Ghanem, Omar M.

ABSTRACTIntroductionEsophageal dysmotility following metabolic bariatric surgery (MBS) may relate to decreased gastric compliance. We investigated high‐resolution esophageal manometry (HRM) and secondary peristalsis assessed by functional lumen imaging probe (FLIP) and their association with intragastric pressure after MBS.MethodsPatients undergoing HRM, FLIP, and barium esophagram (BE) after MBS were included. HRM metrics and proximal intragastric pressure at baseline (IGP baseline), during wet swallow‐induced esophagogastric junction relaxation (IGP EGJ opening), and following wet swallow‐induced esophagogastric junction opening with subsequent closure (IGP post EGJ closure) were measured. Contractile response was assessed during FLIP.ResultsForty patients (26 Roux en Y gastric bypass, 14 sleeve gastrectomy) with FLIP a median of 4 years after MBS, were identified. HRM was normal or consistent with ineffective esophageal motility (IEM) in 33 (82.5%) patients, while the contractile response on FLIP was abnormal (disordered/impaired, absent, or spastic reactive) in 28 (70%). Delayed emptying on BE was numerically more frequent with abnormal FLIP (6% vs. 0%, p = 0.08). IGP post‐EGJ closure (median 21.8 vs. 15 mmHg, p = 0.03) and ∆ IGP post‐EGJ closure—IGP baseline (median 4 vs. 0 mmHg, p = 0.02) were greater and predictive of abnormal contractility on FLIP (OR 1.11, 95% CI 1.00–1.2, p = 0.03 and OR 1.6, 95% CI 1.07–2.39, p = 0.003, respectively).DiscussionAbnormal contractility on FLIP, reflecting disordered secondary peristalsis, frequently occurs despite normal HRM findings after MBS. Secondary peristalsis may be associated with reduced gastric compliance, reflected by elevated proximal intragastric pressure. FLIP contractility could serve as an early marker for post‐MBS esophageal dysfunction.

AbstractEndoscopic sleeve gastroplasty (ESG) is an effective treatment for obesity but typically is not covered by insurance. It is not known whether patients with financial investment in their endoscopic procedure are more likely to achieve and/or maintain weight loss as compared with those who have no financial buy-in. We aimed to compare treatment adherence and outcomes between patients paying out-of-pocket (OOP) and those who underwent ESG as part of any clinical trial where costs were covered by a study protocol (no payment; NP).Data were collected via retrospective chart review. One hundred sixty-four patients who had an ESG with at least 6 months of follow-up were included. Repeated measures with generalized linear model were used to evaluate weight loss at different time points after ESG and labs values at baseline and 1-year follow-up to assess for comorbidity improvement between cohorts. Compliance was evaluated by comparing exercise adherence rates.The pattern of weight loss and change in laboratory values was not different over time between the OOP group (n = 139) and NP group (n = 25). Patients lost an average of 14% (12.2–15.9) and 12.9% (9.3–16.5) of total body weight over all time points, respectively, in both groups (6, 12 and 24 months). Treatment adherence also did not differ between the groups.Having “skin in the game” by paying for ESG OOP does not correlate with better outcomes or treatment adherence, which further supports broad insurance coverage for this procedure.

Introduction: Gastroesophageal reflux disease (GERD) symptoms and the use of proton pump inhibitors (PPIs) remain prevalent after Roux-en-Y Gastric Bypass (RYGB), despite it being known to alleviate reflux. The physiological changes behind long-term GERD and hiatal hernia (HH) prevalence post-RYGB are not commonly investigated. Methods: In this consecutive cohort study, we examined patients who underwent RYGB and subsequent upper endoscopy, conducted by an expert bariatric endoscopist. The primary focus was on pouch endoscopic retrosflexion to evaluate the antireflux barrier (ARB). We gathered data encompassing patient demographics, anthropometrics, comorbidities, and findings from esophagogastroduodenoscopy (EGD) at the time of surgery and during follow-up EGD. Results: Our study included a total of 42 patients, predominantly female (97.5%) and White (100%), with an average age of 53.6±10.6 years and a body mass index (BMI) of 32.9±9.4 kg/m 2 . In our findings, all EGDs revealed the presence of a HH of varying sizes. The average HH size was 2.07±0.87 cm. The esophagogastric junction (EGJ) flap was also effaced in all patients with the majority (90.4%, 38 patients) classified as Hill grade IV and a smaller proportion (9.6%, 4 patients) as Hill grade III. Notably, PPI usage increased from the time of surgery to the time of EGD (69.0% vs. 42.9%, P =0.06). Conclusion: This research highlights the high incidence of HH and EGJ flap effacement in patients after RYGB, potentially elucidating the persistence of reflux symptoms, including weakly acidic or alkaline reflux, post-RYGB.

Objective: Postoperative nausea and vomiting (PONV) is a frequent adverse event after bariatric surgery and is associated with patient dissatisfaction and increased health care burden. Aggressive multimodal antiemetic prophylaxis and the use of propofol infusion during anesthesia are associated with the reduction of PONV. In this study, we examined the use of rescue antiemetics following bariatric surgery performed with 3 different anesthetic strategies designed to reduce PONV: (1) primary volatile (VOL) anesthetic and propofol (PROP) infusion (VOL+PROP), (2) volatile anesthetic with propofol and dexmedetomidine (DEX) infusions (VOL+PROP+DEX), or (3) opioid-sparing total intravenous anesthesia (PROP+DEX). Methods: In this retrospective observational study, we included patients undergoing bariatric surgery from 2018-2022 who received 1 of 3 anesthetics: (1) VOL+PROP, (2) VOL+PROP+DEX, or (3) opioid-sparing PROP+DEX without a VOL. Inverse probability of treatment weighting analysis determined the association between the need for rescue-antiemetics in the postanesthesia care unit (PACU) and following PACU discharge. Results: Three hundred thirty-two patients received VOL+PROP, 354 VOL+PROP+DEX, and 166 PROP+DEX, and all received prophylactic antiemetics during surgery. After surgery, the PROP+DEX patients received fewer rescue antiemetics in the PACU compared with VOL+PROP (11% vs. 24%, P=0.002), and VOL+PROP+DEX fewer compared with VOL+PROP (16% vs. 24%, P=0.023). This differential antinausea effect was limited to PACU stay only. Rescue antiemetic use increased across all anesthetic management groups following PACU discharge until midnight on the day of surgery (ranging from 38% to 46% across groups, P=0.71) and through the first postoperative day (ranging from 47% to 57% across groups, P=0.20). Conclusions: The benefit associated with anesthetic strategies designed to reduce PONV was present but did not persist past PACU discharge. This finding suggests that aggressive perioperative multimodal antiemetic prophylaxis combined with anesthetic strategies designed to prevent PONV after bariatric surgery have only a short-lived effect, thus health care staff in hospital wards may expect to encounter high rates of PONV in these patients. There is a need for the development of novel antinausea treatments to reduce the rate of this frequent postoperative complication.

Metabolic and bariatric surgery has been well described in the existing literature to be an effective and safe modality for weight loss in patients with obesity. Recently, hypoabsorptive procedures such as one-anastomosis gastric bypass (OAGB), biliopancreatic diversion with duodenal switch (BPD-DS), and single-anastomosis duodenoileostomy with sleeve (SADI-S) have gained traction, particularly among patients with severe obesity. These procedures combine restrictive and hypoabsorptive mechanisms, resulting in significant and sustainable weight loss, especially in those with severe obesity and associated comorbidities. However, the risk of malnutrition and nutritional deficiency following these procedures has been a deterrent for surgeons in their adoption. This review evaluates the existing literature on the safety, efficacy, and long-term outcomes of OAGB, BPD-DS, and SADI-S. While these hypoabsorptive procedures represent highly effective options for treating obesity, the associated nutritional complications necessitate the need for long-term follow-up and supplementation and highlight the need for careful patient selection.

Background and Objectives: Type 2 diabetes (T2D), closely associated with obesity, contributes to increased morbidity and mortality due to complications such as cardiometabolic disease. This review aims to evaluate the effectiveness of metabolic and bariatric surgeries (MBS) and endoscopic bariatric therapies (EBTs) in achieving diabetes remission and to examine key predictors influencing remission outcomes. Materials and Methods: This review synthesizes data from studies on MBS and EBT outcomes, focusing on predictors for diabetes remission such as preoperative insulin use, diabetes duration, HbA1c, and C-peptide levels. Additionally, predictive scoring systems, including the Individualized Metabolic Surgery (IMS), DiaRem, Advanced-DiaRem, ABCD, and Robert et al. scores, were analyzed for their utility in forecasting remission likelihood. Results: Key predictors of T2D remission include shorter diabetes duration, lower HbA1c, and higher C-peptide levels, while prolonged insulin use, and higher insulin doses are associated with lower remission rates. Scoring models like IMS and DiaRem demonstrate that lower scores correlate with a higher likelihood of remission, especially for procedures such as Roux-En-Y gastric bypass (RYGB). RYGB generally shows higher remission rates compared to sleeve gastrectomy (SG), particularly among patients with mild disease severity, while EBTs like ESG and IGBs contribute 5–20% total weight loss (TWL) and moderate glycemic control improvements. Conclusions: Both MBS and EBTs are effective for T2D management, with predictive scoring models aiding in individualized patient selection to optimize remission outcomes. Further research to validate these predictive tools across diverse populations could enhance treatment planning for both surgical and endoscopic interventions.

Objective: To develop and validate 2 predictive models, the Diabetes Remission Index (DRI) and the Weight loss–adjusted DRI (W-DRI), for assessing type 2 diabetes (T2D) remission following metabolic and bariatric surgery (MBS). Background: MBS, including Roux-en-Y gastric bypass and sleeve gastrectomy, is highly effective in achieving T2D remission, but outcomes vary across populations. Predicting remission remains critical for individualized patient care and optimizing surgical outcomes. Existing tools focus on general outcomes, and a specific model incorporating weight loss data has been lacking. Methods: This multicenter, retrospective cohort study included patients with T2D and overweight/obesity (body mass index: ≥27 kg/m 2 ) who underwent Roux-en-Y gastric bypass or sleeve gastrectomy between 2008 and 2018. Institution 1 (I-1) data (n = 503) were used to develop and internally validate the models, whereas Institution 2 (I-2) data (n = 409) were used for external validation. The DRI model incorporated preoperative variables, and the W-DRI model, in addition, included postsurgical weight loss. Predictive accuracy was assessed using area under the Receiver Operating Characteristic curve [area under the curve (AUC)], calibration plots, and stratified analyses. Results: In I-1, 44.7% of patients achieved T2D remission, with a DRI model AUC of 0.80. In I-2, 52.6% achieved remission, with a model AUC of 0.78. Incorporating weight loss improved W-DRI predictive accuracy (AUC: 0.82 in I-1, 0.79 in I-2). Calibration plots demonstrated strong agreement between predicted and observed remission rates. An online DRI and W-DRI calculator is available through the Mayo Clinic webpage (https://newsnetwork.mayoclinic.org/dri-calculator/). Conclusions: The DRI and W-DRI models accurately predict T2D remission post-MBS, enabling personalized patient care and informed decision-making. Further validation across diverse populations is warranted.

Summary Metabolic and bariatric surgeries (MBS), including Roux‐en‐Y Gastric Bypass (RYGB) and Sleeve Gastrectomy (SG), have proven effective in promoting long‐term diabetes remission among patients with type‐2 diabetes (T2D). In this multicentre retrospective cohort study, we investigated the effectiveness of RYGB and SG in achieving diabetes remission, specifically among patients with T2D and vascular complications, while accounting for similar baseline diabetes severity. Although various scores predict diabetes remission after bariatric surgery, they do not consider diabetes‐related vascular complications, which can influence outcomes even in patients with similar baseline T2D severity. We collected preoperative data on microvascular (retinopathy, nephropathy, neuropathy) and macrovascular comorbidities (coronary artery disease, cerebrovascular accidents, peripheral artery disease) to compare the efficacy of RYGB and SG. Among 961 patients analysed, those with vascular complications showed higher remission rates with RYGB (OR: 1.97) compared to SG, despite similar baseline diabetes severity. Notably, RYGB patients with microvascular complications had a significant advantage in achieving T2D remission (OR: 2.95). However, no significant differences in remission were observed in patients with macrovascular complications. These findings suggest that RYGB may be more effective than SG in specific patient populations, particularly those with microvascular complications, emphasizing the need for personalized treatment strategies.

Summary Biliopancreatic diversion with duodenal switch (BPD‐DS) and single anastomosis duodeno‐ileostomy with sleeve (SADI‐S) are associated with superior and sustained weight loss outcomes. Despite their growing popularity, long‐term safety profiles, particularly the risk of internal hernia (IH), remain underexplored. This study aimed to evaluate the incidence and characteristics of IH following BPD‐DS and SADI‐S procedures, comparing their clinical presentation, diagnostic methods, and outcomes. A retrospective chart review was performed for patients who underwent BPD‐DS or SADI‐S between 2008 and 2023 in two high‐volume tertiary referral centres for bariatric surgery in the United States. Demographic data, comorbidities, operative details, and follow‐up outcomes were collected. A subgroup analysis of IH cases was conducted to compare the incidence, location of hernias, and diagnostic modalities between procedures. Out of 1160 patients (85.1% BPD‐DS; 14.9% SADI‐S), the overall incidence of IH was 1.12%, with a higher rate in BPD‐DS (0.8%) than in SADI‐S (0.57%). Most IHs occurred within the first 24 months postoperatively. The majority of IHs in BPD‐DS patients were in the pseudo‐Petersen's space. The single IH case in the SADI‐S group occurred in the same space. Most patients presented with abdominal pain and were diagnosed by CT imaging. SADI‐S showed a lower IH rate compared to BPD‐DS, but further studies are needed to confirm these findings. The variability in clinical presentation complicates the diagnosis of IH, emphasizing the need for increased clinical vigilance.

SummaryGlobal obesity rates have risen dramatically, now exceeding deaths from starvation. Metabolic and bariatric surgery (MBS), initially for severe obesity (BMI ≥35 kg/m2), is performed globally over 500 000 times annually, offering significant metabolic benefits beyond weight loss. However, varying eligibility criteria globally impact patient care and healthcare resources. Updated in 2022, ASMBS and IFSO guidelines aim to standardise MBS indications, reflecting current understanding and emphasising comprehensive preoperative assessments. Yet, clinical variability persists, necessitating consensus‐based recommendations. This modified Delphi study engaged 45 global experts to establish consensus on perioperative management in MBS. Experts selected from bariatric societies possessed expertise in MBS and participated in a two‐round Delphi protocol. Consensus was achieved on 90 of 169 statements (53.3%), encompassing multidisciplinary team composition, patient selection criteria, preoperative testing, and referral pathways. The agreement highlighted the critical role of comprehensive preoperative assessments and the integration of healthcare professionals in MBS. These findings offer essential insights to standardise perioperative practices and advocate for evidence‐based guidelines in MBS globally. The study underscores the need for unified protocols to optimise outcomes and guide future research in MBS.