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Journal Watch 29/06/2022

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 the number of metabolic and bariatric procedures performed in the United States in 2020, Single Anastomosis Jejuno-ileal (SAJI) as a revisional procedure, the management strategies of anastomotic ulcer after gastric bypass, a paper reporting the incidence, obstetric outcomes and reinterventions of births after bariatric surgery in the US and the status of mesenteric defects after LRYGB (please note, log-in maybe required to access the full paper).

American Society for Metabolic and Bariatric Surgery 2020 Estimate of Metabolic and Bariatric Procedures Performed in the United States

US authors, writing in SOARD, have reported the latest data on the best estimated number of metabolic and bariatric procedures (MBS) performed in the US in 2020, after reviewing data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, National Surgical Quality Improvement Program, Bariatric Outcomes Longitudinal Database, and Nationwide Inpatient Sample. In addition, data from industry and state databases were used to estimate activity at non-accredited centres.

They reported that compared with 2019, the total number of MBS performed in 2020 decreased from approximately 256,000 to 199,000. They noted that sleeve gastrectomy continued to be the most common procedure. The gastric bypass procedure trend remained relatively stable, and the gastric band procedure trend continued to decline. The percentage of revision procedures and biliopancreatic diversion with duodenal switch procedures increased slightly. The single anastomosis duodeno-ileostomy was listed for the first time in 2020. Intragastric balloons placement declined from the previous year.

They concluded that the 22.5% decrease in MBS volume from 2019 to 2020, which coincided with the COVID-19 pandemic.

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Single Anastomosis Jejuno-ileal (SAJI): a New Model of Malabsorptive Revisional Procedure for Insufficient Weight Loss or Weight Regain After Roux-en-Y Gastric Bypass

Italian researchers, reporting in Obesity Surgery, have discussed the outcomes from a Single anastomosis jejuno-ileal (SAJI) procedure after insufficient weight loss or weight regain or relapse of weight-related comorbidities after Roux-en-Y gastric bypass (RYGB), a new revisional simple operation performed after RYGB failure which adds malabsorption to the previous gastric bypass.

According to the authors, SAJI includes a single jejuno-ileal anastomosis specifically joining the ileum 250–300 cm proximal to the ileo-caecal valve and the jejunum 30 cm below the gastro-jejunal anastomosis on the Roux limb of the previous RYGB. In their study, 31 patients underwent SAJI for insufficient weight loss and/or weight regain after RYGB.

Regarding weight loss after SAJI, %TWL was 27.2 ± 7.4, 31.2 ± 6.4, 33.7 ± 5.9 and 32.9 ± 5.2 at 12, 24, 36 and 48 months, respectively.

One patient required reoperation 36 days after SAJI for epigastrium incarcerated incisional hernia at the previous RYGB laparotomy site. There were no deaths and comorbidity reduction/resolution after SAJI was 83.2% for type 2 diabetes mellitus, 42.8% for arterial hypertension, 72.8% for dyslipidaemia and 45.3% for OSA.

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Management strategies of anastomotic ulcer after gastric bypass and risk factors of recurrence

French researchers, writing in Surgical Endoscopy, have reported that OAGB was the only risk factor of recurrence of marginal ulcers (MU) identified and conversion to RYGB seemed to be effective for the healing.

Based on a retrospective analysis of all MU managed in their tertiary care centre of bariatric surgery during the last 14 years, a descriptive analysis of the cohort, the management strategies and their efficiency were analysed.

Fifty-six patients matched inclusion criteria: 30 were referred to us (13 Roux-en-Y Gastric Bypass—RYGB and 17 One Anastomosis Gastric Bypass—OAGB), 26 were operated on in our institution (24 RYGB and 2 OAGB). Eleven patients had a complicated inaugural MU requiring an interventional procedure in emergency: seven perforations, four haemorrhages. The majority of MU were treated medically as a first-line therapy (n=45; 80.4%). Thirty MU recurred: 20 patients required surgery as a 2nd line therapy, six were operated on as a 3rd line therapy and one had a surgery as a 5th line therapy.

The OAGB was identified as the only risk factor of recurrence (p=0.018), with surgical management was significantly more frequent for patients with a OAGB (84% vs 35% for RYGB, p=0.001); the most performed surgical procedure was a conversion of OAGB to RYGB (n=11, 37.9%).

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Births After Bariatric Surgery in the United States: Incidence, Obstetric Outcomes, and Reinterventions

US researchers, writing in the Annals of Surgery, have reported that giving birth was common in the first two years after bariatric surgery and was not associated with increased risk of reinterventions. Using the IBM MarketScan database, they performed a retrospective cohort study of female patients ages 18-52 undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass from 2011-2017. They reported event rates of adverse obstetric outcomes include pregnancy complications, severe maternal morbidity and delivery complications.

Of 69,503 patients who underwent bariatric surgery, 1,464 gave birth, 85% of births occurring within 21 months after surgery. For 38,922 patients with full two-year follow-up, adverse obstetric event rates were 4.5% for gestational diabetes and 14.2% for hypertensive disorders. Nearly half (48.5%) were first-time Caesarean deliveries. Multivariable logistic regression analysis showed no association between post-bariatric birth and reintervention rate (OR: 0.93, 95%CI: 0.78-1.12).

They authors cautioned that clinicians should consider shifting the dialogue surrounding pregnancy after surgery to shared decision-making with maternal safety as one component.

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Risk of Reopening of the Mesenteric Defects After Routine Closure in Laparoscopic Roux-en-Y Gastric Bypass: a Single-Centre Experience

The status of mesenteric defects (MDs) should be routinely examined during every reoperation after LRYGB and closure of open MDs should be performed, according to authors from Switzerland writing in Obesity Surgery.

Although routine closure of the mesenteric defects (MDs) is recommended to reduce the risk of internal hernias (IH) and subsequent small bowel obstruction (SBO), data about the rates of reopening of the MDs after LRYGB is scarce. Therefore, the authors evaluated the risk of reopening of the MDs after routine closure during LRYGB. The secondary objective was to determine any risk factors associated with the reopening of the MDs.

The study included 162 patients, the median time between LRYGB and reoperation was 17 months. At the time of reoperation, both MDs were closed in 83 patients (51.2%); thus, 79 patients (48.8%) presented at least one open MD. The group of patients with preoperative diagnosis of SBO or with recurrent abdominal pain showed significantly higher rates of open Petersen’s space compared to the group of patients with other preoperative diagnoses.

The authors noted that preoperative BMI<40 kg/m2 at time of LRYGB was associated with a higher risk for an open MD.

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