (OAGB) (8.3%; n = 132) and laparoscopic adjustable gastric banding (LAGB) (7.3%; n = 117). Conclusions Registers of bariatric procedures provide information that helps in planning treatment and predicting possible complications. Adequate reporting of bariatric procedures is necessary to present the importance of the high incidence of obesity and the importance of its treatment. To collect reliable data, a national Polish bariatric surgery registry should be created.

Cigarette smoking and its impact on weight loss after bariatric surgery – a single center, retrospective study.

BACKGROUND Smoking cessation is often associated with weight gain. This study was conducted to verify whether it affects outcomes of bariatric surgery. OBJECTIVES To present cigarette consumption among patients after bariatric surgery in a long-term follow-up and to evaluate whether smoking cessation impacts weight loss. SETTING High-volume bariatric center, Military Hospital, Poland. METHODS We collected data of patients who underwent bariatric surgery between 2003 and 2009. The data included sex, age, weight, body mass index, and smoking habits. An online survey regarding current weight, co-morbidities, and smoking was distributed. Percentage excess weight loss was calculated with an ideal weight for body mass index of 25 kg/m2. RESULTS One hundred seven patients had laparoscopic adjustable gastric banding between 2003 and 2006; 47 were included in the study. The mean follow-up time was 11.2 (±1.2). Of patients, 51% (n = 24) were smokers before surgery. In the follow-up 43% (n = 20) were smokers, of whom 4 patients began smoking after surgery. Twenty-seven patients were nonsmokers, 8 of whom quit over the years (33% of previous smokers). One hundred twenty-seven underwent laparoscopic sleeve gastrectomy between 2006 and 2009; 84 were included in the study. Our median follow-up was 8.0 years. Thirty-two patients never smoked; 52 were smoking before surgery, yet 24 successfully quit. In both groups there were no statistically significant differences in percentage excess weight loss between smokers and nonsmokers, or between those who quit and did not. CONCLUSIONS In the long-term follow-up after laparoscopic adjustable gastric banding, 33% of smokers quit and 17% previously nonsmoking began smoking. After laparoscopic sleeve gastrectomy, 46% of previously smoking patients successfully quit. Smoking status was not significantly associated with weight loss.