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Journal Watch 19/04/2023

Welcome to our weekly round-up of the latest bariatric and obesity-related papers published in the medical literature. As ever, we have looked far and wide to give you an overview of papers including endoscopic TORe to tackle weight regain, salivary pepsin and erosive esophagitis, bariatric VTE risk assessment tools and mesh fixation/non-fixation for TAPP inguinal hernia repair, and more (please note, log-in maybe required to access the full paper).

Transoral Outlet Reduction to Tackle Weight Regain After Roux-en-Y Gastric Bypass: a Single Center Initial Experience

Endoscopic transoral outlet reduction (TORe) by narrowing the dilated gastro-jejunal anastomosis (GJA) appears to be an efficient and safe minimal invasive option to tackle weight regain after RYGB and should be more used in clinical practice, according to researchers from AZ Delta Hospital, Roeselare/Torhout, Belgium.

Writing in Obesity Surgery, they reported a case series of 20 patients referred due to weight regain after RYGB with a dilated GJA. TORe was performed using an endoscopic full-thickness suture device (Apollo OverStitch) to reduce the diameter of the GJA and the volume of the gastric reservoir.

The average time to TORe was 12.1 years after initial RYGB. Patients regained a mean 45.9% of excess body weight loss (EWL) before TORe and had a mean preprocedural BMI of 35.3 kg/m2. They reduced the aperture of the GJA to 5mm which was done with a mean of 1.7 sutures and 3.5 stitches. The mean absolute weight loss was 13 kg and BMI reduction was 3.9 kg/m2 after six months.

After a median follow-up of 22 months, a BMI of 31.4 kg/m2 was observed. Dumping symptoms resolved in four of our patients 6 weeks after TORe. Procedural adverse events were nausea and vomiting, sore throat, mild transient abdominal pain, diarrhoea and constipation.

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Pepsin in saliva for the diagnosis of erosive esophagitis post-sleeve gastrectomy: a prospective observational study

Researchers from Singapore General Hospital, Singapore, have found that salivary pepsin has “excellent sensitivity and negative predictive value” in erosive esophagitis (EE), and could be a potentially useful to preclude the need for post-LSG EGD in asymptomatic patients with low salivary pepsin.

Reporting in Surgical Endoscopy, they assessed the association between and diagnostic value of salivary pepsin concentration and endoscopically proven EE in post-LSG patients as a surrogate for EGD. Twenty patients on routine post-LSG endoscopy were recruited and post-prandial saliva sample was collected and analysed by Peptest lateral flow device. EGD examinations were performed and patients completed a validated 25-item QoLRAD questionnaire.

They reported that a significant correlation between positive endoscopy findings of EE and salivary pepsin concentrations. The normal group had a lower mean fasting pepsin level (13.13 ng/mL ± 18.97) versus the EE-group (90.55 ng/mL ± 81.28, p=0.009) and lower mean post-prandial pepsin level (30.50 ng/mL ± 57.72) versus the EE-group (135.09 ng/mL ± 130.17, p=0.02). The predictive probabilities from the binary regression of fasting and post-prandial pepsin concentrations yield AUC of 0.955 ± 0.044 (95% CI 0.868 to 1.000, p<0.001).

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Extended Postoperative Venous Thromboembolism Prophylaxis after Bariatric Surgery: A Comparison of Existing Risk Stratification Tools and 5-Year MBSAQIP Analysis

Existing metabolic and bariatric surgery (MBS) venous thromboembolism (VTE) risk assessment tools differ widely for inclusion variables, high-risk definition and predictive performance, investigators from Emory University, Atlanta, GA, have found.

Reporting in SOARD, their study reviewed existing risk stratification tools and compared their predictive abilities. Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database they evaluated body mass index (BMI) threshold of 50 kg/m2, Caprini risk assessment model (RAM) and three bariatric-specific tools: the Cleveland Clinic VTE risk tool, the Michigan Bariatric Surgery Collaborative (MBSC) tool, and BariClot.

In total, 709,304 patients were identified with a 0.37% VTE rate. Bariatric-specific tools included multiple predictors: procedure, age, race, gender, operative time, length of stay, heart failure, and dyspnea at rest; operative time was the only variable common to all three. The BMI cut-off and Caprini RAM had higher sensitivity but lower specificity, compared to the MBSC and BariClot tools. While sensitivity of the tools varied widely and was overall low, the Cleveland Clinic tool had the highest sensitivity. The bariatric-specific tools would have recommended extended prophylaxis for 1.1%-15.6% of patients.

“Further research and registry inclusion of all significant risk factors is needed to determine the optimal risk-stratified approach for predicting VTE events and determining the need for extended prophylaxis,” the authors concluded.

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Comparison of mesh fixation and non-fixation in transabdominal preperitoneal (TAPP) inguinal hernia repair: a randomized control trial

Patients who received the non-fixating method of Transabdominal Preperitoneal (TAPP) Inguinal hernia repair experienced lower levels of pain in comparison to the fixation group, according to the outcomes of a randomized control trial by Iranian researchers.

Writing in Surgical Endoscopy, they evaluated and compared fixation and non-fixation of mesh in TAPP hernia repair. One hundred patients (two groups of fifty) were included in the study: both groups had a 15 × 13cm Prolene(polypropylene) mesh. In the fixation group, mesh was fixed to the abdominal wall by endoscopic tacks, while in the non-fixation group, mesh was secured at the proper place without any fixation.

Postoperative pain intensity in the 1st month (p< 0.001) and 3rd month (p<0.001)], in the fixation group were significantly higher than the non-fixation group. However, six months after surgery, pain intensity was almost similar for both groups. In the 6th postoperative month, only one patient experienced recurrence who was in the fixation group. The rate of recurrence and urinary retention between the groups was not significant.

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