Ghanem, Omar M.

Metabolic and bariatric surgery is widely recognized as the most effective and durable treatment for the disease of obesity and its associated comorbidities. In recent years, the field has seen significant advancements, introducing numerous innovative surgical options. This review aims to comprehensively examine these emerging surgical techniques, which have recently received endorsement from the American Society for Metabolic and Bariatric Surgery (ASMBS). Additionally, we will explore new technologies and methodologies supported by the latest scientific evidence. Our analysis will include a critical evaluation of the efficacy, safety, and long-term outcomes of these novel approaches, providing a detailed update on the current state of metabolic and bariatric surgery, highlighting key developments and their potential implications for clinical practice.

Background: The field of metabolic and bariatric surgery (MBS) is currently an expanding surgical field with constant refinements in techniques, outcomes, indications, and objectives. MBS has been effectively applied across diverse patient demographics, including varying ages, genders, body mass indexes, and comorbidity statuses. Methods: We performed a comprehensive literature review of published retrospective cohort studies, meta-analyses, systematic reviews, and literature reviews from inception to 2024, reporting outcomes of MBS using databases such as PubMed, ScienceDirect, and Springer Link. Results: MBS is a safe and efficient therapeutic option for patients with obesity and associated medical conditions (mortality rate 0.03–0.2%; complication rates 0.4–1%). The favorable safety profile of MBS in the short-, mid-, and long-term offers the potential to treat patients with obesity and type 2 diabetes mellitus, immunosuppression, chronic anticoagulation, neoplastic disease, and end-organ failure without increased morbidity and mortality. Conclusions: In conclusion, the future of MBS lies in the ongoing innovation and adapted therapeutic strategies along with the integration of a variety of other techniques for managing obesity. Careful preoperative assessments, coupled with a multidisciplinary approach, remain essential to ensure optimal surgical outcomes and patient satisfaction after MBS.

Background Obesity is intricately associated with type-2 diabetes (T2D) and other cardiovascular conditions, increasing morbidity, mortality, and health care costs. Metabolic and bariatric surgeries (MBS) have shown promising results in significant weight loss and T2D remission, but existing predictive scores for post-MBS diabetes remission do not consider insulin dosage, potentially overlooking a critical factor. Methods A retrospective analysis of patients with T2D who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). The study focused on insulin dosage impact, divided into quartiles, on remission rates post-MBS. The effectiveness of RYGB vs SG was compared within insulin dose quartiles with up to 5 years of follow up. Results A total of 508 patients (64% female, 94.9% White, mean age 53.5 ± 10.5 years, BMI (46.0 ± 8.3 kg/m 2 ) were included in the analysis. This study demonstrates a profound association between insulin dosage quartiles and T2D remission after MBS. Patients with lower insulin requirements showed superior remission rates; those in the lowest quartile had remission rates of 73%, 70%, and 62% at 1, 3, and 5 years, respectively, compared to 34%, 37%, and 36% in the highest quartile ( P < 0.001 across all intervals). RYGB surgery showed a significantly better remission in the second and third insulin quartiles, suggesting its effectiveness over SG for patients with mid-range insulin requirements. Conclusion This study underscores the importance of considering insulin dosage when predicting T2D remission post-MBS. The findings advocate for a more nuanced selection of MBS procedures based on individual insulin profiles, potentially enhancing diabetes remission outcomes.

Metabolic and bariatric surgery (MBS) is the most effective and durable therapeutic intervention for patients with obesity. In recent years, laparoscopic sleeve gastrectomy (SG) has become the most commonly performed primary MBS procedure owing to its technical feasibility and excellent short-term outcomes. Despite these favorable results and perceived advantages, SG is associated with several unique complications. Complications such as a postoperative leak or bleeding have been more commonly observed and reported than others, and their management approaches are well described. However, other complications following SG are far less familiar to surgeons, which may delay recognition and result in poor patient outcomes. Of these complications, we describe splenic injuries; esophageal perforation; staple line malformations; stapling of intraluminal devices; phytobezoar formation; gastro-colic, gastro-pleural and gastro-bronchial fistula; pancreatic leak; and portomesenteric venous thrombosis. It is paramount for surgeons to be aware of these underreported issues and have the resources to learn how to recognize and manage them when they arise. This review aims to describe rare (i.e., reported incidence <1%) and underdescribed complications after SG, focusing on causes, clinical presentation, prevention strategies, and management.

Objective: With drastic variations in bariatric practices, consensus is lacking on an optimal approach for revisional bariatric surgeries. Materials and Methods: The authors reviewed and consolidated bariatric surgery literature to provide specific revision suggestions based on each index surgery, including adjustable gastric band (AGB), sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS), single anastomosis duodenal-ileal bypass with sleeve (SADI-S), one anastomosis gastric bypass (OAGB), and vertical banded gastroplasty (VBG). Results: AGB has the highest weight recurrence rate and can be converted to RYGB, SG, and BPD-DS. After index SG, common surgical options include a resleeve or RYGB. The RYGB roux limb can be distalized and pouch resized in context of reflux, and the entire anatomy can be revised into BPD-DS. Data analyzing revisional surgery after a single anastomosis duodenal-ileal bypass with sleeve was limited. In patients with one anastomosis gastric bypass and vertical banded gastroplasty anatomy, most revisions were the conversion to RYGB. Conclusions: As revisional bariatric surgery becomes more common, the best approach depends on the patient’s indication for surgery and preexisting anatomy.

Objective: Hiatal hernia (HH) and symptomatic gastroesophageal reflux disease are common complications after metabolic bariatric surgery. This meta-analysis aims to investigate the safety and efficacy of ligamentum teres augmentation (LTA) for HH repair after metabolic and bariatric surgeries (MBS). Materials and Methods: CENTRAL, Embase, PubMed, and Scopus were searched for articles from their inception to September 2023 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis system. Results: Five studies met the eligibility criteria, with a total of 165 patients undergoing LTA for HH repair after MBS. The distribution of patients based on surgical procedures included 63% undergoing sleeve gastrectomy, 21% Roux-en-Y gastric bypass, and 16% having one anastomosis gastric bypass. The pooled proportion of reflux symptoms before LTA was 77% (95% CI: 0.580-0.960; I 2 = 89%, n = 106). A pooled proportion of overall postoperative symptoms was 25.6% (95% CI: 0.190-0.321; I 2 = 0%, n = 44), consisting of reflux at 14.5% (95% CI: 0.078-0.212; I 2 = 0%, n = 15). The pooled proportion of unsuccessful LTA outcomes was 12.5% (95% CI: 0.075-0.175; I 2 = 0%, n = 21). Conclusion: Our meta-analysis demonstrated that LTA appears to be a safe and efficacious procedure in the management of HH after MBS.

SummaryMetabolic and Bariatric Surgery (MBS) is effective in improving metabolic outcomes and reducing weight in patients with obesity and diabetes, with less explored benefits in type 1 diabetes (T1D). This study aimed to evaluate the impact of MBS on weight loss and insulin requirements in T1D patients compared to insulin‐treated type 2 diabetes (T2D) patients over a 5‐year period. This retrospective analysis included patients who underwent primary sleeve gastrectomy (SG) or Roux‐en‐Y gastric bypass (RYGB) with a confirmed preoperative diagnosis of either T1D or insulin‐treated T2D. Primary endpoints focusing on weight loss and secondary outcomes assessing changes in insulin dosage and glycemic control. After 5 years, weight loss was similar across groups, with total weight loss at 14.2% for T1D and 17.6% for insulin‐treated T2D in SG, and 22.6% for T1D vs. 26.8% for insulin‐treated T2D in RYGB. Additionally, there was a significant reduction in median daily insulin doses from 140.5 units at baseline to 77.5 units at 1 year postoperatively, sustained at 90 units at 5 years. The differential impact of MBS procedure was also highlighted, where RYGB patients showed a more pronounced and enduring decrease in insulin requirements compared to SG.

Background: The obesity epidemic has led to an increase in the proportion of patients with chronic liver disease due to metabolic associated steatosic liver disease and in the prevalence of obesity in patients with cirrhosis. Metabolic and bariatric surgery (MBS) has been proven to determine weight loss, obesity-related medical problems remission, and liver steatosis, inflammation, and fibrosis improvement. However, cirrhosis and portal hypertension are well-known risk factors for increased morbidity and mortality after surgery. The aim of this study is to evaluate the safety of MBS in patients with compensated advanced chronic liver disease (cALCD) and clinically significant portal hypertension (CSPH). Material and methods: This is an international, multicentric, retrospective study on 63 individuals affected by obesity with cALCD and CSPH who underwent MBS in tertiary referral centers with experts hepatobiliary surgeons between January 2010 and October 2022. The primary endpoint was postoperative mortality at 90 days. The secondary endpoints included postoperative weight loss at last follow-up and postoperative complication rate. In addition, the authors performed subgroup analyses of Child-Pugh (A vs. B) score, MELD (≤9 vs. >9) score, and type of surgery. Results: One patient (1.6%) experienced gastric leakage and mortality. There were three (5%) reported cases of portal vein thrombosis, two (3%) postoperative acute renal failure, and one (1.6%) postoperative encephalopathy. Child-Pugh score A resulted to be a protective factor for intraoperative bleeding requiring transfusion at univariate analysis (OR: 0.73, 95% CI: 0.55–0.97, P=0.046) but not at multivariate analysis. MELD>9 score and the type of surgery did not result to be a risk factor for any postoperative complication. Conclusion: MBS is safe in patients with cALCD and CSPH performed in tertiary bariatric referral centers with hepatobiliary expert surgeons. Larger, prospective studies with longer follow-up periods are needed to confirm these results.

Abstract Background Postoperative nausea and vomiting (PONV) is frequent after bariatric surgery. We hypothesized that when compared with a volatile-based technique incorporating propofol infusions, the need for rescue antiemetics would be reduced by the use of two strategies: 1) the addition of dexmedetomidine infusions, and 2) the avoidance of opioid and volatile anesthetics, and that this reduction would be observed in the PACU following PACU discharge. Methods In this retrospective observational study we included patients undergoing bariatric surgery from 2018–2022 who received one of three anesthetic strategies: 1) volatile anesthetic and propofol infusion (VOL + PROP), 2) VOL + PROP with the addition of dexmedetomidine (DEX), or 3) opioid-sparing total intravenous anesthesia (PROP + DEX). Inverse probability of treatment weighting analysis determined the association between the need for rescue-antiemetics in the PACU following PACU discharge. Results 332 patients received VOL + PROP, 354 VOL + PROP + DEX, and 166 PROP + DEX. PROP + DEX received fewer rescue antiemetics in PACU compared to VOL + PROP (11% vs 24%, P = 0.002), and VOL + PROP + DEX fewer compared to VOL + PROP (16% vs 24%, P = 0.023). This differential effect was limited to PACU stay; antiemetic use increased across all groups following PACU discharge until midnight (ranging from 38–46% across groups, P = 0.71) and through the first postoperative day (ranging from 47–57%, P = 0.20). Conclusions The benefit associated with two PONV prevention strategies, the addition of dexmedetomidine infusion or avoidance of opioid and volatile anesthetics, did not persist after PACU discharge. These findings highlight the challenge of PONV on postoperative wards, and the need for a novel multimodal team approach to mitigate this complication.