Ricard Corcelles

Revisional surgery after sleeve gastrectomy.

Introduction Worldwide, morbid obesity incidence has increased dramatically in the last decade and surgery is at this moment recognized as the only effective treatment with long-term sustained weight loss and resolution or significant improvement in comorbidities. Laparoscopic sleeve gastrectomy (LSG) was successfully carried out by several groups as a bridge to future laparoscopic bariatric procedures with acceptable weight loss and reduction in comorbidities. LSG is considered a safe procedure with sporadically reported complications, such as bleeding or leakage from the staple line, strictures, delayed gastric emptying, gastric dilatation and vomiting. The aim of this publication is to describe complications of this procedure analyze different treatments of these events especially the surgical ones, reporting the technical management based on our experience and on the literature. Material and Methods From March 2003 to December 2009, 294 patients underwent LSG in our Department. Complications are reported prospectively. Results In our series 294 patients were operated and stapler line leak was observed in 11 patients (3.7%). The mean time from the first surgery up to the first reintervention was 15.6±22 days (2 to 78). Only 2 patients (0.68%) had to be operated owing to severe reflux related with the sleeve gastrectomy and the symptomathology was solved with the gastric bypass. Intraabdominal bleeding was observed in 7 patients (2.38%), being reoperated 3 (1.02%) of them. All patients were reoperated by laparoscopic approach and the bleeding vessel was identified in all of them. We identified 3 of 294 patients with strictures (1.02%). One of them was located in the gastroesophageal junction and the other 2 had a central location. The patient with high stenosis required endoscopic dilatation and the other 2 were resolved by a gastric bypass cutting the stomach proximal to the stricture. The global mortality was 0%. All of the patients were reoperated by laparoscopy. Conclusion LSG is a feasible bariatric procedure carried out increasingly in the last few years with low postoperative complications. Regardless, the knowledge of the potential complications associated to LSG and their management is crucial for patients safety.

Safety and effectiveness of bariatric surgery in dialysis patients and kidney transplantation candidates

BACKGROUND Chronic renal disease is known to adversely affect the results of bariatric surgery. There is a paucity of literature on the safety and effectiveness of bariatric surgery on dialysis patients who are at very advanced stages in their renal disease. The objective of this study was to determine the safety and effectiveness of bariatric surgery in dialysis patients. METHODS A retrospective review of a prospectively collected database was conducted for dialysis patients who underwent bariatric surgery between January 2006 and January 2012. Age, gender, body mass index (BMI), cause of renal failure, associated co-morbidities, type of surgery, early and late complications, and mortality were collected. RESULTS Of the 3048 patients undergoing bariatric surgery during the study period, 21 dialysis patients (.7%) were identified. Eighteen patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB), 2 patients underwent laparoscopic sleeve gastrectomy, and 1 patient underwent laparoscopic adjustable gastric banding. Mean preoperative BMI was 47.1±5.5 kg/m(2), and BMI decreased to 35.3±8.4 kg/m(2) after a mean follow-up period of 27.6 months (range = 1.4-78.0 mo). Early major complications (<30 days of surgery) occurred in 2 patients (1 anastomotic leak and 1 anastomotic stricture). Four patients had a late complication, including 1 marginal ulcer with bleeding managed endoscopically, 1 small bowel obstruction requiring laparoscopic lysis of adhesions, 1 cholecystitis requiring cholecystectomy, and 1 anastomotic stricture requiring endoscopic dilation. There was 1 death in this cohort, at 45 days after LRYGB, that was unrelated to a surgery. CONCLUSIONS Chronic renal failure requiring dialysis should not be considered a contraindication to bariatric surgery. Our experience with this patient population has shown excellent medium-term weight loss and an acceptable (albeit increased) risk/benefit ratio.

Individualized Metabolic Surgery Score: Procedure Selection Based on Diabetes Severity

Objective: To construct and validate a scoring system for evidence-based selection of bariatric and metabolic surgery procedures according to severity of type 2 diabetes (T2DM). Background: Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) account for >95% of bariatric procedures in United States in patients with T2DM. To date, there is no validated model to guide procedure selection based on long-term glucose control in patients with T2DM. Methods: A total of 659 patients with T2DM who underwent RYGB and SG at an academic center in the United States and had a minimum 5-year follow-up (2005–2011) were analyzed to generate the model. The validation dataset consisted of 241 patients from an academic center in Spain where similar criteria were applied. Results: At median postoperative follow-up of 7 years (range 5–12), diabetes remission (HbA1C <6.5% off medications) was observed in 49% after RYGB and 28% after SG (P < 0.001). Four independent predictors of long-term remission including preoperative duration of T2DM (P < 0.0001), preoperative number of diabetes medications (P < 0.0001), insulin use (P = 0.002), and glycemic control (HbA1C < 7%) (P = 0.002) were used to develop the Individualized Metabolic Surgery (IMS) score using a nomogram. Patients were then categorized into 3 stages of diabetes severity. In mild T2DM (IMS score ⩽25), both procedures significantly improved T2DM. In severe T2DM (IMS score >95), when clinical features suggest limited functional &bgr;-cell reserve, both procedures had similarly low efficacy for diabetes remission. There was an intermediate group, however, in which RYGB was significantly more effective than SG, likely related to its more pronounced neurohormonal effects. Findings were externally validated and procedure recommendations for each severity stage were provided. Conclusions: This is the largest reported cohort (n = 900) with long-term postoperative glycemic follow-up, which, for the first time, categorizes T2DM into 3 validated severity stages for evidence-based procedure selection.

Failed Surgical Weight Loss Does Not Necessarily Mean Failed Metabolic Effects

The metabolic profile of patients after a failed surgical weight loss procedure is unknown. Long-term clinical outcomes of 31 obese diabetes patients with post-bariatric surgery excess weight loss of ≤25% were assessed. At a median follow-up of 6 years (range, 5-9 years) after surgery, remission and clinical improvement of diabetes occurred in seven (23%) and 13 (42%) patients, respectively. A long-term mean total weight loss of 7.0±4.7% and excess weight loss of 13.7±8.5% were associated with a mean reduction in fasting blood glucose level, from 158.9±66.7 to 128.4±35.3 mg/dL (P=0.03), and a significant decrease in diabetes medication requirements (P<0.001). A significant decrease in systolic blood pressure (11.1±23.4 mm Hg, P=0.01) and level of circulating triglycerides (35.7±73.4 mg/dL, P=0.04) was also observed after surgery. A modest surgical weight loss in the range of 5-10% of initial weight was associated with significant improvement in cardiometabolic risk factors of morbidly obese diabetes patients. The markedly improved glycemic control (65% remission or clinical improvement) may be partly explained by weight-independent antidiabetes mechanisms of certain bariatric surgical procedures.

Psoriasis improvement after bariatric surgery

BACKGROUND Psoriasis is a chronic inflammatory skin disease known to be associated with obesity and metabolic syndrome. Single case reports and small series suggest remission or improvement after bariatric surgery, hypothetically through a GLP-1 mediated mechanism. The objective of this study was to investigate on the effect of bariatric surgery on the clinical behavior of psoriasis in obese patients. METHODS A total of 33 morbidly obese individuals with psoriasis who were on active medical treatment were identified. Demographic characteristics and follow-up data were extracted from our database. Medication usage and percentage of affected body surface area (%ABSA) were recorded preoperatively and at least 6 months after bariatric surgery. RESULTS Nine (27.2%) patients were on systemic therapy at baseline. At a mean follow-up time of 26.2±20.3 months, a mean excess weight loss (EWL) of 48.7± 26.6% was achieved. This was associated with improvement of psoriasis based on downgrade of medication and %ABSA in 30.3% and 26.1% of patients, respectively. In total, 13 of 33 patients (39.4%) had improvement based on either criteria. Eight (24.2%) patients were not on any psoriasis medication at the latest follow-up (P = .001). Older age at the time of surgery (54.8±8.1 versus 48.1±10.4 years, P = .047), Roux-en-Y gastric bypass versus nonbypass procedures (52.4% versus 16.7%, P = .043), and greater EWL (64.2±26.0% versus 43.4± 23.6%, P = .036) predicted improvement. Only 1 (3%) patient experienced worsening after surgery. CONCLUSION Almost 40% of our cohort showed improvement of psoriasis several months after bariatric surgery. Improvement is directly related to the degree of postoperative weight loss and is associated with the Roux-en-Y configuration.

Gastrointestinal hormones and weight loss response after Roux-en-Y gastric bypass

BACKGROUND Mechanisms underlying variable weight loss (WL) response after Roux-en-Y gastric bypass (RYGB) are poorly understood. The objective of this study was to compare gastrointestinal hormonal responses to meal intake, and fasting plasma concentrations of surrogate markers of enterocyte mass and bile acid effect between patients with failed (F-WL) or successful WL (S-WL) after RYGB. METHODS Cross-sectional study including 30 nondiabetic patients, evaluated at≥24 months after RYGB. Cases (F-WL; n = 10) and controls (S-WL; n = 20) were selected based on percent of excess WL (%EWL)<50% or≥50% from 12 months onwards after surgery. Groups were matched for gender, age, presurgical BMI, and length of follow up. Glucagon-like peptide 1 (GLP-1), peptide YY (PYY), GLP-2, and ghrelin responses to a meal challenge, and fasting plasma concentrations of citrulline and serum fibroblast growth factor 19 (FGF-19) were compared. RESULTS F-WL patients presented lesser suppression of ghrelin (incremental area under the curve [iAUC]: F-WL -12490±6530 versus S-WL -31196±4536 pg×mL(-1)×min; P<.01), and lesser increase in the GLP-1 (iAUC: F-WL 3354±737 versus S-WL 5629±542 pmol×L(-1)×min; P = .02) but not in the PYY and GLP-2, response to meal intake. Citrulline concentrations were significantly correlated with time after surgery (rho = .537; P<.01). However, citrulline was higher in S-WL compared to F-WL patients (P<.05). Serum FGF-19 concentration was similar between groups. CONCLUSION Although limited by the cross-sectional design, our data suggest a role of some gastrointestinal hormones as mediators of successful weight loss but argues against larger enterocyte mass after BS as determinant of failed weight loss after RYGB.

Critical appraisal of salvage banding for weight loss failure after gastric bypass

BACKGROUND Placement of an adjustable gastric band (AGB) over the gastric pouch after RYGB failure has had varied results. The aim of this study was to evaluate safety and outcomes of AGB after RYGB failure. METHODS Twenty-eight patients who underwent laparoscopic placement of an AGB around the gastric pouch as a revisional procedure for inadequate weight loss or recidivism after RYGB between 2008-2011 were identified. RESULTS Twenty-four (86%) patients had a dilated gastric pouch and/or stoma. The mean operative and adhesiolysis times were 137.9±52.3 minutes and 83±51 minutes, respectively. History of a previous open RYGB was associated with a longer adhesiolysis time (P = .03). Three (11%) major intraoperative and 5 (18%) early postoperative complications occurred. Late complications (all requiring band removal) were observed in 6 (21%) patients and included ineffectiveness (n = 2), dysphagia/esophageal dilation (n = 2), band erosion (n = 1), and peritonitis (n = 1). In all 4 patients with a normal-sized pouch and stoma at the time of band placement, the band was removed. After a mean follow-up of 38.3±14.8 months, the mean body mass index (BMI) change and median excess weight loss (EWL) after salvage banding were -3.6±4.5 kg/m(2) and 12.7%, respectively. In the subset of patients with a dilated pouch/stoma, BMI less than 42 kg/m(2) at the time of band placement was associated with a significantly higher EWL (41.4%±37.0%) compared with a baseline BMI>42 kg/m(2) (12.1%±7.2%, P = .03). CONCLUSIONS Salvage banding is technically challenging due to dense adhesions, carries significant morbidity, and is associated with only 13% additional EWL. However, this approach may still be an option in carefully selected patients, such as those with previous laparoscopic RYGB who have a dilated pouch and/or stoma and lower BMI.

The incidence of hiatal hernia and technical feasibility of repair during bariatric surgery.

PURPOSE To evaluate the incidence and outcomes of hiatal hernias (HH) that are repaired concomitantly during bariatric surgery. METHODS We identified patients who had concomitant HH repair during bariatric surgery from 2010 to 2014. Data collected included baseline demographics, perioperative parameters, type of HH repair, and postoperative outcomes. RESULTS A total of 83 underwent concomitant HH during study period. The male-to-female ratio was 1:8, mean age was 57.2 ± 10.0 years, and mean body mass index was 44.5 ± 7.9 kg/m(2). A total of 61 patients had laparoscopic Roux-en-Y gastric bypass, and 22 had laparoscopic sleeve gastrectomy. HH was diagnosed before bariatric surgery in 32 (39%) subjects, whereas 51 (61%) were diagnosed intraoperatively. Primary hernia repair was performed with anterior reconstruction in 45 (54%) patients, posterior in 21 (25%), and additional mesh placement in 7 (8%). A total of 24 early minor postoperative symptoms were reported. At 12 month follow-up, mean body mass index improved to 30.0 ± 6.2 kg/m(2), and anti-reflux medication was decreased from 84% preoperatively to 52%. Late postoperative complications were observed in 3 patients. A comparative analysis with a matched 1:1 control group displayed no significant differences in operative time (P = .07), duration of stay (P = .9), intraoperative complications, or early (P = .09) and late post-operative symptoms (P = .3). In addition, no differences were noted in terms of weight-loss outcomes. CONCLUSION The true incidence of HH may be underestimated before bariatric surgery. Combined repair of HH during bariatric surgery appears safe and feasible.

The effect of bariatric surgery on gout: a comparative study

BACKGROUND Obesity is a risk factor for the development of gout. An increased incidence of early gouty attacks after bariatric surgery has been reported, but the data is sparse. The effect of weight loss surgery on the behavior of gout beyond the immediate postoperative phase remains unclear. The objective of this study was to evaluate the pre- and postoperative frequency and features of gouty attacks in bariatric surgery patients. METHODS Charts were reviewed to identify patients who had gout before bariatric surgery. Demographic and gout-related parameters were recorded. The comparison group consisted of obese individuals with gout who underwent nonbariatric upper abdominal procedures. RESULTS Ninety-nine morbidly obese patients who underwent bariatric surgery had gout. The comparison group consisted of 56 patients. The incidence of early gouty attack in the first month after surgery was significantly higher in the bariatric group than the nonbariatric group (17.5% versus 1.8%, P = .003). In the bariatric group, 23.8% of patients had at least one gouty attack during the 12-month period before surgery, which dropped to 8.0% during postoperative months 1-13 (P = .005). There was no significant difference in the number of gouty attacks in the comparison group before and after surgery (18.2% versus 11.1%, P = .33). There was a significant reduction in uric acid levels 13-months after bariatric surgery compared with baseline values (9.1±2.0 versus 5.6±2.5 mg/dL, P = .007). CONCLUSION The frequency of early postoperative gout attacks after bariatric surgery is significantly higher than that of patients undergoing other procedures. However, the incidence decreases significantly after the first postoperative month up to 1 year.

Bariatric and metabolic outcomes in the super-obese elderly

BACKGROUND Numerous reports address bariatric outcomes in super-obese or elderly patients, but data addressing this high-risk combination is lacking. OBJECTIVE The objective of this study was to assess outcomes of bariatric surgery in the super-obese elderly. SETTING Academic institution, United States. METHODS All primary bariatric cases performed on patients aged 65 years or older with a body mass index (BMI) ≥ 50 kg/m(2) were retrospectively analyzed. Surgical approaches included laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB). RESULTS Thirty patients (26 female, 4 male) with a mean age of 67.1 ± 2.7 years and BMI of 55.9 ± 3.9 kg/m(2), who had LRYGB (n = 16), LSG (n = 6), or LAGB (n = 8), were identified. There were no deaths, conversions, or intraoperative complications. Three patients were lost to follow-up after the 3-month visit. The early (<30 d) major morbidity rate was 10.0%. At a median follow-up of 37 (range, 6-95) months, the cohort had a mean BMI of 42.3 ± 6.7 kg/m(2), which corresponded to a mean percent excess weight loss of 44.5% ± 20.5% and mean percent total weight loss of 24.4% ± 12.2%. The most percent excess weight loss was achieved after LRYGB (54.1% ± 19.4%), followed by LSG (48.3% ± 10.2%) and then LAGB (26.2% ± 14.4%). Diabetic medication reduction in number and/or dosage was observed in 40% (6/15) patients, and 33% (5/15) of patients were completely off antidiabetic agents. CONCLUSIONS Although further research is needed, the present data suggest that successful weight loss and metabolic improvement can be achieved safely in the high-risk population of super-obese elderly.