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Background Biliopancreatic diversion with duodenal switch (BPD/DS) is a procedure that has long been considered to have a higher early postoperative morbidity than Roux-En-Y gastric bypass (RYGB). However, patients who undergo BPD/DS have more baseline co-morbidities that may affect the reported early postoperative morbidity. Objective To compare 30-day postoperative morbidity and mortality between BPD/DS and RYGB propensity score-matched cohorts obtained from the MBSAQIP database. Setting Analysis of data obtained from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Methods Retrospective analysis of 21-variable propensity score-matched patients in the BPD/DS and RYGB groups obtained from the MBSAQIP database between 2015 and 2019. Variables included age, sex, body mass index, American Society of Anesthesiologists (ASA) class, and pertinent medical co-morbidities. Data were analyzed for 30-day postoperative morbidity, mortality, reoperation, reintervention, and readmissions. Results Before matching, RYGB and BPD/DS cohorts contained 134 188 and 5079 patients, respectively. After multivariable propensity score matching, each cohort contained 5050 patients. The RYGB group had a higher rate of surgical-site infections than the BPD/DS group (1% versus .5%, P = .007) and a higher rate of blood product transfusions (1.1% versus .6%, P = .018). The rate of other early postoperative complications was similar between the 2 groups (P > .05). There was no statistically significant difference in the 30-day mortality, readmission rate, reoperation rate, or reintervention rate between the 2 groups (P > .05). Conclusion When matched for baseline body mass index and co-morbidities, BPD/DS does not lead to a higher 30-day postoperative morbidity and mortality than RYGB. Patients can be counseled that in the short term, BPD/DS is as safe as RYGB.

Background Duodenal switch (DS) still comprises less than 1% of the overall primary procedures in the United States. Our aim is to explore the reasons behind surgeons’ reluctance to DS adoption. Objectives To determine perceived reasons for the widespread lack of adoption of the DS. Setting Worldwide survey of closed bariatric surgery social media groups. Methods A standardized questionnaire was posted on 2 closed social media bariatric groups. DS was used as an umbrella term that includes traditional BPD with duodenal switch, single anastomosis duodeno-ileostomy (SADI) and loop DS. The questionnaire link was accessible to bariatric surgeons only for a period of 1 week. Results Survey responses (n = 193) were analyzed. The majority (75%) were fellowship-trained bariatric surgeons, and 58% were practicing in the United States. Although 72.9% believed DS to be a good bariatric procedure, it was not being performed by 64% of the respondents. The main reasons behind DS nonadoption included a perceptible high long-term complication rate (43.5%), lack of training (38.1%), and procedure seldomly demanded by patients (31.5%). For surgeons who perform DS, 16.4% use it as a revisional procedure, mainly following sleeve gastrectomy (40.5%). Finally, 29.5% of surgeons believed that the American Society of Metabolic and Bariatric Surgery endorsement of SADI will encourage them to add DS to their practice. They are mostly planning to do so by visiting other surgeons and getting proctored (42.6%). Conclusion This survey will help guide bariatric societies and governing bodies in addressing the issues and concerns preventing surgeons from adopting DS in their practice by elucidating the chief reasons and circumstances behind this occurrence.

Obesity has become an epidemic in several regions globally; it may lead to cardiovascular diseases, diabetes, and dyslipidemia. Despite many therapies, all bariatric procedures fail in some patients. There is a lack of literature comparing treatment effects on specific metabolic indexes. PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched for relevant articles. GeMTC and R software were used to perform a network meta-analysis, draw forest plots, investigate the possibility of statistical heterogeneity, generate I2 statistics, rank probabilities, and evaluate relative effects of surgical procedures. All analyses were based on a Bayesian consistency model. We included 35 randomized controlled trials, comprising 2198 individuals and 13 interventions. For patients with high insulin resistance, single-anastomosis (mini-) gastric bypass (SAGB) and sleeve gastrectomy (SG) may be effective options, with mean differences (95% confidence intervals [CIs]) of -4.45 (-9.04 to -.34) and -4.23 (-6.74 to -2.22), respectively, compared with control groups. For patients with severe dyslipidemia, in addition to SAGB and SG, duodenal switch (DS) may be an effective surgery, with mean differences (95% CIs) of -.97 (-1.39 to -.55), -1.98 (-3.76 to -.19), .53 (.04 to 1.04), and -.94 (-1.66 to -.16) compared with control groups in terms of triglycerides, total cholesterol, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) concentrations, respectively. In adult overweight patients with or without diabetes, SAGB and SG are most effective at ameliorating insulin resistance. SAGB, Roux-en-Y gastric bypass + omentectomy, and DS are useful for reducing triglycerides, total cholesterol, and LDL-C. SG + omentectomy elevates HDL-C concentrations best. Adjustable gastric band and biliopancreatic diversion may not control insulin resistance or dyslipidemia well.

Background Sleeve gastrectomy (SG) is the most common bariatric surgery; however, this approach may induce gastroesophageal reflux disease (GERD). Both obesity and GERD are independent risk factors for esophageal cancer, however the impact of SG on risk of esophageal cancer remains unknown. Objective To evaluate the risk of esophageal cancer after reflux-prone bariatric surgery. Setting Population-level, provincial administrative healthcare database, Quebec, Canada. Methods We identified a population-based cohort of all patients with obesity who underwent reflux-prone surgery (SG and duodenal switch [DS]) or reflux-protective Roux-en-Y gastric bypass (RYGB) during 01/2006–12/2012 in Quebec, Canada. For every surgical patient, 2-3 nonsurgical controls with obesity matched for age, sex, and geography were also identified. Crude incidence rate ratios (IRRs) for esophageal cancer were calculated using person-time analysis. Hazard ratios (HRs) were obtained using multivariate cox regression. Results A total of 4121 patients had reflux-prone procedures and 852 underwent RYGB. At a mean follow-up of 7.6 years, 8 cases of esophageal cancer were identified after bariatric surgery. Compared with RYGB, IRR for esophageal cancer in reflux-prone group was 1.45 (95%CI: .19–65.5) and HR = .83 (95%CI: .10–7.27). The crude incidence rate of esophageal cancer in the reflux-prone group was higher than that of nonsurgical controls (n = 12,159; IRR = 3.46, 95%CI: 1.00–12.5), but after adjustment the difference disappeared (HR = 2.47, 95%CI: .82–7.45). Conclusions Long-term incidence of esophageal cancer after reflux-prone bariatric surgery is not greater than RYGB. While crude incidence of esophageal cancer after reflux-prone surgery is higher than in nonsurgical patients with obesity, such difference disappears after accounting for confounders. Given the low incidence of esophageal cancer and slow progression of dysplastic Barrett esophagus, studies with longer follow-up are needed.

The following position statement is issued by the American Society for Metabolic and Bariatric Surgery in response to inquiries made to the Society by patients, physicians, society members, hospitals, health insurance payors, the media, and others regarding the need and possible strategies for screening endoscopic examination before metabolic and bariatric surgery (MBS), as well as the rationale, indications, and strategies for postoperative surveillance for mucosal abnormalities, including gastroesophageal reflux disease and associated esophageal mucosal injuries (erosive esophagitis and Barrett's esophagus) that may develop in the long term after MBS, specifically for patients undergoing sleeve gastrectomy or Roux-en-Y gastric bypass. The general principles described here may also apply to procedures such as biliopancreatic diversion (BPD) and BPD with duodenal switch (DS); however, the paucity of procedure-specific literature for BPD and DS limits the value of this statement to those procedures. In addition, children with obesity undergoing MBS may have unique considerations and are not specifically addressed in this position statement. This recommendation is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. The statement is not intended to be and should not be construed as stating or establishing a local, regional, or national standard of care. The statement will be revised in the future as additional evidence becomes available.

Background Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a modification of the classic duodenal switch (DS). These modifications are intended to address concerns about DS, including malnutrition, longer operative times, and technical challenges, while preserving the benefits. Objectives To evaluate safety and outcomes of SADI-S as it compares to classic DS procedure. Setting Bariatric Surgery Center of Excellence, University Hospital, Montreal, Canada. Methods In a single-institution prospective cohort study, we compared safety and outcomes of the SADI-S versus DS procedures (ClinicalTrials.gov: NCT02792166 ; registered: 06/2016). Data is depicted as count (percentage) or median (interquartile range). Results There were 42 patients who underwent SADI-S, of whom 11 had it as a second-stage procedure (26%). There were 20 patients who underwent DS, of whom 12 had it as second-stage procedures (60%). Both groups were similar at baseline. The median age was 45 (14) years, 39 (63%) were female, the median body mass index (BMI) was 48.2 (7.7) kg/m2, and 29 (47%) patients had diabetes. The operative time was shorter for 1-stage SADI-S versus DS surgery (211 [70] versus 250 [60] min, respectively; P = .05) but was similar for second-stage procedures (P = .06). The 90-day complication rates were 11.9% (N = 5/42) after SADI-S and 5.0% (N = 1/20) after DS surgery (P = .64). There were no mortalities. Median follow-ups for 1-stage SADI-S and DS were 17 (11) and 12 (24) months, respectively (P = .65). Similar BMI changes were observed after 1-stage SADI-S (17.9 kg/m2 [8.7]) and DS (17.5 kg/m2 [16]; P = .65). At median follow-ups of 10 (20) and 14 (16) months after second-stage SADI-S and DS, respectively (P = .53), surgical procedures yielded added 5.0 kg/m2 (5.8) and 6.5 kg/m2 (7.1) changes in BMI, respectively (P = .26). Complete remission rates for diabetes were 91% after SADI-S (n = 21/23) and 50% after DS (n = 3/6). Compared with the SADI-S procedure, DS surgery was associated with higher frequencies of deficiencies in some fat-soluble vitamins, especially vitamin D. Conclusions The SADI-S procedure is safe, and its short-term outcomes, including weight loss and the resolution of co-morbidities, are similar to those of DS. SADI-S surgery also has promising potential as a second-stage procedure after sleeve gastrectomy.

Background Biliopancreatic diversion with duodenal switch (BPD/DS) is the most effective bariatric surgery in super-obese patients, although technically complex and time consuming. As a primary surgery, single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is similar to BPD/DS in terms of short-term outcomes, but long-term and comparative data are lacking. Objectives The aim of this study was to compare the outcomes of patients submitted to SADI-S and BPD/DS. Setting Public hospital. Methods Obese patients (n = 112) submitted to SADI-S (n = 83) and BPD/DS (n = 29) for obesity treatment were prospectively compared. Results The mean preoperative body mass indexes (BMIs) were 53.41 ± .93 for BPD/DS and 50.61 ± .52 kg/m2 for SADI-S. Follow-up of 48 months was achieved in 18% (n = 21) of patients, with a nonsignificant difference in the percentage of excess BMI loss (%EBMIL; 81.20 ± 3.71 for BPD/DS; 74.82 ± 3.45 for SADI-S). Operative time (164.30 ± 7.78 minutes for BPD/DS; 132.70 ± 7.19 minutes for SADI-S; P = .006) and hospital stay (4.90 ± 1.10 days for BPD/DS; 4.35 ± .70 days for SADI-S; P = .006) were significantly shorter for SADI-S. There was no significant difference in the 30-day postoperative complication rate. No mortality was reported. After surgery, significant improvements were observed in glucose and lipid profiles for both groups. The type 2 diabetes remission rate was 100% for BPD/DS and ranged from 60 to 80% for SADI-S across follow-up times. Dyslipidemia remission followed a similar pattern. Protein deficiency was observed in up to 50% of patients after BPD/DS and 20% after SADI-S, without statistically significances. Conclusion SADI-S and BPD/DS as primary surgery for obesity treatment result in no significant differences in %EBMIL, improvement in obesity-related diseases, nutritional deficiencies, and postoperative morbidity. Nevertheless, there was greater total weight loss after BPD/DS. SADI-S, being less time consuming and technically simpler, can represent an advantage over BPD/DS.

Background It has been well-established that primary bariatric surgery is effective in inducing improvement of diabetes and other associated co-morbidities in patients with obesity. Evidence demonstrating the influence of revisional bariatric surgery on this trajectory, however, is lacking. Objectives We performed a systematic review and meta-analysis to examine the impact of revisional bariatric surgery on obesity-related metabolic outcomes. Setting University Hospital, Singapore Methods We examined outcomes of remission and improvement of diabetes, hypertension, hyperlipidemia, and obstructive sleep apnea. Revisional surgeries included sleeve gastrectomy, Roux-en-Y gastric bypass, pouch revision, duodenal switch, and minigastric bypass. Results Our search identified 33 relevant studies including a total of 1593 patients. Meta-analysis of proportions demonstrated a 92% improvement in diabetes with 50% achieving remission after revisional bariatric surgery. Of patients, 81% achieved improvement of hypertension with 33% achieving complete remission. In both groups, the highest proportion of improvement was observed after revisional duodenal switch. Although reported by fewer studies, a remission of hyperlipidemia was reported in 37% of patients and improvement of obstructive sleep apnea was seen in 86% of patients. Conclusions Revisional bariatric surgery improves the outcomes of obesity-related co-morbidities and should be considered in patients with persistent metabolic disease after primary bariatric surgery.

Background Conversions and revisions after bariatric procedures are inevitable and associated with longer operative time and higher complication rates. Because robot-assisted procedures allow better dissection, robotic conversions and revisions may be more beneficial to the patients than laparoscopic ones. Objectives This study aimed to compare the feasibility and safety of robot-assisted conversions and revisions to laparoscopic procedures. Setting Academic Hospital, United States. Methods A retrospective chart review was performed on 94 consecutive patients who underwent a bariatric conversion or revision (revision of gastrojejunostomy, conversions of vertical sleeve gastrectomy to Roux-en-Y gastric bypass, adjustable gastric banding to sleeve gastrectomy, Roux-en-Y gastric bypass to sleeve gastrectomy, adjustable gastric banding to Roux-en-Y gastric bypass, Roux-en-Y gastric bypass to duodenal switch, and adjustable gastric banding to duodenal switch) between January 1, 2017, and February 28, 2019. Of these, 30 underwent a robot-assisted conversion or revision. Results Patients who underwent a robot-assisted approach were more likely to be older (45.4-versus 38.8-yr old) and lighter (44.6 versus 50.3 kg/m2) than patients who underwent a laparoscopic approach. The mean operative time was longer in the robot-assisted group (155.5 min) than in the laparoscopic group (113.3 min). No difference was observed between the 2 groups in the mean length of hospital stay, 30-day readmission rate, or 30-day reoperation rate. Results were similar when the baseline difference in age and body mass index were accounted for. Conclusions Robot-assisted conversions and revisions were as feasible and safe as laparoscopic procedures. However, operative time was longer in robot-assisted conversions.

Bariatric surgery is associated with concomitant loss in both fat and muscle masses. Literature on muscle composition/quality after bariatric surgery is limited.To measure and compare the changes in fat-free mass with the changes in muscle composition after biliopancreatic diversion with duodenal switch surgery (BPD/DS).Bariatric surgery is associated with concomitant loss in both fat and muscle masses. Literature on muscle composition/quality after bariatric surgery is limited.Forty patients underwent BPD/DS and 22 patients are considered as controls. Bioelectrical impedance analysis (body composition) and computed tomography scan at the midthigh and abdominal levels (muscle composition) were performed at baseline, 6, and 12 months.At 6 and 12 months, the BPD/DS group displayed significant reduction in weight (12 months: -46.6 ± 13.5 kg) and fat-free mass (12 months: -8.2 ± 4.4 kg; both P.001). A significant reduction in abdominal (-15 ± 8%, P.001) and midthigh muscle areas (-18 ± 7%, P.001) was observed during the first postoperative 6 months, followed by a plateau after 6 months (abdominal: -1 ± 5%, midthigh: -1 ± 4%, both P.05). At 6 months, both midthigh fat-infiltrated muscle (-22 ± 10%, P.001) and normal-density muscle (-16 ± 9%, P.001) areas decreased. Further reduction at 12 months was only observed in the fat-infiltrated muscle (-11 ± 8%, P.001) in comparison with an increase in the normal-density muscle area (5 ± 8%, P = .001). There was no significant change for the control group.Reduction in muscle, assessed with computed tomography scans, occurs mostly during the first 6 months postoperatively after BPD/DS. Focus on muscle quantity as well as quality, using precise imaging methods, instead of quantifying total body lean mass, is likely to provide better assessment in body content modulation after BPD/DS.

Background Metabolic and bariatric surgery, despite being the only effective durable treatment for obesity, remains underutilized as approximately 1% of all patients who qualify actually undergo surgery. The American Society for Metabolic and Bariatric Surgery created a Numbers Taskforce to specify annual rate of utilization for obesity treatment interventions and to determine if patients in need are receiving appropriate therapy. Objectives The objective of this study was to provide the best estimated number of metabolic and bariatric procedure performed in the United States in 2018. Setting United States Methods We reviewed data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), National Surgical Quality Improvement Program (NSQIP), Bariatric Outcomes Longitudinal Database (BOLD) and Nationwide Inpatient Sample (NIS). In addition, data from industry and outpatient centers were used to estimate outpatient center activity. Data from 2018 was compared mainly to data from the previous two years. Results Compared to 2017, the total number of metabolic and bariatric procedures performed in 2018 increased from approximately 228,000 to 252,000. The sleeve gastrectomy continues 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 (BPD-DS) procedures increased slightly. Finally, intragastric balloons placement continues as a significant contributor to the cumulative total number of procedures performed but declined from the previous year. Conclusions There was a 10.8% increase in the number of metabolic and bariatric procedures performed in 2018, compared to 2017, with an overall increase of approximately 60% since 2011. When taking into account primary procedures only, approximately 1.1% of patients who qualified for metabolic and bariatric surgery were treated with surgery in 2018.

The introduction and subsequent widespread adaptation of minimally invasive approaches for bariatric surgery have not only changed the outcomes of bariatric surgery but also called into question the management of co-morbid surgical conditions, in particular gallbladder disease. The American Society for Metabolic and Bariatric Surgery Foregut Committee performed a systematic review of the published literature from 1995-2018 on management of gallbladder disease in patients undergoing bariatric surgery. The papers reviewed generated the following results. (1) Routine prophylactic cholecystectomy at the time of bariatric surgery is not recommended. (2) In symptomatic patients who are undergoing bariatric surgery, concomitant cholecystectomy is acceptable and safe. (3) Ursodeoxycholic acid may be considered for gallstone formation prophylaxis during the period of rapid weight loss. (4) Routine preoperative screening and postoperative surveillance ultrasound is not recommended in asymptomatic patients. In the era of minimally invasive surgery, the management of gallbladder disease in patients undergoing bariatric surgery continues to evolve.

Background Unsatisfactory weight loss is common after bariatric surgery in patients with super obesity (body mass index [BMI] ≥50 kg/m2). Unfortunately, this group of patients is increasing worldwide. Objective The aim of this study was to compare long-term weight loss and effect on co-morbidities after duodenal switch (DS) and gastric bypass (RYGB) in super-obese patients. Setting University hospital, Sweden, national cohort. Methods This observational population-based cohort-study of primary DS and RYGB (BMI ≥48 kg/m2) in Sweden from 2007 to 2017 used data from 4 national registers. Baseline characteristics were used for propensity score matching (1 DS:4 RYGB). Weight loss was analyzed up until 5 years after surgery. Medication for diabetes, hypertension, dyslipidemia, depression, and pain were analyzed up until 10 years after surgery. Results The study population consisted of 333 DS and 1332 RYGB, with 60.7% females averaging 38.5 years old and BMI 55.0 kg/m2 at baseline. DS resulted in a lower BMI at 5 years compared with RYGB, 32.2 ± 5.5 and 37.8 ± 7.3, respectively, (P Conclusion This study indicates that super-obese patients have more favorable outcomes regarding weight loss and effect on diabetes and hypertension, after DS compared with RYGB.

Background Loop duodenojejunal bypass with sleeve gastrectomy (LDJB-SG) is a simplified biliopancreatic diversion with duodenal switch. Objectives This study investigated the therapeutic outcomes of LDJB-SG and predictors of type 2 diabetes (T2D) remission in Chinese patients with a body mass index (BMI) of 20 to 32.5 kg/m2. Setting A university hospital. Methods This retrospective study included 28 T2D patients with a BMI of 20 to 32.5 kg/m2 who underwent LDJB-SG. T2DM remission, weight loss, postoperative nutrition status, and complications at 1- and 3-year follow-up were assessed. Remission of T2DM was defined as a fasting blood glucose Results At 1-year follow-up after LDJB-SG, the T2D remission rate was 75% (21/28), and the mean total weight loss was 23.6%. The 3-year T2D remission rate and percent of total weight loss were 68.4% (13/19) and 20.3%, respectively. Univariate and multivariate analysis indicated that duration of T2D was the only risk factor associated with T2D remission (P Conclusion LDJB-SG resulted in acceptable T2D remission and metabolic improvement at 1- and 3-year follow-up in Chinese T2D patients with a BMI of 20 to 32.5 kg/m2. T2D duration may serve as the predictor of T2D remission. LDJB-SG should be performed with caution because of the high incidence of postoperative complications.

Background Duodenal switch (BPD/DS) is gaining popularity as a secondary procedure for inadequate weight loss after an initial operation. Objectives We aimed to generate expert consensus points on the appropriate use of BPD/DS in the revisional bariatric surgical setting. Setting Data were gathered at an international conference with attendees from a variety of different institutions and settings. Methods Sixteen lines of questioning regarding revisional BPD/DS were presented to an expert panel of 29 bariatric surgeons. Current available literature was reviewed extensively for each topic and proposed to the panel before polling. Responses were collected and topics defined as achieving consensus (≥70% agreement) or no consensus ( Results Consensus was present in 10 of 16 lines of questioning, with several key points most prominent. Conclusions As a second-stage procedure, BPD/DS is most appropriate after sleeve gastrectomy (SG) for the treatment of super morbid obesity (96.7% agree) or as a subsequent operation for a reliable patient with insufficient weight loss after SG (88.5%). In a patient with weight regain and reflux and/or enlarged fundus after SG, Roux-en-Y gastric bypass is preferable and BPD/DS should be avoided (90%). BPD/DS should not be used prophylactically in patients with a history of jejunoileal bypass who are otherwise doing well (80.8%). Applicability of BPD/DS is limited by technical difficulty; 86.2% of experts would routinely recommend or consider the procedure if it were more technically feasible after failed bypass. No consensus was found on approaches to revision of BPD/DS for protein malnutrition.

High-level evidence of the impact of bariatric surgery on nonalcoholic fatty liver disease (NAFLD) is lacking. We conducted a systematic review and meta-analysis according to the Cochrane guidelines to assess the resolution of NAFLD after bariatric surgery. We searched PubMed, EMBASE, Web of Science, and CENTRAL for English language publications on bariatric surgery and NAFLD. We included randomized controlled trials and observational studies of patients with NAFLD who underwent bariatric surgery and were assessed by liver biopsy or liver function tests. Duodenal switch and biliopancreatic diversion were excluded. Our primary outcome was histologic or biochemical improvement of NAFLD. Twenty-one studies (12 Roux-en-Y gastric bypass [RYGB], 3 adjustable gastric banding, 2 sleeve gastrectomy, 1 vertical banded gastroplasty, 3 multiple procedures) enrolling 2374 patients were included. The pooled proportion of patients who had improvement of steatosis was 88% (95% confidence interval [CI]: .80, .94). Steatohepatitis improved in 59% (95% CI: .38, .78) and fibrosis improved or resolved in 30% of patients (95% CI: .21, .41). Similarly, aspartate aminotransferase (AST) improved in 32% of patients (95% CI: .22, .42) and alanine aminotransferase improved in 62% of patients (95% CI: .42, .82). After RYGB, the number of patients who had improvement in NAFLD was higher than the average of all the pooled studies. Bariatric surgery improves steatosis and steatohepatitis in the majority of patients and improves or resolves liver fibrosis in 30% of patients. RYGB has a greater impact on NAFLD histology compared with other procedures. This contemporary meta-analysis strongly suggests that bariatric surgery should be considered as a treatment of NAFLD.

Background The safety profile of bariatric surgery in patients with class I obesity, or body mass index ≥30 and Objective To assess the safety profile of bariatric surgery in patients with class I obesity. Setting The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data set. Methods The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 to 2016 data sets were queried for class I obesity patients who underwent primary bariatric procedures. The 30-day postoperative safety profile, predictors of adverse events, and comparison between Roux-en-Y gastric bypass (RYGB) versus sleeve gastrectomy (SG) were studied. Results A total of 8628 cases with a mean preoperative body mass index of 33.7 ± 1.1 kg/m2 were analyzed: 1838 (21.3%) underwent RYGB, 6243 (72.4%) underwent SG, 530 (6.1%) underwent gastric banding, and 17 (.2%) underwent duodenal switch; 33.9% had diabetes and 75% had hypertension. The composite morbidity rate (defined as presence of any of 24 postoperative adverse events) for the entire cohort was 3.8%, and the serious morbidity rate (presence of any of 9 serious complications) was .7%. The 30-day mortality rate was .05% (4 cases). Presence of chronic kidney disease was found to be associated with higher composite and serious morbidity (composite morbidity: odds ratio 5.1, 95% confidence interval 2.22–11.71; serious morbidity: odds ratio 5.66, 95% confidence interval 1.52–21.14). SG patients had significantly better short-term safety outcomes than RYGB patients. Conclusion Findings from this study, the largest series to date, indicate that bariatric surgery is safe in patients with class I obesity, with very low risk of morbidity and mortality.

Background Sleeve gastrectomy (SG) has become the predominant bariatric surgery worldwide. However, the surgical management in case of failure is still debated. Objectives To evaluate the risks and benefits of converting SG to biliopancreatic diversion with duodenal switch (BPD-DS) for suboptimal outcome after SG. Setting University-affiliated tertiary care center. Methods We included all patients who underwent a laparoscopic second-stage duodenal switch (DS) for weight loss failure after SG and had a minimal follow-up of 2 years. Patients were matched 1:1 for age, sex, body mass index, and year of surgery with a group of patients who underwent a single-stage laparoscopic BPD-DS. Data were obtained from our prospective electronic database and are reported as the mean ± standard deviation, comparing 2- versus 1-stage BPD-DS. Results A total of 118 patients were included (59 in each group). There was no significant difference in initial body mass index (53.8 ± 9.7 versus 52.7 ± 7.8 kg/m2, P = .4), age (44.0 ± 10.2 versus 43.4 ± 9.6 yr, P = .5), and sex ratio (37 female/22 male, P > .9) between the 2 groups. Mean follow-up was 59.9 ± 27 months, with an 85% (n = 100) follow-up rate. Patients were converted to BPD-DS after a mean 24.4 ± 10.2 months. There was no short- or long-term mortality. Major 90-days complications occurred in 2%, 5%, and 5% after SG, second-stage DS and single-stage BPD-DS, respectively (P > .05). At the time of conversion, the excess weight loss for SG was 39 ± 17% and total weight loss was 20 ± 9%. After DS or single-stage BPD-DS, the excess weight loss was 74.8 ± 18% versus 87.9 ± 18% at 1 year (n = 107, P = .00021), 80.2 ± 17% versus 92.3 ± 14% at 2 years (n = 100, P = .002), and 80.2 ± 18% versus 87.2 ± 16% at 3 years (n = 70, P = .6). Total weight loss was 38.7 ± 9% versus 44.5 ± 8% at 1 year (P = .0004), 41.2 ± 9% versus 46.8 ± 7% at 2 years (P = .001), and 42.3 ± 9% versus 45.1 ± 9% at 3 years (P = .2). The incidence of type 2 diabetes and hypertension before surgery were 61% versus 54% and 58% versus 47%. Remission rate for type 2 diabetes increased from 59% to 94% after second-stage DS (P = .001), which is identical to first-stage BPD-DS (94%). Remission of hypertension increased from 42% to 77% after second-stage DS (P = .03) and was 71% after first-stage BPD-DS (P = .8). Conclusion Second-stage DS is an effective option for the management of suboptimal outcomes of SG, with an additional 41% excess weight loss and 35% remission rate for type 2 diabetes. At 3 years, the global outcomes of staged approach did not significantly differ from single-stage BPD-DS; however, longer-term outcomes are still needed.

Background National quality programs have been implemented to decrease the burden of adverse events on key outcomes in bariatric surgery. However, it is not well understood which complications have the most impact on patient health. Objective To quantify the impact of specific bariatric surgery complications on key clinical outcomes. Setting The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Methods Data from patients who underwent primary bariatric procedures were retrieved from the MBSAQIP 2015 participant use file. The impact of 8 specific complications (bleeding, venous thromboembolism [VTE], leak, wound infection, pneumonia, urinary tract infection, myocardial infarction, and stroke) on 5 main 30-day outcomes (end-organ dysfunction, reoperation, intensive care unit admission, readmission, and mortality) was estimated using risk-adjusted population attributable fractions. The population attributable fraction is a calculated measure taking into account the prevalence and severity of each complication. The population attributable fractions represents the percentage reduction in a given outcome that would occur if that complication were eliminated. Results In total, 135,413 patients undergoing sleeve gastrectomy (67%), Roux-en-Y gastric bypass (29%), adjustable gastric banding (3%), and duodenal switch (1%) were included. The most common complications were bleeding (.7%), wound infection (.5%), urinary tract infection (.3%), VTE (.3%), and leak (.2%). Bleeding and leak were the largest contributors to 3 of 5 examined outcomes. VTE had the greatest effect on readmission and mortality. Conclusion This study quantifies the impact of specific complications on key surgical outcomes after bariatric surgery. Bleeding and leak were the complications with the largest overall effect on end-organ dysfunction, reoperation, and intensive care unit admission after bariatric surgery. Furthermore, our findings suggest that an initiative targeting reduction of post–bariatric surgery VTE has the greatest potential to reduce mortality and readmission rates.

Background Bariatric surgery, despite being the most successful long-lasting treatment for morbid obesity, remains underused as only approximately 1% of all patients who qualify for surgery actually undergo surgery. To determine if patients in need are receiving appropriate therapy, the American Society for Metabolic and Bariatric Surgery created a Numbers Taskforce to specify annual rate of use for obesity treatment interventions. Objectives The objective of this study was to determine metabolic and bariatric procedure trends since 2011 and to provide the best estimate of the number of procedures performed in the United States in 2016. Setting United States. Methods We reviewed 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 outpatient centers were used to estimate outpatient center activity. Data from 2016 were compared with the previous 5 years of data. Results Compared with 2015, the total number of metabolic and bariatric procedures performed in 2016 increased from approximately 196,000 to 216,000. The sleeve gastrectomy trend is increasing, and it continues to be the most common procedure. The gastric bypass and gastric band trends continued to decrease as seen in previous years. The percentage of revision procedures and biliopancreatic diversion with duodenal switch procedures increased slightly. Finally, intragastric balloons placement emerged as a significant contributor to the cumulative total number of procedures performed. Conclusions There is increasing use of metabolic and bariatric procedures performed in the United States from 2011 to 2016, with a nearly 10% increase noted from 2015 to 2016.

Bariatric procedures are increasingly being used, but data on bowel habits are scarce.To assess changes in gastrointestinal function and patient-scored symptoms after Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion with duodenal switch (BPD/DS).University hospital in Sweden.We recruited 268 adult patients (mean age of 42.5 yr, body mass index 44.8, 67.9% female) listed for RYGB and BPD/DS. Patients answered validated questionnaires prospectively concerning bowel function, the Fecal Incontinence Quality of Life Scale, and the 36-Item Short Form Health Survey before and after their operation.Postoperatively, 208 patients (78.2% of 266 eligible patients) answered the questionnaires. RYGB patients had fewer bowel motions per week (8 versus 10) and more abdominal pain postoperatively (P.001). Postoperatively, the 35 BPD/DS patients (69% versus 23%) needed to empty their bowel twice or more than twice daily, reported more flatus and urgency, and increased need for keeping a diet (P.001). Concerning Fecal Incontinence Quality of Life Scale, coping and behavior was slightly reduced while depression and self-perception scores were improved after RYGB. Lifestyle, coping and behavior, and embarrassment were reduced after BPD/DS (P.05). In the 36-Item Short Form Health Survey, physical scores were markedly improved, while mental scores were largely unaffected.RYGB resulted in a reduced number of bowel movements but increased problems with abdominal pain. In contrast, BPD/DS-patients reported higher frequency of bowel movements, more troubles with flatus and urgency, and increased need for keeping a diet. These symptoms affected quality of life negatively, however, general quality of life was markedly improved after both procedures. These results will be of great value for preoperative counseling.

Background Biliopancreatic diversion with duodenal switch (BPD-DS) is one of the most effective bariatric surgeries, in terms of weight loss and remission of co-morbidities. It is however associated with a significant risk of protein and nutritional deficiency, as well as gastrointestinal side effects. Objectives To assess the effect of increasing the strict alimentary limb on weight loss, nutritional deficiency and quality of life, compared with standard BPD-DS. Settings University-affiliated tertiary care center. Methods Prospective randomized double blind (patient-evaluator) trial in which patients were assigned in a 1:1 ratio to undergo a modified BPD-DS with a long alimentary limb (1 m from Treitz ligament, n=10) or a standard biliopancreatic diversion (strict alimentary limb of 1.5 m, n=10). Common channel was kept at 100 cm in both groups. Follow-up at 12 months was completed in all patients. Results Initial weight (126 ± 10 versus 125 ± 17, P = .92), age (40 ± 7 versus 37 ± 8, P = .35), and sex ratio (1 female/9 males) were similar in both groups. Excess weight loss and total weight loss were significantly higher in the standard BPD-DS group (93.4 ± 12% versus 73.3 ± 7%, P = .0007 and 46 ± 5.6% versus 37 ± 3.4%, P = .0004). The study group had significantly higher vitamin D, manganese, and copper levels at 12 months. Both groups had similar drop in glycated hemoglobin, cholesterol levels, and resolution of co-morbidities at 12 months. Long alimentary limb was associated with significantly less bowel movements a day (1.6 ± .97 versus 2.55 ± 1.01, P = .01), less gastrointestinal side effects (bloating and gas, P P = .04) and calcium supplement. Quality of life was significantly improved in both groups in all domains (all P Conclusion At 12 months, weight loss was lesser in the long alimentary limb group. There was however no difference in the remission of co-morbidities and higher levels of vitamin D, manganese, and copper. Gastrointestinal adverse effects and the need for pancreatic enzymes were less with similarly excellent quality of life at 12 months. Longer follow-up is necessary to evaluate long-term weight loss and nutritional deficiencies.

With the culture of safety and lowering risks that took place 20 years ago, sleeve gastrectomy has emerged as a procedure of choice. Hence, for super- and super-super-obese patients, there is a tendency these days to perform surgeries in 2 stages, and sleeve is the procedure of choice. Because sleeve is not part of a classic bilio-pancreatic diversion, it is unlikely that this operation will be done as a second stage, making this operation obsolete.

Background No method preoperatively predicts the postoperative bariatric surgery outcomes in individual patients. Decisions for or against surgery and operation choice remain subjective. Only 1% of qualifying patients embrace bariatric surgery. Objective To predict preoperatively and validate prospectively the weight and co-morbidity resolution in individual patients after open Roux-en-Y gastric bypass (RYGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic adjustable gastric band (LAGB), sleeve gastrectomy (SG), and biliopancreatic diversion/duodenal switch (BPD/DS). Setting Surgical Review Corporation BOLD database, 2007–2010. Methods A total of 166,601 patients who had undergone RYGB (n = 5389), LRYGB (n = 83,059), LAGB (n = 67,514), SG (n = 8966), or BPD/DS (n = 1673) were randomized into modeling (n = 124,053) and validation (n = 42,548) groups. From preoperative data, multivariate linear and logistic regression predicted weight and co-morbidities at 2, 6, 12, 18, and 24 months postoperatively. Model fit was examined by R 2 and receiver operating characteristic/area under the curve and predicted versus observed results via Pearson correlation coefficient and sensitivity/specificity. Results Follow-up at 2/24 months was 120,909/11,014 for the modeling group and 41,528/3703 for validation. Weight models' R 2 was .910, .813, .725, .638, and .613 at 2, 6, 12, 18, and 24 months, respectively. The categorical receiver operating characteristic/area under the curve was .617 to .949 for 24-month predictions. Pearson continuous coefficients were .969 and .811 at 2 and 24 months, respectively. The median 24-month sensitivity and specificity of co-morbidity resolution were 79.2% and 97.42%, respectively. Conclusions Prospectively validated preoperative models predict, in individual patients, weight and obesity co-morbidities 2 years in advance for RYGB, LRYGB, LAGB, SG, and BPD/DS. This advance knowledge facilitates choosing the operation that is best for each individual and may encourage more patients to choose bariatric surgery.

Primary bariatric surgery has been proven to be effective in weight loss and improvement of weight-related metabolic co-morbidities. However, a small proportion of patients after bariatric surgery either have persistent hyperglycemia or relapse after initial remission of their metabolic disease. Revisional bariatric surgery has been evaluated extensively for weight recidivism and postoperative complications. However, there has not been any high-level evidence validating the utility of revisional bariatric surgery on recurrent metabolic diseases, especially diabetes. In this review of 30 studies, we aimed to summarize the evidence and determine whether revisional surgery can have a positive impact on metabolic diseases that were not reversed by initial bariatric intervention. Overall, 14-38% of patients had residual diabetes at the time of revisional surgery. Depending on the index surgery and subsequent reconstruction, revisions induced 20-80% additional excess weight loss, or further decrease of body mass index by 10-30%. Improvement of diabetes was seen in 65-100% of patients. Specifically, conversion to Roux-en-Y gastric bypass (RYGB) yielded improvement of diabetes in 79%, 72%, and 62% of patients who previously had vertical banded gastroplasty (VBG), adjustable gastric banding (AGB), or sleeve gastrectomy (SG), respectively. Converting AGB to SG improved diabetes in 65% of patients, and SG to duodenal switch improved diabetes in 79% of patients. Revision of the gastric pouch or stoma in RYGB yielded improvement of diabetes in 79% of patients. Further clinical and mechanistic research is needed to better delineate the role of revisional bariatric surgery in patients with residual metabolic disease.

Background The single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) was designed in 2007 to reduce the side effects of biliopancreatic diversion with duodenal switch (BPD-DS) by replacing the Roux-en-Y construction with a single duodeno-ileal anastomosis and combining the common channel with the alimentary limb. Several variants using different channel lengths were published. The objective of this study was to identify the published cases of SADI-S and variants and assess the results regarding potential benefits on side effects and revisions. Methods PubMed, ClinicalTrials.gov, and the databases of 3 relevant surgical journals were searched for any publication from 2007 to date. Results In all, 19 studies were analyzed. After identifying overlaps, 1,041 patients among 9 institutions were identified: 304 with SADI-S, 667 with stomach intestinal pylorus sparing surgery, and 70 with single anastomosis duodenojejunal bypass with sleeve gastrectomy. There were no postoperative deaths and the early complication rate was 7.3% (range 1.6–14%). The mean operative time was 100.8 minutes (range 69.9–181.7 min). The mean 1-year percentage of excess weight loss (%EWL) was 78.7% (range 61.6–87%) and percentage of total weight loss (%TWL) was 36.8% (range 32.7–41.1%). Two studies reported a 2-year %TWL of 38.7% and a single study reported a 5-year %TWL of 37%. A total of 50% of patients had biological data at 1 year. One retrospective study found no difference between BPD-DS and SIPS for vitamin deficiency at 2 years, but there was less severe diarrhea and malnutrition after SIPS. The revision rate increased from 2% to 7% after SADI-S between 2- and 5-year follow-up. Conclusion There are still limited long-term data available for single anastomosis duodenal switch. In the absence of published prospective randomized trials, no evidence exists in favor of this variant of the BPD-DS despite a possible trend in less malabsorption side effects.

Background The traditional duodenal switch is performed using a Roux-en-Y configuration. This procedure has proven to be the most effective procedure for long-term weight loss and co-morbidity reduction. Recently, stomach intestinal pylorus sparing surgery (SIPS) has been introduced as a simpler and potentially safer variation of the duodenal switch (DS). It is a single anastomosis end-to-side proximal duodeno-ileal bypass with a sleeve gastrectomy. In this study, we compare our outcomes between biliopancreatic diversion with duodenal switch (BPD-DS) and SIPS at 2 years. Setting This is a retrospective analysis from a single surgeon at a single private institution. Methods We analyzed data from 182 patients retrospectively, 62 patients underwent BPD-DS while 120 other patients underwent SIPS between September 2011 and March 2015. A subset analysis was performed comparing data from both procedures to evaluate weight loss and complications. Results Of 182 patients, 156 patients were beyond 1 year postoperative mark and 99 patients were beyond 2 year postoperative mark. Five patients were lost to follow-up. None of our patients had complications resulting in death. BPD-DS and SIPS had statistically similar weight loss at 3 months but percent excess weight loss (%EWL) was more with BPD-DS than SIPS at 6, 9, 12, 18, and 24 months. Patient lost a mean body mass index (BMI) of 23.3 (follow-up: 69%) and 20.3 kg/m 2 (follow-up: 71%) at 2 years from the BPD-DS and SIPS surgery, respectively. However, patients who had undergone SIPS procedure had significantly shorter operative time, shorter length of stay, fewer perioperative and postoperative complications than BPD-DS ( P P Conclusion The SIPS is a simplified DS procedure. The SIPS eliminates one anastomosis and compared with BPD-DS has fewer perioperative and postoperative complications, shorter operative time and length of stay, and similar nutritional results at 2 years. However, weight loss was more with BPD-DS. A fair criticism is that the vast majority of BPD-DS cases were done before the SIPS cases. As a result, experience and learning curve cannot be completely dismissed when viewing postoperative complications.

Background Gastroesophageal reflux (GERD) is a symptom frequently found in obese patients, and often is related to the presence of a hiatal hernia (HH). Surgeons may evaluate for the presence of HH on esophagogastroduodenoscopy (EGD). However, preoperative endoscopic presence or absence of a significant HH does not always correlate with intraoperative findings. Objective To compare the rate of detection of repairable HH between clinical, endoscopic, and intraoperative methods Setting Independent, university-affiliated teaching hospital Methods A retrospective chart review of all consecutive patients who had undergone a primary bariatric procedure sleeve gastrectomy, gastric bypass, or biliopancreatic diversion/duodenal switch with routine preoperative EGD in a single institution from 2009–2013 was performed. Data points included the diagnosis of GERD/heartburn/proton pump inhibitor or histamine antagonist from history, the diagnosis of HH from preoperative EGD, and the diagnosis of HH intraoperatively that merited repair. Results 1570 consecutive patients were included in the study. Eight hundred fifty-seven (55%) had diagnosis of GERD or heartburn, and 713 (45%) were asymptomatic (negative for GERD or heartburn). Hiatal hernia repair was performed in 153 (18%) patients with the diagnosis of GERD or heartburn and in 107 (15%) patients without the diagnosis of GERD and or heartburn. In all, 434 (28%) out of 1570 patients had a finding of HH on EGD; 204 (47%) were repaired. On endoscopy, 326 (75%) were defined as small, 87 (20%) as moderate, and 21(5%) as large HH. Of these, repairs were done on 128 (39%), 60 (70%), and 16 (76%). The sensitivity of detecting repairable HH by clinical indicators such as GERD or heartburn was 55% (P = .123) and sensitivity of EGD findings was 78% (P = .000). Specificity was 46% and 82%, respectively. Conclusion Small HH are over-diagnosed with EGD, as most do not require repair. However, moderate and large HH are accurately detected.

Objective Concerns about an excessive loss of fat-free mass (FFM) after bariatric surgery prompted this comparison of operated versus matched nonoperated controls regarding FFM. Setting University Hospital and University Research Unit in an urban medical center. Methods Body composition with bioelectric impedance (Tanita 310, Tanita Corp, Arlington Heights, IL) was measured approximately 2 years after bariatric surgery in weight stable patients and nonoperated weight stable controls matched for body mass index (BMI), gender, and age. t tests provided comparisons. Analysis of variance was used to compare FFM changes for 4 procedures. Levene's test evaluated variance. Results Patients (n = 252; 24.7±15 mo after surgery) and nonoperated controls (n = 252) were matched for gender (71.8% female), age (44.5±11.0 yr), and BMI (32.8±7.0 kg/m 2 ). Patients had different surgical procedures: 107 gastric bypasses (RYGBs), 62 biliopancreatic diversions with duodenal switch (BPD/DSs), 40 adjustable gastric bands (AGBs), and 43 sleeve gastrectomies (LSGs). FFM percentage was significantly higher in the operated patients than controls, 66% versus 62%, P P P = .17). Conclusion Weight-reduced bariatric surgery patients have greater FFM compared with nonoperated matched controls. These findings support surgically assisted weight loss as a physiologic process and in general patients do not suffer from excessive FFM depletion after bariatric procedures.

Background With promising short-term results, laparoscopic sleeve gastrectomy (SG) has become the second most frequently performed bariatric procedure worldwide. Aside from a growing number of reports covering up to 10 years of follow-up, only limited data have been published so far on long-term results. Objectives The aim of the study was to present a 10-year follow-up for SG. Setting University hospital setting, Austria. Methods We present the first complete 10-year follow-up of 53 consecutive patients who underwent SG before 2006. In this multicenter study, weight loss success, weight regain, and revisional surgery were analyzed beside Bariatric Analysis and Reporting Outcome System (BAROS) scores. Results A mean maximum percent excess weight loss of 71±25% (percent total weight loss: 28±15%) was reached at a median of 12 (range 12–120) months after SG. At 10 years, a mean percent excess weight loss of 53±25% was achieved by 32 patients, corresponding to a percent total weight loss of 26.3±13.4%. Nineteen of the 53 patients (36%) were converted to Roux-en-Y gastric bypass (n = 18) or duodenal switch (n = 1) due to significant weight regain (n = 11), reflux (n = 6), or acute revision (n = 2) at a median of 36 months. Two patients died at 3 and 101 months postoperatively, unrelated to SG. A total of 31 patients (59%) suffered from weight regain of 10 kg or more, among them 24 patients (45%) with 15 kg or more, 16 patients (30%) with 20 kg or more, and 7 patients (13%) with 25 kg or more weight regain from nadir. Mean BAROS score was 2.4±2.2 at 10 years follow-up, classifying SG as "fairly efficient." Conclusion Within a long-term follow-up of 10 years or more after SG, a high incidence of both significant weight regain and intractable reflux was observed, leading to conversion, most commonly to Roux-en-Y gastric bypass.

Background The Roux-en-Y gastric bypass (RYGB) is a very effective treatment for obesity and its related co-morbidities. However, some patients fail to achieve>50% of their excess weight loss (EWL), and others regain much of the weight that they lost. Objective The purpose of this study was to analyze early outcomes after conversion of RYGB to duodenal switch (DS) in terms of weight loss, change in co-morbidities, and complications. Setting This is a retrospective analysis from 1 surgeon at a single private institution. Methods We analyzed data from 32 obese patients retrospectively who underwent revision for failed RYGB. Nine patients underwent DS with Roux-en-Y reconstruction (RYDS), and 23 patients underwent single anastomosis DS between October 2012 and December 2015. Regression analyses were performed for all follow-up weight-loss data. Results The patients experienced mean EWL of 16.2% over an average of 16 years (range: 0–38) with their primary RYGB surgery. Of 32 patients who underwent revision DS , 22 patients are beyond the 1-year postoperative mark (follow-up 81.8%), and 15 patients are beyond the 2-year postoperative mark (follow-up 73.3%). One patient was lost to follow-up. The patients experienced mean EWL of 31.2%, 45.1%, 51%, 54.2%, 56%, and 56.4% at 3, 6, 9, 12, 18, and 24 months, respectively, after their revisional surgery. Mean total weight loss achieved at 12 and 24 months was 27.7% and 29.2%, respectively. There was no statistical significant difference in mean %EWL at 12 months ( P = .468) and 24 months ( P = .266) between RYDS and single anastomosis DS. Conclusion A laparoscopic revision from RYGB to DS is an effective weight-loss operation with midterm follow-up of 2 years. Though long-term follow-up is warranted to measure recidivism, the initial data seem favorable.

Background There are minimal long-term data on biliopancreatic diversion (BPD) with or without duodenal switch (BPD/DS). Objectives To investigate the long-term weight loss, co-morbidity remission, complications, and quality of life after BPD and BPD/DS. Setting An academic, university hospital in the United States. Methods We conducted a retrospective review of patients who underwent BPD or BPD/DS between 1999 and 2011. Outcomes included weight loss measures at 2, 5, and 10–15 years postoperatively; co-morbidity remission; long-term complications; nutritional deficiencies; and patient satisfaction. Results One hundred patients underwent BPD (34%) or BPD/DS (64%). Mean preoperative body mass index (BMI) was 50.2 kg/m2. Mean follow up was 8.2 years (range: 1–15 yr) with 72% of eligible patients in active follow up at 10–15 years postoperatively. Excess weight loss (EWL) was 65.1% at 2 years, 63.8% at 5 years, and 67.9% at 10–15 years. Approximately 10% higher %EWL was achieved for those with preoperative BMI Conclusion This clinical experience supports the long-term positive safety profile and efficacy of BPD and BPD/DS at a single U.S. center. Higher levels of excess weight loss are achieved by patients with a lower preoperative BMI and BPD/DS. Although nutritional deficiencies and postoperative complications are common, patient satisfaction remains high.

Background Insufficient weight loss (percentage of excess weight loss [%EWL] Objectives This study evaluates the conversion of RYGB to BPD/DS using a novel gastric reconstruction technique based on a "hybrid sleeve" using the existing gastrojejunal anastomosis of the RYGB. Setting All the procedures were performed at a private hospital. Methods The consecutive patients who were eligible for conversion since 2010 were reviewed; eligibility included %EWL≤50% and normal gastric pouch. The gastrojejunal anastomosis of the RYGB was untouched and the gastric fundus was resected. The gastric continuity was restored by an anastomosis between a short segment of the alimentary limb and the gastric antrum. A standard BPD/DS was then performed without restoration of the jejunal continuity. Results Fourteen patients were converted to BPD/DS for a mean body mass index (BMI) of 44.3±6.0 kg/m 2 , a mean %EWL of 33.4%, and a percentage of total weight loss (%TWL) of 15.3±11.7%. The BMI before RYGB was 54.4±13.1 kg/m 2 , with half of the patients being super-obese. All but 3 conversions were completed as a single stage and laparoscopically in a mean of 177 minutes. The 30-day complication rate was 28.5%. No patient was lost to follow-up over a mean 25.8 months and the BMI of the 12 patients with a follow-up≥3 months is 33.2±7.2 kg/m 2 . With reference to the initial weight of the patients, the mean %EWL is 73.5% and %TWL is 37.6±16.0%. On average, patients benefited from a 21.1% TWL through the conversion of their RYGB. Conclusions This procedure allows for an easier conversion of RYGB to BPD/DS and appears to be the most effective procedure for resuming weight loss. Nutritional consequences and weight loss are similar to the primary BPD/DS results. However, the benefits and risks must be carefully assessed according to the definition of weight loss failure.

Background Biliopancreatic diversion with duodenal switch (BPD-DS) with a 100-cm common channel has been our treatment of choice for morbid obesity since the early 1990s. This procedure offers excellent long-term weight loss but can be associated with significant side effects. Objectives To assess the effect on clinical and nutritional parameters of increasing the common channel to 200 cm. Settings University-affiliated tertiary care center. Methods Patients who underwent a BPD-DS with a 200-cm common channel (study group, n=36) were matched 1:1 for age, sex, body mass index (BMI), and main co-morbidities with patients who underwent a BPD-DS with a 100-cm common channel (control group). The strict alimentary limb was 150 cm in both groups. Results The mean age was 55±9 versus 53±7 years ( P = .3), with 50% women and a BMI of 49±8 kg/m 2 versus 50±6 kg/m 2 ( P = .9). Follow-up rate was 97%, with a minimum follow-up of 3 years. There were no significant differences in the remission rate of major co-morbidities between the 2 groups. At 3 years, the excess weight loss was 61±22% versus 68±18% ( P = .18) and the total weight loss was 33±11% versus 38±9% ( P = .055) in the study group versus control group, respectively. The study group had a lower incidence of severe protein deficiency (11% versus 19%, P = .3) and hyperparathyroidism (17.1% versus 35.3%, P = .17); required a lower amount of vitamins A and D ( P P = .03). Conclusion In this population, BPD-DS with a 200-cm common channel offered similar remission rate of co-morbidities compared with standard BPD-DS. It was associated with similar weight loss at nadir, followed by a more significant weight regain. It might yield a lower rate of nutritional complications. Long-term randomized data are needed to detect other potential advantages.

Single anastamosis loop duodenal switch (SALDS) is a new surgical technique that was first described by Torres in Spain [1]. As this procedure is gaining in popularity worldwide, it is important to document the rare complications associated with it [2]. An unusual complication that can occur is retrograde filling of the afferent limb, causing symptoms like partial bowel obstruction. However, this has not been described in the literature as occurring after SALDS. This paper presents the first 2 cases of retrograde filling of the afferent limb causing chronic nausea that have been seen after laparoscopic SALDS surgery and subsequent management.

omega-loop. The DIA is created as an end-to-side anastomosis completely handsewn. The ileum with the marked location for the CC-BPL anastomosis is positioned closely to the BPL six centimeters proximal to the DIA. A side-to-side CC-BPL anastomosis is performed. By dividing the bowel between the two anastomosis the omega-loop-construction is transformed into a Roux-y construction. The mesenteric defects are closed with nonresorbable staples. Conclusion: In our experience, the SOFY Duodenal Switch with an omega-loop transferred to a Roux-y construction is the most feasible procedure regarding operating time, overview of the anatomically correct positioning of the different limbs and the surgical workflow. The closure of the mesenteric defects is facilitated presumably leading to a lower rate in internal herniation.

Background Laparoscopic sleeve gastrectomy (LSG) has rapidly become increasingly popular in bariatric surgery. However, in the long-term follow-up, weight loss failure and intractable severe reflux after primary LSG can necessitate further surgical interventions. Objectives To evaluate the safety and the efficiency of revisional sleeve gastrectomy (ReSG). Setting Private hospital. Methods From October 2008 to October 2014, 61 patients underwent ReSG. All patients with failure after primary LSG underwent radiologic evaluation, and an algorithm of treatment was proposed. Results Sixty-one patients (54 women, 7 men; mean age 40.8 yr) with a body mass index (BMI) of 39.4 kg/m² underwent ReSG. The primary LSG was performed for mean BMI of 46.2 kg/m² (range 35.4–77.9). The mean interval time from the primary LSG to ReSG was of 37.5 months (9–80 mo). The indication for ReSG was insufficient weight loss in 28 patients (45.9%), weight regain in 29 patients (47.5%), and gastroesophageal reflux disease (GERD) in 4 patients. In 42 patients the gastrografin swallow results were interpreted as primary dilation and in the remaining 19 cases as secondary dilation. The computed tomography (CT) scan volumetry was obtained in 38 patients with mean gastric volume of 436.3 cc (275–1056 cc). All cases were completed by laparoscopy with no intraoperative incidents. The mean operative time was 39 minutes (range 29–70 min) and the mean hospital stay was 3.5 days (range 3–16 d). One perigastric hematoma and 2 cases of gastric stenosis were recorded. The mean BMI decreased to 29.2 kg/m 2 (range 20.2–37.5); the mean percentage of excess weight loss (%EWL) was 58.5% (±25.3) ( P Conclusion The ReSG may be a valid option for failure of primary LSG. Further prospective clinical trials are required to compare the outcomes of ReSG with those of laparoscopic Roux-en-Y gastric bypass or duodenal switch for weight loss failure after LSG.

Background Bariatric operations achieve a high remission rate of type 2 diabetes in patients with morbid obesity. Malabsorptive operations usually are followed by a higher rate of metabolic improvement, though complications and secondary effects of these operations are usually higher. Objectives Analyze the results of a simplified duodenal switch, the single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) on patients with obesity and type 2 diabetes mellitus (T2 DM). Setting University Hospital, Madrid, Spain. Methods Ninety-seven T2 DM patients with a mean body mass index (BMI) of 44.3 kg/m 2 were included. Mean preoperative glycated hemoglobin was 7.6%, and mean duration of the disease was 8.5 years. Forty patients were under insulin treatment. SADI-S was completed with a sleeve gastrectomy performed over a 54 French bougie and a 200 cm common limb in 28 cases and 250 cm in 69. Results Follow up was possible for 86 patients (95.5%) in the first postoperative year, 74 (92.5%) in the second, 66 (91.6%) in the third, 46 (86.7%) in the fourth and 25 out of 32 (78%) in the fifht postoperative year. Mean glycemia and glycated hemoglobin decreased immediately. Control of the disease, with HbA1c below 6%, was obtained in 70 to 84% in the long term, depending on the initial antidiabetic therapy. Most patients abandoned antidiabetic therapy after the operation. Absolute remission rate was higher for patients under oral therapy than for those under initial insulin therapy, 92.5% versus 47% in the first postoperative year, 96.4% versus 56% in the third and 75% versus 38.4% in the fifth. A short diabetes history and no need for insulin were related to a higher remission rate. Three patients had to be reoperated for recurrent hypoproteinemia. Conclusion SADI-S is an effective therapeutic option for obese patients with diabetes mellitus.

Background Laparoscopic sleeve gastrectomy (SG) has become accepted as a stand-alone procedure as a less complex operation than laparoscopic duodenojejunal bypass with sleeve gastrectomy (DJB-SG). Objectives The aim of this study was to compare one-year results between DJB-SG and SG. Setting University hospital. Methods A total of 89 patients who received a DJB-SG surgery were matched with a group of SG that were equal in age, sex, and body mass index (BMI). Complication rates, weight loss, and remission of co-morbidities were evaluated after 12 months. Results The mean preoperative patient BMI in the DJB-SG and SG groups was similar. There were more patients with type 2 diabetes mellitus (T2DM) in the DJB-SG group than in the SG group. The mean operative time and length of hospital stay (LOS) were significantly longer in the DJB-SG group than in the SG group. At 12 months after surgery, the BMI was lower and excess weight loss higher in DJB-SG than SG. Remission of T2DM was greater in the DJB-SG group. Low-density lipoprotein, total cholesterol, and metabolic syndrome (MS) improved after operation in both groups. Conclusions In this study DJB-SG was superior to SG in T2DM remission, triglyceride improvement, excess weight loss, and lower BMI at 1 year after surgery. Adding duodenal switch to sleeve gastrectomy increases the effect of diabetic control and MS resolution.

Background Biliopancreatic diversion with duodenal switch (BPD-DS) has been reported to be the most effective procedure for weight loss and minimizing postoperative weight regain. However, because of its technical complexity and concerns for higher operative and metabolic complications, it has not obtained widespread acceptance among patients or bariatric surgeons. Nevertheless, the use of robotic systems has been increasing because of its ability to overcome technical challenges, such as torque, freedom of movement, and precision. The objective of this study was to review the efficacy and safety of robotic assistance in laparoscopic BPD-DS. Methods A prospectively maintained database of patients who underwent robotic-assisted laparoscopic BPD-DS between 2008 and 2013 was reviewed retrospectively. Results A total of 179 consecutive patients (137 female and 42 male) were included in the study. The mean age was 44 years (20–72 yr). Mean body mass index (BMI) was 50.3 kg/m2 (35–78.8 kg/m2), and the number of preoperative co-morbidities was 6.6 (2–14). Mean operative time for a typical BPD-DS with appendectomy was 249 minutes (162–413 min), which increased to 278 minutes (193–463 min) in adhesiolysis associated cases and increased to 272 minutes (186–431 min) if additional procedures, such as hiatal hernia repair, cholecystectomy, or Meckel's diverticulum resection, were included. All procedures were completed as a single-stage operation. There were no major intraoperative complications. Two patients had unexpected returns to the operating room during the same admission: one for an endoscopic release of an inadvertently sutured nasogastric tube and the other for port site infection. Median hospital stay was 2.7 days (1–13). Two patients had significantly longer stays for carpal tunnel syndrome exacerbation (9 d) and port site infection (13 d). Postoperatively, the median excess weight loss at 1, 3, 6, 9, 12, 18, 24, and 36 months with follow-up of 71% of patients at 1 year, 45% of patients at 2 years, and 15% of patients at 5 years, was 19%, 35.9%, 53.1%, 65.6%, 74.6%, 79.9%, and 75.8%, respectively. Diabetes, hypertension, and hyperlipidemia went into remission 95.5%, 92.1%, and 92% of the time, respectively. No mortality occurred. Conclusions Robotically assisted duodenoileal anastomosis during laparoscopic BPD-DS is a feasible, well-tolerated, and effective alternative to assist in the technically challenging part of the operation.

Background After sleeve gastrectomy, many surgical options are available in patients with insufficient weight loss. Duodenal switch is typically considered the operation that results in higher weight loss, although it is, perhaps unjustly, considered technically difficult and may be accompanied by severe side effects. Single-anastomosis duodenoileal bypass with sleeve gastrectomy is a simplification of the duodenal switch that may behave as a standard biliopancreatic diversion but is easier and quicker to perform. Given its effectiveness as a primary surgery we hypothesized that it would be successful as a second-step operation. The objective of this study was to analyze the weight loss and co-morbidities resolution after a single-anastomosis duodenoileal bypass (SADI) performed as a second step after sleeve gastrectomy. Methods Sixteen patients with an initial body mass index of 56.4 kg/m 2 and a mean excess weight loss of 39.5% after a sleeve gastrectomy were submitted to a single-anastomosis duodenoileal bypass with a 250-cm common channel. Results There were no postoperative complications. The mean excess weight loss was 72% 2 years after the second-step surgery. The complete remission rate was 88% for diabetes, 60% for hypertension, and 40% for dyslipidemia. The mean number of daily bowel movements was 2.1. One patient suffered an isolated episode of clinical hypoalbuminemia. Conclusion SADI is a safe operation that offers a satisfactory weight loss for patients subjected to a previous sleeve gastrectomy. The side effects are well tolerated, and complications are minimal.

Background Morbidly obese patients undergoing bariatric surgery have high rates of gastroesophageal reflux and are often treated with acid-reducing medications (ARM) such as proton pump inhibitors or H2-blockers. The objective of this study was to evaluate the effect of bariatric procedures on the utilization of ARM. We analyzed data from the clinical registry of the Michigan Bariatric Surgery Collaborative on 35,477 patients undergoing bariatric surgery between January 2006 and October 2012 who completed both baseline and 1-year follow-up surveys. Procedures included laparoscopic adjustable gastric banding (LAGB, n=2,627), Roux-en-Y gastric bypass (RYGB, n=6,410), sleeve gastrectomy (SG, n=1,567), and biliopancreatic diversion with duodenal switch (BPD/DS, n=162). Methods Rates of ARM at 1 year by procedure type were compared using logistic regression analysis. Models were adjusted for patient characteristics, baseline co-morbidities, weight loss, and hiatal hernia repair. Results Overall ARM use at baseline was 37.7% and declined to 29.6% at 1 year after bariatric surgery. The proportion of patients starting an ARM at 1 year when they were not using one at baseline by procedure was LAGB (13.9%), RYGB (19.2%), SG (21.6%), and BPD/DS (26.7%). The proportion of patients discontinuing an ARM at 1 year when they were using one at baseline by procedure was LAGB (55.6%), RYGB (56.2%), SG (37.3%), and BPD/DS (42.1%). Compared with LAGB on multivariable analysis, the likelihood of ARM use at 1 year was higher for SG (OR 1.70, 95% CI 1.45–1.99) and BDP/DS (OR 1.53, CI .97–2.40) but not different for RYGB (OR 1.02, CI .90–1.16). Conclusion Overall ARM use decreases after bariatric surgery; however, it is not uniform and depends on procedure type. SG is a significant predictor for ARM use at 1 year.

The biliopancreatic diversion with duodenal switch (BPDDS) is considered to be the most effective bariatric procedure for introduction and maintenance of weight loss and resolution of obesity-related co-morbidities [1]. Scopinaro described the biliopancreatic diversion (BPD) in 1979 with a partial distal gastrectomy, closure of the duodenal stump, a Roux-en-Y gastroenterostomy, and an anastomosis between the biliary and the alimentary limb 50 cm proximal to ileocecal valve [2]. To gain control of complications related to Scopinaro’s procedure, the common channel was lengthened and the duodenal switch (DS) was added. The latter comprises a vertical sleeve gastrectomy with preservation of the pylorus and a duodenoileostomy [3]. In 1999 a laparoscopic approach for the DS procedure was introduced [4]. Study results concerning postoperative complication rates comparing open and laparoscopic DS are inconsistent [5,6]. This might be a result of the complexity of the surgery and the relatively small number of procedures performed worldwide. Internal herniation (IH) is a common complication after bariatric surgery. It has been shown that the closure of the mesenteric defects reduces the risk of IH and ileus. Closure of the mesenteric defects is technically challenging during standard laparoscopic DS with the entero-entero-anastomosis (EA) in the lower part of the abdomen. For successful advancement of the laparoscopic DS, the following 3 aims were defined that the novel procedure had to fulfill: (1) enhancement of the surgical workflow, (2) better overview of the correct positioning of the different limbs, and (3) facilitation of the closure of the mesenteric defects. The presented procedure accomplishes these targets.

Liver failure (LF) and liver transplant (LT) are rare after a biliopancreatic diversion/duodenal switch procedure for obesity, but occasionally it may happen. Two clinical cases are presented. One patient, 18 years ago, had LF, but a liver donor could not be found, and the patient died. The second patient, 2 years ago, received a successful LT and is now well and asymptomatic. Careful follow-up, medical management and surgical intervention may prevent the occurrence of LF. Transplantation and bowel reversal may be necessary.

Background Malabsorptive bariatric procedures require multiple vitamin supplements, especially regarding fat-soluble vitamins. The exact amount required to maintain normal serum concentrations is still largely unknown. Based on the initial postoperative prescription, we assessed the number of adjustments and the amount of vitamins/micronutrients to normalize the biological markers 2 years after the biliopancreatic diversion with duodenal switch (BPD/DS). Methods A total of 112 consecutive patients had a laparoscopic BPD/DS between February 2007 and November 2010 for a body mass index of 53.1±5.9 kg/m² at a private hospital. Complete blood checks with vitamin status were obtained at each of the 3-month interval visits during the 1st postoperative year as well as twice during the 2nd year. Results Initially, all of the patients were prescribed daily 25,000 International units (IU) of vitamin A, 1000 mg of calcium, multivitamins, and 1900 IU of vitamin D3. Significant adjustments were necessary 3.6±1.1 times during this period. A total of 80% of the patients required added vitamin A, vitamin D, as well as calcium, zinc, and iron. After 2 years,≥20% of patients exhibited vitamin A and iron deficiency with low prealbumin or micropenic anemia. Seventy percent had vitamin D deficiency and 50% secondary hyperparathyroidism. Conclusion The initial prescription was insufficient to cover the requirements after BPD/DS. At least 3000 mg of calcium with 7000 IU of vitamin D, 50,000 IU of vitamin A, 40 mg of zinc, and 200 mg of iron must be prescribed to start with. The trend toward a decrease in 25 OH vitamin D and hyperparathyroidism remains difficult to control although it can result from increased bone turnover during the early postoperative period.

Background There is a lack of knowledge about the patient’s experience of excess skin after bariatric surgery in patients with body mass index, (BMI)>50 kg/m2. The objective of this study was to evaluate experience of excess skin after laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) or laparoscopic Roux-en-Y gastric bypass (LRYGB) and explore possible gender differences. Another aim was to analyze possible correlation between the reported experiences of excess skin with changes in weight, BMI, and hip and waist circumference after surgery. Methods One and/or 2 years after gastric bypass or duodenal switch surgery 57 patients responded to a specific questionnaire. The questionnaire included questions about the amount of excess skin and how much discomfort it caused. Furthermore, the patients were measured concerning weight and waist and hip circumference. Results One year after surgery, a majority of the patients experienced excess skin scored as>2 (“a lot of” or “very much”). The patients in the BPD/DS group experienced significantly more excess skin compared to patients in the LRYGB group. Women experienced more excess skin and discomfort on several body parts than men. The correlations between changes in BMI and the reported experience and discomfort of excess skin were low. There was a low to moderate correlation between changes in waist and hip circumference measures and the experience of excess skin on stomach and buttocks. Conclusion Weight loss after LRYGB and BPD/DS in super-obese patients is associated with substantial discomfort from excess skin. Women reported more discomfort and experienced more excess skin than men. There was a low correlation between experience of excess skin and changes in weight, BMI, and circumference measures.

Background The use of endoluminal stents has been proposed for the management of fistulas and anastomotic strictures after bariatric surgery. The objective of our study was to determine the success of endoscopically placed, self-expandable metal stents (SEMS) in bariatric patients specifically with either chronic persistent anastomotic or staple line leaks/fistulas or chronic, persistent anastomotic strictures. Methods We treated 21 patients including 5 with chronic staple line leaks/fistulas (4 from the gastric sleeve after biliopancreatic diversion with duodenal switch [BPD/DS] and 1 after removal of an eroding laparoscopic adjustable gastric band) and 16 with chronic anastomotic strictures (15 at the gastrojejunostomy after Roux-en-Y gastric bypass and 1 at the duodenoileal anastomosis after BPD/DS). Patients with early leaks or anastomotic strictures were excluded. Results All but one of these patients had been referred to our institution after chronic treatment elsewhere was unsuccessful with prior stent placement for fistulas or multiple endoscopic dilations for strictures. Their bariatric operations had been performed a mean of 386 days beforehand. Stent placement was performed successfully in all patients without complications but was successful in only 4 of 21 patients (19%)—2 with chronic fistulas and 2 with chronic anastomotic strictures. Stent migration occurred in 10 patients (47%); the migrated stents were removed/replaced endoscopically in 7 patients but required elective operative removal in 3 with concomitant correction of the leak, fistula, or anastomotic stricture; none were operated emergently. Conclusion Only 4 of 21 patients with a chronic persistent leak or anastomotic stricture were treated definitively using a SEMS. Although endoluminal stents may not lead to resolution of a chronic leak or stricture, SEMS may suppress ongoing sepsis and allow patients to undergo nutritional resuscitation orally before operative correction.