Yves Michael Borbély

Early Results of the Swiss Multicentre Bypass or Sleeve Study (SM-BOSS): A Prospective Randomized Trial Comparing Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass

Objective:Laparoscopic sleeve gastrectomy (LSG) has been proposed as an effective alternative to the current standard procedure, laparoscopic Roux-en-Y gastric bypass (LRYGB). Prospective data comparing both procedures are rare. Therefore, we performed a randomized clinical trial assessing the effectiveness and safety of these 2 operative techniques. Methods:Two hundred seventeen patients were randomized at 4 bariatric centers in Switzerland. One hundred seven patients underwent LSG using a 35-F bougie with suturing of the stapler line, and 110 patients underwent LRYGB with a 150-cm antecolic alimentary and a 50-cm biliopancreatic limb. The mean body mass index of all patients was 44 ± 11.1 kg/m2, the mean age was 43 ± 5.3 years, and 72% were female. Results:The 2 groups were similar in terms of body mass index, age, sex, comorbidities, and eating behavior. The mean operative time was less for LSG than for LRYGB (87 ± 52.3 minutes vs 108 ± 42.3 minutes; P = 0.003). The conversion rate was 0.9% in both groups. Complications (<30 days) occurred more often in LRYGB than in LSG (17.2% vs 8.4%; P = 0.067). However, the difference in severe complications did not reach statistical significance (4.5% for LRYGB vs 1% for LSG; P = 0.21). Excessive body mass index loss 1 year after the operation was similar between the 2 groups (72.3% ± 22% for LSG and 76.6% ± 21% for LRYGB; P = 0.2). Except for gastroesophageal reflux disease, which showed a higher resolution rate after LRYGB, the comorbidities and quality of life were significantly improved after both procedures. Conclusions:LSG was associated with shorter operation time and a trend toward fewer complications than with LRYGB. Both procedures were almost equally efficient regarding weight loss, improvement of comorbidities, and quality of life 1 year after surgery. Long-term follow-up data are needed to confirm these facts.

Effects of postbariatric surgery weight loss on adipokines and metabolic parameters: comparison of laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy—a prospective randomized trial

BACKGROUND Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) lead to rapid improvement in insulin sensitivity even before weight loss occurs. Adipokines are closely linked to obesity and insulin resistance. To date, it is unclear whether the different anatomic changes of the various bariatric procedures have different effects on hormones of adipocyte origin. In the present prospective, randomized study, we compared the 1-year follow-up results of LRYGB and LSG concerning weight loss, metabolic control, and fasting adipokine levels. METHODS Of 23 nondiabetic morbidly obese patients, 12 were randomized to LRYGB and 11 to LSG. The patients were investigated before and 1 week, 3 months, and 12 months after surgery. The fasting levels of glucose, insulin, lipids, and adipokines (leptin, adiponectin, and fibroblast growth factor-21) were analyzed. RESULTS The body weight decreased markedly (P <.001) after either procedure (percentage of weight loss 16.4% ± 1.3%, 24.8% ± 1.7%, and 34.5% ± 2.7% after LRYGB and 13.1% ± 1.1%, 20.7% ± 1.5%, and 27.9% ± 2.6% after LSG at 2, 6, and 12 mo, respectively). The Homeostasis Model Assessment Index declined from 8.0 ± 1.5 preoperatively to 2.9 ± .2 at 12 months after LRYGB and from 7.5 ± 1.7 preoperatively to 3.3 ± .3 at 12 months after LSG. The lipid profiles were normalized. The concentrations of circulating leptin levels decreased by almost 50% as early as 1 week postoperatively and continued to decrease until 12 months postoperatively. Adiponectin increased progressively. The fibroblast growth factor-21 levels did not change over time. No difference was found between the LRYGB and LSG groups. CONCLUSION Both procedures led to significant weight loss associated with the resolution of the metabolic syndrome. The serum leptin levels decreased and adiponectin increased with weight loss, paralleled by improved insulin sensitivity.

Laparoscopic Sleeve Gastrectomy Versus Roux-Y-Gastric Bypass for Morbid Obesity-3-Year Outcomes of the Prospective Randomized Swiss Multicenter Bypass Or Sleeve Study (SM-BOSS).

Objective: Laparoscopic sleeve gastrectomy (LSG) is performed almost as often in Europe as laparoscopic Roux-Y-Gastric Bypass (LRYGB). We present the 3-year interim results of the 5-year prospective, randomized trial comparing the 2 procedures (Swiss Multicentre Bypass Or Sleeve Study; SM-BOSS). Methods: Initially, 217 patients (LSG, n = 107; LRYGB, n = 110) were randomized to receive either LSG or LRYGB at 4 bariatric centers in Switzerland. Mean body mass index of all patients was 44 ± 11 kg/m2, mean age was 43 ± 5.3 years, and 72% of patients were female. Minimal follow-up was 3 years with a rate of 97%. Both groups were compared for weight loss, comorbidities, quality of life, and complications. Results: Excessive body mass index loss was similar between LSG and LRYGB at each time point (1 year: 72.3 ± 21.9% vs. 76.6 ± 20.9%, P = 0.139; 2 years: 74.7 ± 29.8% vs. 77.7 ± 30%, P = 0.513; 3 years: 70.9 ± 23.8% vs. 73.8 ± 23.3%, P = 0.316). At this interim 3-year time point, comorbidities were significantly reduced and comparable after both procedures except for gastro-esophageal reflux disease and dyslipidemia, which were more successfully treated by LRYGB. Quality of life increased significantly in both groups after 1, 2, and 3 years postsurgery. There was no statistically significant difference in number of complications treated by reoperation (LSG, n = 9; LRYGB, n = 16, P = 0.15) or number of complications treated conservatively. Conclusions: In this trial, LSG and LRYGB are equally efficient regarding weight loss, quality of life, and complications up to 3 years postsurgery. Improvement of comorbidities is similar except for gastro-esophageal reflux disease and dyslipidemia that appear to be more successfully treated by LRYGB.

Effect of Laparoscopic Sleeve Gastrectomy vs Laparoscopic Roux-en-Y Gastric Bypass on Weight Loss in Patients With Morbid Obesity: The SM-BOSS Randomized Clinical Trial

Importance Sleeve gastrectomy is increasingly used in the treatment of morbid obesity, but its long-term outcome vs the standard Roux-en-Y gastric bypass procedure is unknown. Objective To determine whether there are differences between sleeve gastrectomy and Roux-en-Y gastric bypass in terms of weight loss, changes in comorbidities, increase in quality of life, and adverse events. Design, Setting, and Participants The Swiss Multicenter Bypass or Sleeve Study (SM-BOSS), a 2-group randomized trial, was conducted from January 2007 until November 2011 (last follow-up in March 2017). Of 3971 morbidly obese patients evaluated for bariatric surgery at 4 Swiss bariatric centers, 217 patients were enrolled and randomly assigned to sleeve gastrectomy or Roux-en-Y gastric bypass with a 5-year follow-up period. Interventions Patients were randomly assigned to undergo laparoscopic sleeve gastrectomy (n = 107) or laparoscopic Roux-en-Y gastric bypass (n = 110). Main Outcomes and Measures The primary end point was weight loss, expressed as percentage excess body mass index (BMI) loss. Exploratory end points were changes in comorbidities and adverse events. Results Among the 217 patients (mean age, 45.5 years; 72% women; mean BMI, 43.9) 205 (94.5%) completed the trial. Excess BMI loss was not significantly different at 5 years: for sleeve gastrectomy, 61.1%, vs Roux-en-Y gastric bypass, 68.3% (absolute difference, −7.18%; 95% CI, −14.30% to −0.06%; P = .22 after adjustment for multiple comparisons). Gastric reflux remission was observed more frequently after Roux-en-Y gastric bypass (60.4%) than after sleeve gastrectomy (25.0%). Gastric reflux worsened (more symptoms or increase in therapy) more often after sleeve gastrectomy (31.8%) than after Roux-en-Y gastric bypass (6.3%). The number of patients with reoperations or interventions was 16/101 (15.8%) after sleeve gastrectomy and 23/104 (22.1%) after Roux-en-Y gastric bypass. Conclusions and Relevance Among patients with morbid obesity, there was no significant difference in excess BMI loss between laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass at 5 years of follow-up after surgery. Trial Registration clinicaltrials.gov Identifier: NCT00356213

Effect of Laparoscopic Sleeve Gastrectomy vs Laparoscopic Roux-en-Y Gastric Bypass on Weight Loss in Patients With Morbid Obesity

Importance Sleeve gastrectomy is increasingly used in the treatment of morbid obesity, but its long-term outcome vs the standard Roux-en-Y gastric bypass procedure is unknown. Objective To determine whether there are differences between sleeve gastrectomy and Roux-en-Y gastric bypass in terms of weight loss, changes in comorbidities, increase in quality of life, and adverse events. Design, Setting, and Participants The Swiss Multicenter Bypass or Sleeve Study (SM-BOSS), a 2-group randomized trial, was conducted from January 2007 until November 2011 (last follow-up in March 2017). Of 3971 morbidly obese patients evaluated for bariatric surgery at 4 Swiss bariatric centers, 217 patients were enrolled and randomly assigned to sleeve gastrectomy or Roux-en-Y gastric bypass with a 5-year follow-up period. Interventions Patients were randomly assigned to undergo laparoscopic sleeve gastrectomy (n = 107) or laparoscopic Roux-en-Y gastric bypass (n = 110). Main Outcomes and Measures The primary end point was weight loss, expressed as percentage excess body mass index (BMI) loss. Exploratory end points were changes in comorbidities and adverse events. Results Among the 217 patients (mean age, 45.5 years; 72% women; mean BMI, 43.9) 205 (94.5%) completed the trial. Excess BMI loss was not significantly different at 5 years: for sleeve gastrectomy, 61.1%, vs Roux-en-Y gastric bypass, 68.3% (absolute difference, −7.18%; 95% CI, −14.30% to −0.06%; P = .22 after adjustment for multiple comparisons). Gastric reflux remission was observed more frequently after Roux-en-Y gastric bypass (60.4%) than after sleeve gastrectomy (25.0%). Gastric reflux worsened (more symptoms or increase in therapy) more often after sleeve gastrectomy (31.8%) than after Roux-en-Y gastric bypass (6.3%). The number of patients with reoperations or interventions was 16/101 (15.8%) after sleeve gastrectomy and 23/104 (22.1%) after Roux-en-Y gastric bypass. Conclusions and Relevance Among patients with morbid obesity, there was no significant difference in excess BMI loss between laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass at 5 years of follow-up after surgery. Trial Registration clinicaltrials.gov Identifier: NCT00356213

Wernicke Encephalopathy: a Future Problem Even After Sleeve Gastrectomy? A Systematic Literature Review

Wernicke encephalopathy (WE) is a serious complication of bariatric surgery with significant morbidity and mortality. A few cases have been reported in the literature, mainly in patients after a Roux-en-Y gastric bypass. Since sleeve gastrectomy (SG) has become a more established and popular bariatric procedure, WE is expected to appear more frequently after SG. We performed a literature review on WE after SG, and 13 cases have been found to be sufficiently documented. The risk of WE needs to be considered in patients with a prolonged vomiting episode and any type of neurological symptoms, independent of the presence of any surgical complications.

Exocrine Pancreatic Insufficiency after Roux-en-Y gastric bypass

BACKGROUND Gastric resection, short bowel syndrome, and diabetes mellitus are risk factors for development of exocrine pancreatic insufficiency (EPI). Reasons are multifactorial and not completely elucidated. OBJECTIVES To determine the prevalence of EPI after distal (dRYGB) and proximal Roux-en-Y gastric bypass (pRYGB) and to assess the influence of respective limb lengths. SETTING University hospital, Switzerland. METHODS The study comprised 188 consecutive patients who underwent primary dRYGB (common channel<120 cm, biliopancreatic limb 80-100 cm) or pRYGB (alimentary limb = 155 cm, biliopancreatic limb 40-75 cm) and who were followed-up for at least 2 years. Patients with a history of gastrointestinal or hepatobiliary resection (except for cholecystectomy), postoperative pregnancy, and any revision of RYGB (gastric pouch, limb lengths) were excluded. EPI was defined by clinical symptoms in combination with fecal pancreatic elastase-1<200 μg/g stool or fecal pancreatic elastase-1>200 and<500 μg/g stool and positive dechallenge-rechallenge test with pancreatic enzyme replacement therapy. RESULTS Mean follow-up was 52.2 months (range 24-120). Seventy-nine patients (42%) underwent dRYGB, and 109 (58%) underwent pRYGB. Of those, 59 (31%) patients were diagnosed with EPI after a mean 12.5±16.3 months. There was a significant difference between dRYGB and pRYGB groups in initial body mass index (dRYGB 47.1±8.1 kg/m(2) versus pRYGB 42.7±6.1 kg/m(2); P<.01), patients in Obesity Surgery Mortality Risk Score group C (13% versus 3%; P = .02), and prevalence of EPI (48% versus 19%; P<.01). Neither overall small bowel length nor absolute or relative limb lengths were influencing factors on EPI after dRYGB. CONCLUSION Prevalence of EPI after dRYGB (48%) and pRYGB (19%) is of clinical importance. There was no significant difference in absolute or relative limb lengths between EPI and non-EPI groups after dRYGB.

Complex hernias with loss of domain in morbidly obese patients: role of laparoscopic sleeve gastrectomy in a multi-step approach

BACKGROUND Morbid obesity and its associated co-morbidities are risk factors for the development of abdominal hernias, add complexity to their repair, and increase perioperative risk. Repair of hernias with loss of domain (LoD) is further complicated by risk of abdominal compartment syndrome. A staged concept with an initial weight loss procedure might enable a reposition of the herniated viscera, improve co-morbidities for, and prohibit abdominal compartment syndrome in the subsequent repair. OBJECTIVE To evaluate a multistep treatment strategy that entails initial laparoscopic sleeve gastrectomy (LSG) followed by open repair in the treatment of complex hernias with LoD in morbidly obese patients SETTING: University hospital METHODS: Retrospective analysis of all patients (n = 15) with morbid obesity and hernias with LoD treated in a staged concept between April 2010 and December 2015 RESULTS: Median initial body mass index was 45 kg/m2. All hernias were recurrent incisional hernias with≥2 failed repairs. No major complications occurred during or after LSG. After a median of 185 days, the second stage at a median body mass index of 33.6 kg/m2 was performed. No bowel resections were needed. The only major perioperative complication was pneumonia in 2 patients (13%). Within 24 months (6-68) after the second step, there were 3 reoperations (small recurrence [7%], infected seroma [7%], and infected mesh [7%]). One patient (7%) was lost to follow-up after 2 years. CONCLUSION A 2-step approach to treat massive hernias with LoD in morbidly obese patients is safe and effective. LSG as initial weight loss procedure addresses LoD successfully without a need for further preoperative measures to condition for hernia repair.

Bilateral chylothorax following neck dissection: a case report.

BackgroundChylothorax is an extremely rare but potentially life-threatening complication after radical neck dissection. We report the case of a bilateral chylothorax after total thyroidectomy and cervico-central and cervico-lateral lymphadenectomy for thyroid carcinoma.Case presentationA 40-year-old European woman underwent total thyroidectomy and neck dissection for papillary thyroid carcinoma. Postoperatively she developed dyspnoea and pleural effusion. A chylothorax was found and the initial conservative therapy was not successful. She had to be operated on again and the thoracic duct was legated.ConclusionThe case presentation reports a very rare complication after total thyroidectomy and neck dissection, but it has to be kept in mind to prevent dangerous complications.

Acute pancreatitis after Roux-en-Y gastric bypass surgery due to reflux into biliopancreatic limb

p f 9 w t a u t i t g g Laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) is the most commonly performed bariatric surgical procedure [1]. It has become a low-risk intervention, with low mortality and morbidity [2]. Several different variations of LRYGB have een developed, each with specific advantages. However, all rocedures share the typical anastomosis-related complications f bleeding, leak, or stenosis, as well as early intestinal obtruction [3]. Perioperative acute pancreatitis is uncommon, although bile stones after bariatric procedures are known sequelae in the long term [4]. We describe a rare case of acute pancreatitis shortly after RYGB due to reflux of the intestinal contents into the biliopancreatic limb.