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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 Single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is a simplification of the duodenal switch (DS) in which the alimentary limb is eliminated, and the common channel is lengthened from 200 to 300 cm. Short-term results have demonstrated that SADI-S is safe and reproducible and that weight loss and comorbidities resolution are comparable to biliopancreatic diversion or DS. Objective To analyze the long-term outcomes of SADI-S. Methods From May 2007 to December 2015, 164 patients were consecutively submitted to a one-step SADI-S. The mean age was 47 years, and the mean body mass index (BMI) was 45.8 kg/m2. A total of 101 patients had type 2 diabetes, 91 arterial hypertension, 81 obstructive apnea, and 118 dyslipidemia. Limb length was 200 cm in 50 cases, 250 cm in 99, and 300 cm in 15. Results There was no mortality. One patient had a gastric leak, and 2 patients had an anastomotic leak. A total of 25% of the patients were lost to follow-up at 10 years. Excess weight loss and total weight loss were 87% and 38% at 5 years and 80% and 34% at 10 years. A total of 12 patients were submitted to revisional surgery for hypoproteinemia. Preoperatively 41 diabetics were under insulin treatment; at 5 years, 7 remained with insulin and 12 at 10 years. Mean glycemia was 104 mg/dL at 5 years and 118 mg/dL at 10 years. Mean HbA1c was 5.51% at 5 years and 5.86 at 10 years. Conclusion In the long term, SADI-S offers satisfactory weight loss and comorbidities resolution. Graphical Abstract

The most effective long-term treatment for severe obesity is bariatric surgery with improvement or resolution of obesity-related comorbidities. Single-anastomosis procedures including single-anastomosis duodenoileal bypass and one-anastomosis gastric bypass are relatively new procedures that are gaining popularity worldwide. These surgical techniques are perceived to be less complex with a shorter learning curve in comparison to the standard biliopancreatic diversion with duodenal switch and Roux-en-Y gastric bypass; however, long-term outcomes and complications remain controversial. This article aims to review one-anastomosis procedures, evaluate their outcomes, and review potential complications.

Bariatric surgery is the most effective modality to stably reduce weight and related comorbidities in patients suffering from class II and III obesity. Data comparing long-term safety and efficacy of the three most effective bariatric operations are limited in patients with BMI ≥ 50 kg/m2, which complicate shared surgeon–patient decision making regarding optimal procedure selection. A retrospective analysis was performed on all patients with BMI ≥ 50 kg/m2 who underwent biliopancreatic diversion with duodenal switch (BPD/DS), Roux-en-Y gastric bypass (RYGB), or sleeve gastrectomy (SG) at our institution between 2009 and 2019. Data collected from patients’ electronic medical records included operative details as well as BMI and presence and resolution of obesity-related comorbidities at 0, 6, 12, 24, 48, and 60 months post-operatively. Among 537 patients with BMI ≥ 50 kg/m2 who had a primary bariatric procedure, 93 patients underwent BPD/DS (17.3%), 341 patients underwent RYGB (63.5%), and 103 patients underwent SG (19.2%). BMI decreased by 23.7 kg/m2 in BPD/DS, 14.7 kg/m2 in RYGB, and 13.6 kg/m2 in SG cohorts at 60 months post-operatively (p

Purpose In patients with type 2 diabetes mellitus (T2DM), bariatric surgery appears to be more effective than medical treatment (MT) at improving glycaemic control and decreasing cardiovascular risk. However, long-term effectiveness has not been systematically assessed using randomised controlled trials. In this study, we aimed to systematically assess randomised controlled trials, with at least 5 years of follow-up, on bariatric surgery in patients with T2DM and BMI ≥ 25 kg/m2, as well as to compare different bariatric procedures. Material and methods PubMed, SCOPUS and Web of Science were searched. We performed a network meta-analysis to evaluate the comparative effectiveness of the different procedures and MT in terms of full T2DM remission, weight loss, complications and cardiometabolic biomarkers. The quality of evidence was assessed using the Cochrane Risk of Bias Tool and CINeMA. Results We included 11 primary studies. Laparoscopic one-anastomosis gastric bypass (LOAGB) was found to be one of the most effective treatments for full remission of T2DM (I2 = 0, inconsistency p value = 0.9223). Biliopancreatic diversion without duodenal switch was found to be more effective than laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding regarding percent total cholesterol and low-density lipoprotein change. Regarding percent high-density lipoprotein and weight change, all analysed surgical treatments were shown to be more effective than MT. The confidence rating in our results was overall moderate, but most studies had high risk of performance and detection bias. Conclusion Bariatric surgery seems to be effective for T2DM remission. LOAGB appears to be a good option in this context, and a possible alternative to laparoscopic duodenal switch, but the included primary studies in our review are not sufficiently powered to establish a more definitive conclusion. More studies with longer follow-up times are needed to comprehensively assess bariatric surgery in T2DM.

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.

As a modification of the duodenal switch (DS), single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) has recently become very popular and is successful for weight loss and T2DM remission. However, current studies have been mostly aimed at patients with severe obesity. In this study, we firstly compare primary SADI-S to the Roux-en-Y gastric bypass (RYGB) in Chinese with diabetes and BMI< 35 kg/m2. Using a propensity score (PS) matching analysis, we analyzed all patients with diabetes and BMI< 35 kg/m2 who underwent primary SADI-S or RYGB. All surgeries were conducted by a single surgeon at a Chinese center from June 2017 to January 2019. Twenty-six patients who underwent SADI-S and 65 patients who underwent RYGB were included in our analysis. Of these, 26 (100%) of patients in the SADI-S group and 43 (66%) of patients in the RYGB group completed the 24-month follow-up. No severe perioperative complication was observed in either group. There was a statistically higher percentage of total weight loss with SADI-S at the 2-year follow-up when compared to RYGB (p = 0.017 after PS correction). After PS adjustment, 76.5% of patients in the SADI-S group and 82.4% of patients in the RYGB group achieved complete remission of T2DM (p = 1.000). Nutritional outcomes were similar in the two groups. In Chinese with diabetes and BMI< 35 kg/m2, with comparable T2DM remission and nutritional outcomes, primary SADI-S allows for better weight loss than RYGB. Compared with RYGB, SADI-S is also a safe, effective, and feasible treatment for these patients.

There are no comparative studies on the long-term outcomes after the primary traditional duodenal switch (DS) and single-anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S). This study aims to compare the long-term outcomes in a matched cohort. This study took place in a single private institute, in the USA. Data from 266 patients who underwent a primary laparoscopic traditional DS or primary laparoscopic SADI-S from September 2011 to December 2015 by four surgeons were used for a retrospective matched cohort. Data were obtained by matching every DS patient to a SADI-S patient of the same age, sex, and body mass index (BMI). In addition, only patients that were out at least 5 years and had a minimum 5-year follow-up were included in the study. The matched cohort included 30 DS and 30 SADI-S patients. There were no statistically significant differences in the preoperative characteristics and baseline comorbidities between both groups. The SADI-S patients had significantly shorter operative time and length of stay. The overall long-term complications, especially the long-term Clavien-Dindo grade IIIb complications, were significantly fewer with SADI-S. At 6 years, the DS patients had statistically higher %EWL; however, the ending BMIs were statistically similar between both groups. There were no significant differences in the long-term comorbidity and nutritional outcomes of both groups. The long-term failure rates were comparable. Most long-term outcomes of SADI-S were either similar or significantly better than DS. Part of the reasons could be the surgeon’s learning curve and the small sample sizes of both groups.

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.

Aims Bariatric surgery (BS) is recommended for subjects with a Body Mass Index (BMI) over of 40 kg/m2 or with a BMI between 35 and 40 kg/m2 with obesity-related comorbidities. Aim of the study was to compare different types of BS with medical therapy (MT) for the treatment of obesity. Data synthesis We conducted a network-meta-analysis (NMA) including randomized clinical trials comparing different BS techniques versus MT in people with obesity, with a duration ≥24 weeks (PROSPERO, #CRD42020160359). Primary endpoint was BMI. Indirect comparisons of different types of surgery were performed by NMA. Types of BS included: laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass, sleeve gastrectomy (SG), bilio-pancreatic diversion (BPD); greater curvature plication (GCP); one-anastomosis gastric bypass (OAGB); Laparoscopic Vertical Banded Gastroplasty (LVBG) and duodenal switch (DS). 43 trials were retrieved in this metanalysis. BS was associated with a significant reduction in BMI, systolic blood pressure, triglyceride and fasting glucose, and with a significant increase of HDL cholesterol when compared to MT. In direct comparisons, RYGB was more effective than LAGB, LVBG, and GCP, but less effective than DS, whereas LAGB was less effective than LVBG and SG. In the NMA, DS and BPD appeared to be more effective than other procedures. Conclusions BS produces a greater weight loss than MT in morbidly obese patients, inducing a greater improvement of obesity-associated metabolic parameters. Available data are insufficient to assess the effect of BS on mortality. Different surgical procedures are heterogeneous for efficacy and safety.

Circulating micronutrient levels of both serum copper and zinc have been studied to varying degrees in both the general public and patients having undergone bariatric surgery. According to the 2019 ASMBS clinical guidelines, copper supplementation is recommended for patients undergoing metabolic surgery, especially after Roux-en-Y gastric bypass and duodenal switch. Copper excess has not been previously reported to any significant degree in any population. In this study, we investigate an elevated serum copper level in the pre-surgical intervention population of the Bariatric Center of the University Medical Center–New Orleans, a primary safety net hospital for the state of Louisiana. Five hundred five consecutive patients from the bariatric surgery undergoing a workup for surgical intervention were assessed. Patients were included regardless of whether they proceeded to surgery. The study was conducted as a retrospective review of deidentified data that was collected as part of our routine workup for bariatric surgery. The study population of the clinic consisted of a mean BMI of approximately 50 kg/m2, with 91% of the population reporting female and 69% recording an African American race. It was discovered in this population that 26% of the patients had an elevated copper level of > 155 mcg/dl. Additional analysis was performed attempting to elucidate an environmental role in the elevation by qualitative analysis of patient’s location of residence using reported home address. Additional variables were studied as well including serum zinc concentration, age, BMI, and race to address any correlative variables with our findings. This study identifies an elevated serum copper concentration in a pre-intervention underserved bariatric center population positively associated with BMI, female gender, and African American race. Additional studies will be necessary to see if these trends are also apparent in normal weight controls, or if weight loss influences copper levels. Pre-existing serum copper deficiencies may be more prevalent in the bariatric populations than previously believed. Increased serum copper in this population was positively associated with increased BMI, age, and female gender compared to that of the male group. Increased serum copper was also associated more closely with African American ethnicity compared to Caucasian patients.

Background Bariatric surgery is more effective in the management of morbid obesity and related comorbidities than is conservative therapy. Pylorus-preserving single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-SG) is a modified duodenal switch technique. Gastric plication (GP) is an alternate to SG. Methods Morbidly obese (BMI of > 40, or > 35 in the presence of diabetes or prediabetes) patients were recruited and operated on to perform SADI with GP. Complications related to surgery were recorded to assess the feasibility of the procedure. Weight-loss outcomes were analysed to determine efficacy. Minnesota Multiphasic Personality Inventory 2 (MMPI-2) was recorded after 1 year of follow-up, and test scales were used to describe physiological phenomena. Results Seventeen middle-aged (mean: 40 years) patients were involved in our study; 15 of them were females. The mean duration of surgery was 205 min. There were no complications of conversion, death, bleeding, VTE or 30-day readmission to hospital. We did experience CD4a (pulmonary insufficiency due to chronic lung disease) and a CD3b (anastomosis leakage treated laparoscopically) complications. Vomiting occurred in three cases (CD1). Obesity-related comorbidities showed favourable resolution rates (77.8% for hypertension, 81.2% for dyslipidaemia, 100% for diabetes at the 1-year follow-up). Weight-loss outcomes were favourable (53.20 EWL%, and 35.58 TWL% at 1-year follow-up). Greater weight loss caused significantly higher levels of Depression (t(13.958) = − 2.373; p = 0.00; p t(13.301) = − 2.954; p = 0.00; p t(13.408) = − 1.914; p = 0.02; p Conclusion According to our safety study, SADI-GP is a promising malabsorptive procedure, but a long-term high-volume case series or a randomised controlled trial is necessary to evaluate complication rates and weight-loss outcomes. Emotional dysregulation is common among bariatric surgery patients according to personality inventory data; therefore, psychological follow-up and psychotherapeutic support are necessary for weight-loss maintenance.

Background The alarming rise in the worldwide prevalence of obesity is paralleled by an increasing burden of type 2 diabetes mellitus (T2DM). Metabolic surgery is the most effective means of obtaining substantial and durable weight loss in individual obese patients with T2DM. There are randomized trials that justify the inclusion of metabolic surgery into the treatment algorithm for patients with T2DM, but remission rates of T2DM after metabolic surgery can display great variability. Aim To discuss the most commonly used surgical options including vertical sleeve gastrectomy, adjustable gastric banding, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch. Methods We also report from observational and randomized controlled studies on rate of remission of T2DM after the surgical procedures. Results In light of the recent findings, metabolic surgery is a safe and effective treatment option for obese patient with T2DM, but further studies are needed to clarify better the rate of diabetes remission. Conclusion In light of the recent findings, metabolic surgery is a safe and effective treatment option for obese patients with T2DM, but further studies are needed to clarify better the rate of diabetes remission.

The outcomes of laparoscopic biliopancreatic diversion with duodenal switch (BPD-DS) on gastro-esophageal reflux disease (GERD) are not well elucidated. This retrospective review included patients undergoing laparoscopic primary BPD-DS at Mayo Clinic from 2009 to 2019. GERD parameters analyzed included subjective symptom report/anti-reflux medication intake and/or endoscopic findings. GERD-HRQL questionnaire was also utilized post-operatively. Three subgroups were employed to stratify patients depending on GERD outcomes: the “No-effect” subgroup included patients where surgery did not affect either positively (GERD resolution) or negatively (de novo GERD) GERD outcome, “De novo GERD” subgroup, and “GERD-resolved” subgroup. Multinomial logistic modeling was used to examine associations with the 3-level GERD subgroup (p

Over the last decade, sleeve gastrectomy (SG) has steadily gained popularity and has now become the most commonly performed bariatric procedure in the United States. It is technically less complex than Roux-en-Y gastric bypass (RYGB) or biliopancreatic diversion with duodenal switch and has relatively good weight loss results in addition to comorbidity resolution. The long-term complication profile is appealing to patients and surgeons alike, save one issue, gastroesophageal reflux disease (GERD). GERD is frequently seen in bariatric surgery patients; thus, proper patient selection for SG is paramount. However, SG effects on GERD remain controversial in the literature. Thus, patients are intensively cautioned of the possibility of de novo GERD or worsening of already existing GERD following SG. Therefore, it is imperative that the discussion also occurs regarding potential treatment options if GERD does occur. GERD management following SG consists of a multitude of options. While lifestyle modifications and proton pump inhibitors remain the initial treatment of choice, some will have persistent symptoms needing additional interventions, which may range from a variety of endoscopic techniques (lower esophageal sphincter [LES], radiofrequency ablation, magnetic LES augmentation, and antireflux mucosectomy) to ReSleeve and ultimately conversion to RYGB.

We present the case of a woman with a history of biliopancreatic diversion and duodenal switch procedure who developed severe malnourishment requiring total parenteral nutrition during three pregnancies. The widespread use of bariatric surgery, particularly among those of reproductive age, has led to an increase in the number of women who become pregnant following bariatric surgery. There is a paucity of evidence to guide nutritional recommendations for women during pregnancy post bariatric surgery. We review this literature and summarize key published evidence and provide comprehensive recommendations concerning the common challenges in the management of nutrition status during pregnancy. The focus is on the impact of malabsorptive bariatric surgeries on pregnancy outcomes, nutrient deficiencies, recommendations for micro- and macronutrient monitoring and supplementation, and altered glucose metabolism and implications for diabetes screening. Optimizing pregnancy outcomes for individuals following bariatric surgery requires multidisciplinary team management including obstetrical providers, obstetric medicine specialists, and dietitians.

Single-anastomosis duodenal switch (SADS) has become increasingly popular. This review compared the conceptual difference between Eastern (SADS-E) and Western (SADS-W) countries. After searching for SADS through PubMed and high-impact journals, 19 articles with 2280 patients were included for analysis. We found SADS-W was reserved for patients with a high body mass index (BMI) without type 2 diabetes mellitus (T2DM). Surgeons performing SADS-W used larger bougies and preferred shorter common channels. However, SADS-E was mainly preferred in T2DM patients with a low BMI. SADS-E bypassed less bowel and used smaller bougies. The spectra of major postoperative complications, nutritional deficiencies, and gastrointestinal disorders were different between SADS-E and SADS-W. SADS-W yielded better weight loss and better T2DM remission than SADS-E. SADS are effective bariatric and metabolic procedures with promising therapeutic outcomes and acceptable safety.

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.

Single-anastomosis duodeno–ileal bypass with sleeve gastrectomy (SADI-S) is a bariatric procedure based on the standard duodenal switch surgery. It was first introduced in 2007 as a procedure for individuals with clinically severe obesity. Till date, primary SADI-S has not been used on Chinese with diabetes and body mass index (BMI) < 35 kg/m2. Here, we account the use of this novel surgery in Chinese with diabetes and BMI < 35 kg/m2. All relevant medical information, involving patients with diabetes and BMI < 35 kg/m2, who received primary SADI-S at Beijing Shijitan Hospital from June 2017 to December 2018, was retrospectively assessed. Twenty-six patients were selected for evaluation, and all of them completed a 2-year follow-up. The age, diabetic duration, and preoperative BMI were 35.5 (range 20–63) years, 3.5 (range 0.5–18) years, and 34.40 (range 28.74–34.96) kg/m2, respectively. At 24 months, the percentage of total body weight loss (%TWL) and BMI were 26.26 (range 13.33–43.88) and 24.72 (range 17.96–29.07) kg/m2, respectively. There were no serious complications or sequelae within a 2-year follow-up. In addition, for diabetes, 20/23 people achieved complete remission, whereas 3 achieved partial remission. SADI-S is a highly effective and feasible bariatric surgery for Chinese having diabetes and BMI < 35 kg/m2. However, care must be taken to follow a strict criteria for patient selection and to monitor patients carefully for the detection of postoperative nutritional sequelae.

Background Without the needed medical support, bariatric surgery can be associated with post-operative malnutrition and associated nutrient deficiencies. We aimed to evaluate the cost difference of perioperative infusion requirements and TPN between GBP and BPD-DS. Methods All patients undergoing GBP or BPD-DS procedures between August 2015 and June 2018 were included. Information was collected to standardize the nutritional information into two categories: (1) oral supplementation and standard intravenous infusions, as predicted costs forming part of preoperative quote and (2) infusions prescribed for malnutrition, based on blood biochemistry, caterized as unexpected costs. Results A total of 573 patients over 3 years (GBP 60%, BPD-DS 40%) were included in the analysis. The average predicted costs from oral supplementation for both surgery groups and prophylactic infusions for BPD-DS were GBP (46.90USD) vs. BPD-DS (154.13 USD) (p-value = NS). Unexpected costs for infusions to correct nutritional deficiencies were GBP (199.14 USD) vs. BPD-DS (127.29 USD) (p-value = NS). TPN incidence rate was GBP (2.1%) and BPD-DS (12.7%) (p-value < 0.001) and admission rate per patient was GBP (0.9) and BPD-DS (0.63) (p-value < 0.05). Costs for acquiring TPN were GBP (153.58 USD) vs. BPD-DS (268.76 USD). Total unexpected costs were GBP (352.72 USD) vs. BPD-DS (396.05 USD) (p-value = NS). Conclusion Nutrient deficiencies are known to occur within both GBP and BPD-DS surgeries, even up to 3 years. The admission rate/patient, requiring TPN, was higher in the GBP group, indicating that BPD-DS surgery can be efficient and cost-effective with holistic and multitherapeutic post-surgery care. BPD-DS procedures should be reserved for centers with a comprehensive and experienced multidisciplinary team enforcing stringent follow-up regimes.

Revisional bariatric surgery (RBS) is becoming more common, with an estimated increase of more than 300% from 2017 to 2018. For these complex procedures, the role of robotics is still debated. The purpose of our study is to report the safety and effectiveness of robotic-assisted RBSs. A retrospective review of electronic medical records was conducted for robotic-assisted RBSs performed at the Mayo Clinic in Florida, between January 1, 2016, and January 1, 2020. Peri- and postoperative data were analyzed, reviewing patient characteristics, indications for surgery, and outcomes. From 160 RBSs performed during the study period, 67 were robotic-assisted and met inclusion criteria. Primary procedures included sleeve gastrectomy (26 [38.8%]), adjustable gastric band (24 [35.8%]), Roux-en-Y gastric bypass (14 [20.9%]), vertical-banded gastroplasty (2 [3.0%]), and duodenal switch (1 [1.5%]). RBSs performed were Roux-en-Y gastric bypass (49 [73.1%]), redo gastrojejunostomy (14 [20.9%]), and duodenal switch (4 [6.0%]). Rate of conversion to open procedure and rate of readmission 1 month after surgery were 6.0% and 7.5%, respectively. Rate of 30-day Clavien-Dindo grade III or higher adverse events was 4.5%. No anastomotic leaks were documented. Fifty-two patients presented with preoperative symptoms, and 69.2% reported improvement after RBS. Mean (SD) excess weight loss was 57.62% (23.80) 12 months after RBS. Robotic-assisted RBSs are safe with low major adverse event rates. Symptom resolution and weight loss outcomes are acceptable.

Objective: Retrospective case-matched comparison of magnetic liver retraction to a bedrail-mounted liver retractor in bariatric surgery specifically targeting short-term postoperative outcomes, including pain and resource utilization. Background: Retraction of the liver is essential to ensure appropriate visualization of the hiatus in bariatric surgery. Externally mounted retractors require a dedicated port or an additional incision. Magnetic devices provide effective liver retraction without the need of an incision. Methods: The sample consisted of primary and revisional bariatric surgery patients, including Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and biliopancreatic diversion with duodenal switch (BPD-DS) operations. Propensity score analysis was used to match patients with magnetic retraction to patients with a bedrail-mounted retractor with a 1:2 ratio using preoperative characteristics. Baseline characteristics and postprocedure outcomes were compared using two-sample t-tests or Wilcoxon rank sum tests and chi-square or Fisher's exact test as appropriate. Results: One hundred patients met inclusion criteria for the use of magnetic liver retraction (45 RYGB, 35 SG, 20 BPD-DS) with 196 suitable matched external retractor patients identified. Patients were matched and comparable for all preoperative characteristics except for transversus abdominus plane block (27% versus 47%). Patients in the magnet cohort had significantly decreased mean 12-hour postoperative pain scores (2.9 versus 4.2, P = .004) and decreased hospital length of stay (LOS) (1.5 versus 1.9 days, P = .005) while operating room supply were higher in the magnet cohort ($4600 versus $4213, P = .0001). Conclusions: Magnetic liver retraction in bariatric surgery is associated with decreased postoperative pain scores, decreased hospital LOS, and increased operating supply costs.

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 In comparison with purely restrictive procedures, combined restrictive and malabsorptive procedures seem to produce better weight loss and comorbidity control in patients with morbid obesity. Two-stage bariatric surgery is popular and is a safe and efficient strategy for patients with super obesity (BMI > 50 kg/m2) and super-super obesity (BMI > 60 kg/m2). Methods The patient in this video was a 36-year-old man with an initial BMI of 53.2 kg/m2. Two-stage bariatric surgery was planned. The patient underwent the first stage, laparoscopic sleeve gastrectomy, in 2018. Eighteen months after surgery, his lowest BMI was 38.8 kg/m2, and his excess weight loss was 50.9%. In 2021, he regained weight and reached a BMI of 42.4 kg/m2. Then, a second-stage bariatric surgery was performed. Results As shown in the video, combined re-sleeve and single anastomosis sleeve ileal (SASI) bypass constituted the second stage of bariatric surgery. During the operation, adhesiolysis was first performed, and the stomach was mobilized through a lateral-to-medial approach. Gastric transection was performed with a 36-Fr bougie. Then, the ileocecal junction was identified, and a location 250 cm from the cecum was selected as the anastomosis site. Gastro-ileal anastomosis (3 cm in diameter) was established with a stapler, and the two-layer suture method was used to close the defect. The postoperative period was uneventful, and the patient was discharged 5 days after surgery. Conclusions Combined re-sleeve and SASI bypass has a few surgical morbidities and is promising as an alternative to second-stage duodenal switch in patients with super obesity.

There are no formal guidelines for choosing among different bariatric surgery procedures for obesity treatment. So, our aim was to evaluate whether post-absorptive metabolite and hormone profiles could aid the surgeon decision when considering bariatric surgery interventions. Subjects (N=38) previously submitted to biliopancreatic diversion with duodenal switch (BPD-DS, n=9), single anastomosis duodenal–ileum bypass with sleeve gastrectomy (SADI-S, n= 9), long biliopancreatic limb Roux-en-Y gastric bypass (RYGB-M, n= 11), and classic RYGB (RYGB-C, n= 9) underwent a mixed meal test to evaluate post-absorptive glucose, total amino acid (AA), insulin, and GLP-1 profiles. Glucose, AA, insulin, and GLP-1 excursions were lower after BPD-DS when compared to other surgeries. SADI-S resulted in lower glucose but similar AA and insulin excursions when compared to RYGB-M. The highest GLP-1 excursion was observed after RYGB-M. There were no significant differences in glucose or AA post-prandial excursions between RYGB procedures, yet insulin excursion was higher after RYGB-C when compared to RYGB-M. Post-prandial metabolite excursions diverge across bariatric procedures being lowest after BPD-DS, intermediate after SADI-S, and highest after RYGB, in parallel with the anti-diabetic efficacy and malabsorption risk reported for each type of intervention. SADI-S and RYGB-M seem to elicit similar post-prandial hormonal profiles, with potentially lower risk of protein malnutrition when compared to BPD-DS. Post-absorptive metabolite and hormone profiles could provide a rationale as decision-aid when choosing among bariatric surgery interventions, as long as these findings are validated in future trials.

Single-anastomosis duodenoileal bypass with sleeve gastrectomy/one anastomosis duodenal switch (SADI-S/OADS) was developed as a bariatric operation with reduced overall morbidity and lasting weight loss results. We performed a systematic review of the literature, including 14 studies reporting on weight loss, comorbidity resolution, postoperative complications, and nutritional deficiencies following SADI-S. Twelve months after SADI-S, the mean total body weight lost ranged from 21.5 to 41.2%, with no weight regain being observed after 24 months. The comorbidity resolution rate was 72.6% for diabetes, 77.2% for dyslipidemia, and 59.0% for hypertension cases. The need for reoperation was the most common postoperative complication. While several patients developed nutrient deficiencies, SADI-S seems to be an overall safe and effective bariatric operation.

Morbid obesity is a global chronic disease, and bariatric procedures have been approved as the best method to control obesity. Roux-en-Y gastric bypass is one of the most common bariatric surgeries in the world and has become the gold standard procedure for many years. However, some patients experience weight regain or weight loss failure after the initial bypass surgery and require revisional or conversional interventions. International databases including PubMed, International Scientific Indexing (ISI), and Scopus were considered for a systematic search of articles that were published by 5th of May 2020. Forty-one published studies, which reported revision procedure on 1403 patients, were selected and analyzed for this review. The selected studies were categorized into six groups of revision procedures, including laparoscopic pouch resizing and/or revision of gastro-jejunal anastomosis (GJA), adjustable or non-adjustable gastric band over pouch ± pouch/GJA resizing, endoscopic revision of gastric GJA ± pouch, distal Roux-en-Y gastric bypass (DRGB), biliopancreatic diversion with duodenal switch (BPD-DS) or single anastomosis duodeno-ileal bypass with gastric sleeve (SADI-S), DRGB + Band or pouch/GJA resizing. Revision procedures result in more weight loss after the initial weight loss procedures. In the one-year follow-up, DRGB by itself with standardized mean difference (SMD) of - 1.24 presented a greater decrease in body mass index (BMI). DRGB plus band or pouch/GJA resizing, BPD-DS or SADI, adjustable or non-adjustable gastric banding over pouch ± pouch/GJA resizing, endoscopic pouch and/or GJA revision and laparoscopic pouch or/and GJA resizing revealed a lower decrease in BMI in order, respectively. In the three-year follow-up, BPD-DS or SADI-S method with SMD of - 1.40 presented the highest decrease in BMI. In follow, DRGB alone, adjustable or non-adjustable gastric banding over gastric pouch ± pouch / GJA resizing, DRGB + Band or gastric pouch/GJA resizing, laparoscopic pouch and/or GJA resizing and endoscopic revision of pouch and/or GJA revealed less reduction in BMI, respectively. In the five-year follow-up, DRGB alone procedures with SMD of - 2.17 presented the greatest reduction in BMI. Subsequently, BPD-DS or SADI-S, laparoscopic pouch and/or GJA size revision, and endoscopic revision of GJA/pouch revealed less overall decrease in BMI in order. All methods of revision procedures after the initial RYGB have been effective in the resolution of weight regain. However, based on the findings in this systematic review, it seems DRGB or BPD-DS/SADI-S is the most effective procedure in the long-term follow-up outcome. More studies with a higher number of patients and even longer follow-ups will be required to obtain more accurate data and outcome.

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.

The classic duodenal switch (DS) represents a minority of bariatric procedures due to its high complexity and potential for complications. A retrospective chart review was conducted on 100 laparoscopic DS cases from 2014 to 2018 at an accredited program in a rural community hospital and compared to 100 laparoscopic Roux-en-Y gastric bypasses (RYGB). Primary outcomes were 30-day morbidity and mortality. Secondary outcomes included anastomotic leak and remission of type 2 diabetes. There were more demographic risk factors for DS. The 30-day morbidity was higher for DS compared to RYGB (31% vs 13%, respectively; p = 0.0037). There was one mortality for DS and none for RYGB. There were statistically significant longer intraoperative times, greater EBL, and greater decrease in BMI for DS. The DS had a lower incidence of anastomotic ulcers (4% vs 13%, respectively; p = 0.0289), with a higher incidence of subsequent surgery beyond 30 days (21% vs 8%, respectively; p = 0.0160). There were 3 anastomotic leaks for DS and none for RYGB, although not statistically significant (p = 0.2463). The DS was more likely to eradicate hypertension, but the RYGB was more likely to eradicate GERD. There were no statistically significant differences for type 2 diabetes remission (92.1% vs 89.5%, respectively; p = 0.7239). Laparoscopic DS offers greater weight loss and hypertension remission, with lower incidence of anastomotic ulcers, but at the expense of greater morbidity and need for subsequent surgery, with no significant differences in type 2 diabetes remission when compared to RYGB in a rural community hospital program.

Surgical revision rates are high, reaching 41% at 10 years after Laparoscopic gastric band (LAGB). Surgical revision may include re-banding, laparoscopic sleeve gastrectomy (LSG), duodenal switch (DS), or laparoscopic Roux-en-Y gastric bypass (LRYGB). LRYGBP has been proposed as the procedure of choice after failure of restrictive procedures with better results than any other procedure. LRYGB as a revisional bariatric surgery is hazardous compared with primary LRYGB. However, controversy as to whether revisional bariatric surgery should be performed as a one-step revision or as a two-step revision. We aim to compare the mortality and morbidity between one-step versus two-step revisional surgery from LAGB to LRYGB. Retrospective cohort study of our revisional surgery from LAGB to LRYGB between November 2007 and December 2016. Revisional surgery was indicated in cases of inadequate weight loss or weight regain and after band-related complications. Gastric band removal and conversion to LRYGB was either in a one-step or a two-step procedure, according to the indication of this revisional surgery and based on the intra-operative decision. One-step group included 107 patients, two-step group had 76 patients. Dindo-Clavien I-II: 5 complication in the one-step group, whereas 4 complication were seen in the two-step group (P = 1.000). Dindo-Clavien ≥ IIIa complications: 10 complication in the one-step group, whereas 2 complications in the two-step group (P = 0.127). One-step revision is safe and feasible, without significant increased morbidity when performed in a specialized institution. However, proper patient selection is of the utmost importance.

Dehydration treatments (DT) provide intravenous fluids to patients in the outpatient setting; however, the utilization of DT is not well-described. We characterize the cohort receiving DT, the first year it was recorded in a bariatric-specific database. A retrospective cohort analysis of patients undergoing bariatric surgery between January 1, 2016, and December 31, 2016, in 791 centers in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data file. Patients ≥ 18 years with a body mass index (BMI) ≥ 35 kg/m2 who underwent laparoscopic adjustable gastric band (LAGB), sleeve gastrectomy (LSG), Roux-en-Y gastric bypass (LRYGB), and biliopancreatic diversion with duodenal switch (LBPD/DS) were identified. Unadjusted and adjusted rates of DT were analyzed. In addition, adjusted rates and indication for readmission were reviewed. The overall rate of dehydration treatments was 3.5% for the 141,748 bariatric surgery cases identified. Patient comorbidities of gastroesophageal reflux (GERD) (odds ratio (OR) 1.49; 95% CI, 1.40–1.59), insulin-dependent diabetes (OR = 1.19; 95% CI, 1.07–1.33), and LRYGB (OR = 1.45; 95% CI, 1.36–1.54) were associated with higher odds of DT. DT only had the highest odds of readmission (OR = 6.22; 95% CI, 5.55–6.98) compared to other outpatient visits. Nausea and vomiting, or fluid, electrolyte, or nutritional depletion was the most common indication for readmission in all groups. Patients with GERD utilized dehydration treatments after bariatric surgery. DT was highly associated with readmissions, and a better understanding of the clinical application of DT will allow bariatric centers to develop programs to further optimize outpatient treatments.

Although the link between achalasia and morbid obesity is unclear, the reported prevalence is 0.5–1% in this population. For bariatric surgery patients, optimal type and timing of achalasia intervention is uncertain. Patient charts from a single academic institution were retrospectively reviewed. Between 2012 and 2019, 245 patients were diagnosed with achalasia, 13 of whom underwent bariatric surgery and were included. Patients were divided into two groups depending on the timing of their achalasia diagnosis and bariatric surgery. Groups were compared in terms of type and timing of intervention as well as treatment response. Group 1 included 4 patients diagnosed with achalasia before bariatric surgery. Three had laparoscopic Heller myotomy (LHM) and 1 had a per oral endoscopic myotomy (POEM). These patients had laparoscopic gastric bypass (LGB) within 5 years of achalasia diagnosis. Postoperatively, 1 had severe reflux with regurgitation necessitating radiofrequency energy application to the lower esophageal sphincter. All had relief from dysphagia. Group 2 included 9 patients diagnosed with achalasia after bariatric surgery. Achalasia subtypes were evenly distributed. Initial operations were: 5 LGB, 2 laparoscopic sleeve gastrectomy (LSG), 1 duodenal switch (DS), 1 lap band. One LSG patient was converted to LGB concurrently with LHM. On average, achalasia was diagnosed 8.3 years after bariatric surgery. Achalasia interventions included: 1 pneumatic dilation, 1 Botox injection, 1 POEM, 6 LHM. While LHM was the most common procedure, 4 of 6 patients experienced recurrent dysphagia, one of whom required esophagectomy. Achalasia is a challenging problem in the bariatric surgery population. Recurrent symptoms are common. Patients treated for achalasia after bariatric surgery tended to have worse symptom resolution than those diagnosed prior to bariatric surgery. Additional prospective studies are needed to elucidate whether interventions for achalasia should be performed concurrently or in a particular sequence for optimal results.

There are only a small number of studies providing a comparison between SADI-S and Hess-Marceau’s BPD/Duodenal Switch (RY-DS) operations. We aimed to compare 5-year results of SADI-S 250 (common limb 250 cm) with RY-DS. Data of patients who underwent open SADI-S (n 226) and RY-DS (n 528) were retrospectively studied. EWL(%), EBMIL(%), TWL(%), antidiabetic effect, complications, and revision rate were compared between the two groups. After the first 12 months, EWL% (77.0% vs 73.3%) and TWL% (39.4% vs 38.9%) were statistically significantly better after SADI-S (p 0.05). At nadir to 24–36 months, EWL, TBWL, and EBMIL after SADI-S was comparable to the RY-DS group. Up to the fourth and fifth year, better weight loss (TBWL, EBMIL, EWL) was observed after RY-DS than after SADI-S. Early complication rate was less (2.65%) in the SADI-S group vs 5.1% in the RY-DS. Protein deficiency and small bowel obstruction rates were also lower after SADI-S. 93.4% of patients achieved total remission of their diabetes. 7.5% of patients in the SADI-S group had symptoms of bile reflux, which was a main indication for revisions. SADI-S has many advantages over RY-DS. However, weight loss and antidiabetic effects after the third year were marginally lower after SADI-S compared to RY-DS. SADI-S is less dangerous in terms of malabsorption and looks to be a reasonable alternative to RY-DS as a metabolic operation. RY-DS could be implemented for weight regain and/or bile reflux after SADI-S.

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.

Universally, obesity has been affected more than 650 million and converts as global health problem. Obesity is equally affecting starting from children to elder population. Obese subjects are converting into severe obese and then into morbid obesity. Body mass index is proning from 30 to 50 kg/m2 in the adult population. Obesity is connected with the future complications of hypertension, type 2 diabetes mellitus, cardiovascular, stroke, osteoarthritis, obstructive sleep apnea and liver diseases. Loosing of body fat is the only option to avoid obesity and this could be achieved with routine physical activity and diet modifications. Obesity subjects may fail to achieve the daily routine activities or insufficient activity may be involved and finally fail to lose the body fat after the medical course. Then these severe or morbidity obese can be lose with the existing surgery. Currently, Bariatric Surgery (BS) has become the active treatment for long-term weight loss. Various types (Roux-en-Y gastric bypass, sleeve gastrectomy and duodenal switch and the jejunoileal bypass) of BS are performed on the gastrointestinal tract. Throughout the world population, BS has found to be safe in losing the weight and avoiding the future and long-term complications. The prevalence of overweight and obesity in Saudi Arabia is an issue in terms of incidence and health consequences. Maximum obesity studies involved in Saudi Arabia has proven to be develop the long-term complications in the future involving from child to morbid obesity. Limited bariatric studies carried out in the Saudi subjects confirmed as effective tool in lowering the body fat and avoiding the life-threatened complications of human diseases. So, this review recommends BS as effective and safe surgical treatment to lose body fat in the Saudi population. However, post-operative monitoring is mandatory to follow-up.

BACKGROUND: Little is known regarding the variation in training level and potential clinical impact of the first assistant in bariatric surgery. We describe the postoperative 30-day complications and readmissions following elective bariatric procedures by training level of the first assistant. METHODS: The ACS-MBSAQIP database was queried to identify patients who underwent elective sleeve gastrectomy, Roux-En-Y gastric bypass, duodenal switch, band placement, and revision from 2015 to 2016. Patients were divided into cohorts based on training level of the first assistant (attending, fellow, resident, physician assistant/nurse practitioner, none). Outcomes included 30-day death or serious morbidity (DSM) and readmission. Multivariable logistic-regression models, adjusting for patient and procedure characteristics, were estimated to examine differences in outcomes by first assistant training level. RESULTS: Of 410,535 procedures performed between 2015 and 2016, the training level of the first assistant included 21.3% attending, 8.7% fellow, 16.5% resident, 37.6% PA/NP, and 15.9% none. Operative time was significantly longer in the fellow and resident first assistant cohorts when compared to all other cohorts. Overall rates of 30-day DSM were low, ranging from 3.2-3.8%, while 30-day readmission rates ranged from 5.1-5.9%. Following adjustment for patient characteristics and type of procedure, first assistant training level had no significant impact on DSM or readmission. CONCLUSIONS: Variation in training level of the first assist during bariatric surgery had no influence on DSM or readmissions. This provides reassurance that the inclusion of a wide range of first assistants in bariatric procedures does not negatively impact patient outcomes.

Introduction: After bariatric surgery (BS), patients might suffer from nutrient maldigestion, malabsorption, and vitamin deficiencies. In this study, our aim was to assess pancreatic functions after BS using fecal elastase-1 assay (FE-1). Material and Methods: Sixty patients (21M) undergoing BS and 20 (6M) healthy controls were included into the study. Stool samples were collected 1 year after surgery. Ten patients from one anastomosis gastric bypass (OAGB) and single anastomosis duodenal switch (SADS) groups with the lowest value of FE-1 and GIQLI scores were given pancreatic enzyme replacement therapy (PERT). After PERT, FE-1, excess weight loss (EWL), BMI, GIQLI scores, and vitamin D levels were measured. Results: Vitamin D levels were detected as 19.04 (9–46.5) pg/ml, 15.1 (8.4–23.6) pg/ml, 17.8 (5–30) pg/ml, and 21.79 (11–40.3) pg/ml after sleeve gastrectomy (SG), OAGB, SADS, and control groups, respectively (p = 0.04). GIQLI scores in the first year were found to have increased in all patients (p = 0.02). FE-1 levels were found as 642.35 (566.3–711.4) μg/g, 378.52 (183.5–561.1) μg/g, 458.88 (252.5–593, 5) μg/g, and 518.2 (351.6–691) μg/g for the SG, OAGB, SADS, and control groups, respectively. There was a strong inverse correlation between EWL and FE-1 levels at the end of the first year (Spearman’s rho = − 0.688, p = 0.003). After having performed PERT for patients with the lowest FE-1 levels, the levels increased to 683.39 (615.5–720) μg/g in the OAGB and 691.5 (643.1–720) μg/g in the SADS groups (p = 0.011). Conclusion: FE-1 measurements demonstrated that many patients suffer from malabsorption after OAGB or SADS, whereas functions remain normal after SG. PERT corrects pancreatic functions without affecting weight loss and also contributes to the normal serum level of vitamin D. 32885359

Sleeve gastrectomy (SG) is the most common primary bariatric surgery. Long-term, up to 20% of patients may need revisional surgery. We aimed to evaluate the short-term outcomes of various revisional bariatric surgeries after a failed primary SG. This is a single-center retrospective study of a prospectively collected database of obese patients who underwent revisional bariatric surgery during 2010–2018 for a failed previous SG. Failure was defined as inadequate weight loss (

Background: Obesity is a complex chronic disease, which represents a severe and growing health issue all over the world. Bariatric surgery is an option when medical treatments failed. The average of complications is low. Common bile duct stones in a patient who underwent weight loss surgery, especially Roux-en-Y gastric bypass, one anastomosis gastric bypass, or duodenal switch, is challenging due to the difficult access to the biliary duct. Methods: We describe the different techniques we used to perform the treatment of common bile duct stones after a gastric bypass was performed. Results: The highlights of the different treatments to solve this big issue that is common bile duct after gastric bypass are described, such as the endoscopic, the surgical, the percutaneous, and combined ones. Conclusion: There are several therapeutic options; many of them have already demonstrated excellent results. Even though there is not a gold standard technique, the total endoscopic approach performed by trained hands should be the first line of treatment. Percutaneous approach represents also a safe and effective option that can avoid reoperations in an important number of patients. However, the choice will depend on the severity of the case to face with, the availability of resources, and the experience of the team.

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.

Elevated lipoprotein(a) (Lp(a)) level is an independent risk factor for cardiovascular diseases. Lifestyle intervention studies targeting weight loss revealed little to no significant changes in Lp(a) levels. The impact of interventions that induce substantial weight loss, such as bariatric surgery, on Lp(a) levels is currently unclear. To determine the acute and long-term impact of bariatric surgery on Lp(a) levels in patients with severe obesity. Sixty-nine patients with severe obesity underwent biliopancreatic diversion with duodenal switch (BPD-DS) surgery. The lipid profile was evaluated and Lp(a) levels were measured before surgery and at 6 and 12 months after BPD-DS surgery. Median Lp(a) levels at baseline were 11.1 (4.1–41.6) nmol/L. Six months and 12 months after the BDP-DS surgery, we observed an improvement of lipid profile. At 6 months, we observed a 13% decrease in Lp(a) levels (9.7 (2.9–25.6) nmol/L, p

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 Bariatric surgery (BS) may be associated with significant malabsorption and nutritional deficiencies. METHODS Between March 1987 and January 2017, we performed 922 liver transplants (LT) at our institution; 33 had antecedent BS. We matched the BS cohort to LT recipients without BS (1:3 matching) based on exact matching for gender and cancer and inverse variance matching for age, LT body mass index, MELD score, and transplant date. RESULTS We analyzed outcomes in 132 LT recipients (33 BS; 99 non-BS). The BS cohort comprised 26 (79%) women with a mean age of 52.4 years. The BS procedures included 20 Roux-en-Y gastric bypass (61%), 6 jejunoileal bypass (18%), 3 gastric band (9%), 2 sleeve gastrectomy (6%), and 1 duodenal switch (3%). The primary indications for LT listing were alcoholic cirrhosis (9; 27%), nonalcoholic steatohepatitis (7; 21%), hepatitis C (8; 24%), and hepatocellular carcinoma (3; 9%). At LT, body mass index for the BS cohort was 29.6, and MELD was 24. Compared with matched controls, BS recipients did not have longer LT length of hospital stay (17.8 versus 15.7 d, P = 0.71), longer intensive care unit length of stay (5.3 versus 4.1 d, P = 0.16), or higher 30-day complication rate (76% versus 85%, P = 0.43). Overall patient survival was similar (1- and 3-y survival was 90.1% and 75.9% for BS; 90.9% and 76.4% for non-BS, P = 0.34). CONCLUSIONS A history of BS does not portend a deleterious effect on LT outcomes.

Although Roux-en-Y gastric bypass is a powerful procedure, achieving and maintaining significant weight loss remains challenging in superobese populations. Transit bipartition with sleeve gastrectomy is derived from biliopancreatic diversion with duodenal switch and might improve weight loss control. Two series of 71 primary laparoscopic Roux-en-Y gastric bypass (RYGB) and transit bipartition (TB) with a body mass index ≥ 50 kg/m2 were retrospectively compared after 2 years. Postoperative course, side effects, nutritional status, and weight outcomes were reviewed. Weight was expressed as BMI, percentage of excess BMI lost (%EBMIL), and percentage of total weight lost (%TWL). The 2 groups were comparable for age and BMI of 51.9 ± 1.8 for RYGB and 51.6 ± 5 for TB. TB was longer to perform (92 vs 74 min, p ≤ 0.001) with a 30-day complication rate of 4.2% and 5.6%, but there was 1 death after RYGB. Weight loss was greater after TB compared with RYGB with %EBMIL of 85.3 ± 15.8% vs 73.9 ± 17.2% (p = 0.0002). One TB patient suffered from protein malnutrition but none after RYGB. After TB, 7% of the patients experienced > 3 stools a day and 1 patient required revision, while 3 patients had diarrhea after RYGB. Late reoperations were required for 7 and 1 patients after RYGB and TB. Comorbidity improvement was similar. In a superobese population, TB appeared relatively safer compared with RYGB. It achieved a better weight loss at 2 years with a trend for more digestive side effects.

Traditional duodenal switch (DS) typically leaves a short common channel and is infrequently performed in part due to increased risk of malnutrition. We compared nutritional deficiencies between DS with a moderate channel length and standard proximal Roux-en-Y gastric bypass (RYGB). We conducted a retrospective review of 61 matched pairs who underwent DS or RYGB using our institutional database; patients were matched on sex, age, race, and BMI. DS was performed with a common channel length between 120 and 150 cm. Thirty-day complications, total body weight loss (TBWL) %, and nutritional labs up to 24 months were compared using paired t test and Wilcoxon rank sum tests. Weight loss was similar at each time point (all p > 0.1). DS patients had lower vitamin D levels at 6 months, lower calcium levels at 6 and 12 months, and lower hemoglobin at 12 months and otherwise equivalent (all p

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.

Introduction Single-anastomosis duodenal switch has been suggested to be an effective bariatric procedure that offers excellent weight loss and by lengthening the common channel the potential to reduce micronutrient deficiencies. Purpose To evaluate the weight loss, comorbidity resolution and the 1-year nutritional outcomes of the single-anastomosis duodenal switch (SADS) procedure. Setting Multiple US Hospitals. Methods From October 2014 to January 2017, 120 patients were enrolled at six sites across the USA and underwent the SADS procedure. Weight loss, comorbidities, quality of life, and adverse events were followed post-procedure for 12 months. Results At 1, 6, and 12 months, 98.3%, 85.5%, and 77.1% of the patients were available for assessment, respectively. At 12 months, patients showed significantly reduced body mass index when compared to baseline (46.8 ± 5.8 vs 29.8 ± 4.4, P P Conclusions SADS is a highly efficacious weight loss procedure with significant comorbidity reduction at 1 year. At 1 year, complications and vitamin and mineral deficits appear to be consistent with other malabsorption operations. Long-term follow-up is needed, especially around complications and vitamin deficiencies.

The worldwide prevalence of obesity nearly tripled between 1975 and 2016. There are limited data quantifying national trends. The aim of this study is to evaluate and summarize current trends in bariatric surgery in Israel. Data for all bariatric surgeries (BS) performed between January 2014 and December 2018 was collected from the Israel National Bariatric Surgery Registry (INBSR) and analyzed. During the study period, 42,296 BS were included in the INBSR. Females accounted for 68% and the mean age and body mass index were 41.6 ± 12.6 years and 42.0 ± 5.4 kg/m2, respectively. Most of the patients were Jewish, but there was a significant rise in number of Arabs undergoing BS during the study period. There was a gradual decline in the annual numbers of BS, except for a small rise in 2015. There was a significant rise in the rate of One Anastomosis-Mini Gastric Bypass (OAGB-MGB), from 0.1% in 2014 to 46.1% in 2018, making it the most prevalent BS in that year. Laparoscopic sleeve gastrectomy (SG) surgeries decreased steadily, from 80% in 2014 to 37% in 2018. The annual rate of Roux-en-Y gastric bypass (RYGB) remained essentially constant at 10%. The annual rates of gastric banding decreased sharply and the annual rates of duodenal switch, single anastomosis duodenal switch and biliopancreatic diversion were negligible. Bariatric surgery was distributed evenly between private (50.4%) and public (49.6%) hospitals. The numbers of BS are decreasing in Israel. There is a gradual but noticeable shift from SG to OAGB-MGB.