Ghanem, Omar M.

Marginal ulcer (MU) is a potential complication following Roux-en-Y gastric bypass (RYGB), with a mean prevalence of 4.6%. Early identification and prompt intervention are crucial to mitigating further complications. The pathophysiology of MU is complex and involves multiple factors, including smoking, Helicobacter pylori infection, non-steroidal anti-inflammatory drug (NSAID) use, and larger pouch size. Patients with MU may experience acute or chronic abdominal pain. Rarely, they may present with a complication from the ulceration, such as bleeding, perforation, or strictures. Following diagnosis by endoscopy, management of MU typically involves modification of risk factors and medical therapy focused on proton pump inhibitors. In case of complicated ulcers, surgical intervention is often required for the repair of the perforation or resection of the stricture. For recurrent or recalcitrant ulcers, endoscopic coverage of the ulcer bed, resection of the anastomosis, and abdominal or thoracoscopic truncal vagotomy may be considered. This review aims at providing an overview of the etiology, diagnosis, and management of MU after RYGB.

Abstract Bariatric surgeries are often complicated by de-novo gastroesophageal reflux disease (GERD) or worsening of pre-existing GERD. The growing rates of obesity and bariatric surgeries worldwide are paralleled by an increase in the number of patients requiring post-surgical GERD evaluation. However, there is currently no standardized approach for the assessment of GERD in these patients. In this review, we delineate the relationship between GERD and the most common bariatric surgeries: sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), with a focus on pathophysiology, objective assessment, and underlying anatomical and motility disturbances. We suggest a stepwise algorithm to help diagnose GERD after SG and RYGB, determine the underlying cause, and guide the management and treatment.

Background: Gastrojejunal (GJ) anastomotic stenosis is a well-described complication after Roux-en-Y gastric bypass (RYGB); however, its impact on weight loss outcomes is not well elucidated. Methods: We performed a retrospective cohort study of adult patients who underwent RYGB at our institution between 2008 and 2020. Propensity score matching was used to match 30 patients who developed GJ stenosis within the first 30 days post-RYGB with 120 control patients who did not develop this outcome. Short and long-term complications and mean percentage of total body weight loss (TWL) were recorded at 3 months, 6 months, 1 year, 2 years, 3 to 5 years, and 5 to 10 years postoperatively. Hierarchical linear regression modeling was used to analyze the association between early GJ stenosis and the mean percentage of TWL. Results: Patients who developed early GJ stenosis had a 13.6% increase in the mean percentage of TWL when compared with controls in the hierarchical linear model [P < 0.001 (95% CI: 5.7; 21.5)]. These patients were also more likely to present to an intravenous infusion center (70% vs 4%; P < 0.01), require readmission within 30 days (16.7% vs 2.5%; P < 0.01), and/or develop an internal hernia (23.3% vs 5.0%) postoperatively. Conclusions: Patients who develop early GJ stenosis after RYGB have a greater degree of long-term weight loss compared with patients who do not develop this complication. Although our findings support the key contribution that restrictive mechanisms play in maintaining weight loss after RYGB, GJ stenosis remains a complication associated with significant morbidity.

Abstract Background Obesity is associated with an increased incidence of at least 13 types of cancer. Although bariatric surgery has been associated with a reduced risk of hormonal cancers, data for non-hormonal cancers are scarce. The aim of this study was to evaluate the effect of bariatric surgery on the incidence of non-hormonal cancers. Methods Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles between 1984 and 2018, following the PRISMA system. Meta-analysis was conducted using a random-effect model with subgroup analysis by procedure and cancer type. Results From 2526 studies screened, 15 were included. There were a total of 18 583 477 patients, 947 787 in the bariatric group and 17 635 690 in the control group. In comparison to the non-surgical group, the bariatric group had a lower incidence of cancer (OR .65 (95 per cent c.i. 0.53 to 0.80); P &lt; 0.002). In the subgroup analysis, Roux-en-Y gastric bypass and sleeve gastrectomy were associated with decreased risk of developing cancer, while no difference was observed with adjustable gastric banding. When evaluated by cancer type, liver (OR 0.417 (95 per cent c.i. 0.323 to 0.538)), colorectal (OR 0.64 (95 per cent c.i. 0.49 to 0.84)), kidney and urinary tract cancer (OR 0.77 (95 per cent c.i. 0.72 to 0.83)), oesophageal (OR 0.60 (95 per cent c.i. 0.43 to 0.85)), and lung cancer (OR 0.796 (95 per cent c.i. 0.45 to 0.80)) also presented a lower cancer incidence in the bariatric group. Conclusion Bariatric surgery is related to an almost 50 per cent reduction in the risk of non-hormonal cancers.

Background: Biliopancreatic diversion with duodenal switch (BPD-DS) is an effective yet technically challenging bariatric surgery with many complications. Alternatively, single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) was recently introduced as a simplified bariatric procedure. This meta-analysis aimed to assess the safety and efficacy of SADI-S compared with BPD-DS in the management of patients with obesity. Methods: Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles from their inception to May 2022 by 2 independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis system. The review was registered prospectively with PROSPERO (CRD42022333521). Results: From 123 studies screened, 6 studies met the eligibility criteria, with a total of 1847 patients with obesity undergoing either SADI-S (n=818) or BPD-DS (n=1029). Preoperative body mass index was similar between the 2 groups, and the BPD-DS group had a greater % excess body mass index loss (EBMIL) (MD=−10.16%, 95% confidence interval: −11.80, −8.51, I2=0%) at 2 years compared with the SADI-S group. There was no difference observed in preoperative comorbidities and remission, including diabetes, hypertension, and dyslipidemia between SADI-S and BPD-DS cohorts. Compared with BPD-DS, SADI-S had shorter hospital stays (MD=−1.36 d, 95% CI: −2.39, −0.33, I2=86%), and fewer long-term (>30 d) complications (OR=0.56, 95% CI: 0.42, 0.74, I2=20%). Conversely, among nutritional deficiency outcomes, the SADI-S group had few patients with abnormal vitamin D (OR=0.51, 95% CI: 0.36, 0.72, I2=0%) values than the BPD-DS group. Conclusions: SADI-S has shown to be a possible alternative treatment option to BPD-DS in managing patients with obesity. Despite the promising results, further randomized controlled studies with more extended follow-up periods are necessary to ascertain the safety and efficacy of the treatment.

BACKGROUND: Malnutrition after bariatric operation is a rare but potentially life-threatening complication. The safety and efficacy of revisional bariatric operation in malnourished patients are not well elucidated. STUDY DESIGN: We performed a retrospective chart review of patients who underwent revisional bariatric operation for severe malnutrition at our institution between 2008 and 2020. Associations of demographic and clinical characteristics with dichotomous outcomes of interest were examined using Fisher’s exact tests, Cochran-Armitage tests for trend, and two-sample t-tests when appropriate. RESULTS: Fifty-three patients underwent revisional bariatric operation for malnutrition from 2008 and 2020. The median follow-up was 24 months. The anatomy before revision was Roux-en-Y gastric bypass (n = 40, 75%), biliopancreatic diversion with duodenal switch (n = 6, 11%), sleeve gastrectomy (n = 4, 8%), and mini gastric bypass (n = 3, 6%). The percentage of patients requiring supplemental or total nutritional support decreased from 89% preoperatively (47% on enteral feedings and 42% on total parenteral nutrition (TPN) with or without tube feeding) to 13.2% at the last encounter after revision (7.5% still requiring enteral feedings and 5.7% on TPN). There was an association between the number of prior abdominal operations and postoperative pneumonia (p 0.03) and need for blood transfusion (p 0.01). There were no associations between major complications or last encounter nutrition and any preoperative variables other than age at the time of operation. There were 2 mortalities during a median follow-up of 24 months, and both occurred more than 1 year postoperatively. CONCLUSION: Revisional operation for severely malnourished bariatric operation patients is effective in the discontinuation of supportive nutrition. Postoperative complications are increased but not prohibitive.

BACKGROUND: The MBSAQIP has been used to evaluate risk and create risk models. Previous studies have determined what complications matter most. STUDY DESIGN: This study was a registry-based analysis of patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) between January 1, 2015, and December 31, 2019, at centers participating in MBSAQIP. Cases were identified using Current Procedural Terminology. Patients less than 18 years old were excluded. A chi-square test was used to assess differences in the prevalence of complications and effects across years. Using a multivariable Poisson regression model with a link log and robust estimation, prevalence ratio estimates and 95% CI were obtained. RESULTS: A total of 690,770 observations met the inclusion criteria. Mean (SD) age was 44.5 (±12.0) years, and mean (SD) BMI was 45.2 kg/m2 (±7.9). SG cases accounted for 73.45% of all observations. There was a significant relative reduction in readmissions, end-organ dysfunction, and all-cause mortality from 2015 to 2019 in the SG subgroup. There were also noticeable reductions in 30-day readmission, ICU admission, and end-organ dysfunction in the RYGB subgroup. For complications, bleeding, postoperative pneumonia, and stroke were significantly decreased in the RYGB subgroup, but only bleeding was significantly decreased in the SG subgroup during the 5-year study period. CONCLUSIONS: There has been a continuous improvement in several (but not all) outcomes through the years that the MBSAQIP has been collecting data. Different outcomes were reduced between the SG and RYGB subgroups, and the decrease in all-cause mortality was only noted in the SG subgroup.

Background Roux-en-Y gastric bypass (RYGB) is a recognized, safe bariatric procedure with minimal complications. Marginal ulceration, however, remains a challenging problem with an incidence of 8-12%. While chronic NSAID use is an established risk factor for ulcer formation, aspirin use itself as a cause for marginal ulceration is still unclear. We aim to compare the rates of marginal ulceration in RYGB with and without aspirin use. Methods PubMed, ScienceDirect, Cochrane, Web of Science, and Google Scholar were searched for articles between 2008 and 2021 by two independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). The risk of bias was assessed using Newcastle-Ottawa Scale. Meta-analysis was conducted using a fixed-effect model. Results From 5324 studies screened, we included 3 studies. Two studies had a low risk of bias, and the other one presented a high risk of bias on the Newcastle-Ottawa Scale. We included 24,770 patients, 1911 with aspirin use and 22,859 without aspirin use. After the meta-analysis, patients who used aspirin had a significantly higher marginal ulceration rate than those who did not (OR = 1.33 [95% CI 1.08 to 1.63], P < .002; I 2 = 39%). Conclusions Aspirin use is associated with increased rates of marginal ulceration after RYGB.