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One anastomosis gastric bypass (OAGB) presently constitutes 7.6% of all metabolic and bariatric surgery (MBS) procedures globally. Despite being approved by the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) as a standalone MBS procedure and two consensus efforts in the past, multiple areas of controversies remain. This consensus builds upon previous consensus efforts to address unresolved controversies in the field. A modified Delphi consensus exercise was conducted over 4 weeks under the aegis of the MGB-OAGB International Club. A panel of 86 bariatric experts from 25 countries participated in 3 rounds of voting on 29 questions on patient selection, technical standardization, revisional surgeries, and post-operative care. Consensus was defined as at least 70% agreement. Consensus was achieved on 22 out of 29 questions. Key areas of agreement included suitability of OAGB for adolescents above the age of 15 years and patients with class 1 obesity with uncontrolled type 2 diabetes. Patients with severe esophagitis and Barrett's esophagus were not considered as good candidates for OAGB. Crural repair with OAGB was considered as an appropriate procedure in patients with large hiatus hernia. While a bilio-pancreatic limb (BPL) length of 150 - 200 cm was deemed suitable, it was recommended to tailor the BPL length to prevent protein energy malnutrition. It was also agreed to routinely administer ursodeoxycholic acid and proton-pump inhibitors for 6 months post-operatively. This modified Delphi consensus represents a critical step forward in addressing the controversies surrounding OAGB. It also emphasizes on the importance of individualized patient care and the need for ongoing research to refine surgical practices and improve outcomes., Competing Interests: Declarations. Competing Interest: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Hiatal hernia (HH) is a common condition. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of HH., Methods: Systematic reviews were conducted for four key questions regarding the treatment of HH in adults: surgical treatment of asymptomatic HH versus surveillance; use of mesh versus no mesh; performing a fundoplication versus no fundoplication; and Roux-en-Y gastric bypass (RYGB) versus redo fundoplication for recurrent HH. Evidence-based recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluations methodology by subject experts. When the evidence was insufficient to base recommendations on, expert opinion was utilized instead. Recommendations for future research were also proposed., Results: The panel provided one conditional recommendation and two expert opinions for adults with HH. The panel suggested routinely performing a fundoplication in the repair of HH, though this was based on low certainty evidence. There was insufficient evidence to make evidence-based recommendations regarding surgical repair of asymptomatic HH or conversion to RYGB in recurrent HH, and therefore, only expert opinions were offered. The panel suggested that select asymptomatic patients may be offered surgical repair, with criteria outlined. Similarly, it suggested that conversion to RYGB for management of recurrent HH may be appropriate in certain patients and again described criteria. The evidence for the routine use of mesh in HH repair was equivocal and the panel deferred making a recommendation., Conclusions: These recommendations should provide guidance regarding surgical decision-making in the treatment of HH and highlight the importance of shared decision-making and consideration of patient values to optimize outcomes. Pursuing the identified research needs will improve the evidence base and may allow for stronger recommendations in future evidence-based guidelines for the treatment of HH., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Robotic Roux-en-Y gastric bypass (RRYGB) is an innovative alternative to traditional laparoscopic approaches. Literature has been published investigating its safety/efficacy; however, the quality of reporting is uncertain. This systematic review used the Idea, Development, Exploration, Assessment and Long-term follow-up (IDEAL) framework to assess the reporting quality of available literature. A narrative summary was formulated, assessing how comprehensively governance/ethics, patient selection, demographics, surgeon expertise/training, technique description and outcomes were reported. Forty-seven studies published between 2005 and 2024 were included. There was incomplete/inconsistent reporting of governance/ethics, patient selection, surgeon expertise/training and technique description, with heterogenous outcome reporting. RRYGB reporting was poor and did not align with IDEAL guidance. Robust prospective studies reporting findings using IDEAL/other guidance are required to facilitate safe widespread adoption of RRYGB and other surgical innovations., (© 2024. The Author(s).)

Roux-en-Y gastric bypass has been considered the gold standard bariatric procedure for decades. The surgical technique for Roux-en-Y gastric bypass and perioperative management for patients who undergo the procedure are still being improved for better clinical outcomes, shorter hospitalization, and faster return to normal activity. In the past 15 years there have been similar improvements and further development of novel surgical weight loss procedures. As data on other surgical alternatives emerge, the data need to be compared with Roux-en-Y gastric bypass to determine noninferiority. Further long-term investigations are needed to determine superiority of one bariatric procedure over another., Competing Interests: Disclosure None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Previous studies have reported that roux-en Y gastric bypass surgery (RYGBS) can benefit patients with type 2 diabetes mellitus (T2DM). However, their conclusions are still inconsistent. Thus, this study will aim to assess the effect of RYGBS for patients with T2DM., Methods: In this study, the electronic databases of MEDLINE, EMBASE, CENTRAL, CINAHL, AMED, and CNKI from inceptions to the present without any limitations to language and publication status. All randomized controlled trials on assessing the effect of RYGBS for patients with T2DM will be included in this study. Two independent authors will carry out study search and selection according to the previous designed inclusion and exclusion criteria. At the same time, 2 authors will independently evaluate the risk of bias assessment by Cochrane risk of bias tool. Any disagreements between 2 authors will be solved by a third author through discussion. RevMan 5.3 software will be utilized for statistical analysis., Results: This study will summarize the most recent studies and will provide a deeper understanding about using the effect of RYGBS for patients with T2DM., Conclusions: The findings of this study will present the existing evidence for the effect of RYGBS for patients with T2DM., Systematic Review Registration: INPLASY202040127.

Background: The most commonly performed bariatric procedures are laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (LSG). Impact of learning curves on operative outcome has been well shown, but the necessary learning curves have not been clearly defined. This study provides a systematic review of the literature and proposes a standardization of phases of learning curves for RYGB and LSG., Methods: A systematic literature search was performed using PubMed, Web of Science, and CENTRAL databases. All studies specifying a number or range of approaches to characterize the learning curve for RYGB and LSG were selected., Results: A total of 28 publications related to learning curves for 27,770 performed bariatric surgeries were included. Parameters used to determine the learning curve were operative time, complications, conversions, length of stay, and blood loss. Learning curve range was 30-500 (RYGB) and 30-200 operations (LSG) according to different definitions and respective phases of learning curves. Learning phases described the number of procedures necessary to achieve predefined skill levels, such as competency, proficiency, and mastery., Conclusions: Definitions of learning curves for bariatric surgery are heterogeneous. Introduction of the three skill phases competency, proficiency, and mastery is proposed to provide a standardized definition using multiple outcome variables to enable better comparison in the future. These levels are reached after 30-70, 70-150, and up to 500 RYGB, and after 30-50, 60-100, and 100-200 LSG. Training curricula, previous laparoscopic experience, and high procedure volume are hallmarks for successful outcomes during the learning curve.

Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) can be considered as either a primary procedure or second stage procedure. Malnutrition is rare but could lead to a reversal of the SADI-S. The aim of this manuscript is to present the management and technique of weight regain after proximalization of a SADI-S by converting it to a gastric bypass.

Background: The safety and efficacy of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) to treat obesity and associated comorbidities, including diabetes mellitus, is well established. As diabetes may add risk to the perioperative period, we sought to characterize perioperative outcomes of these surgical procedures in diabetic patients., Methods: Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, we identified patients who underwent LSG and LRYGB between 2015 and 2017, grouping by non-diabetics (NDM), non-insulin-dependent diabetics (NIDDM), and insulin-dependent diabetics (IDDM). Primary outcomes included serious adverse events, 30-day readmission, 30-day reoperation, and 30-day mortality. Univariate and multivariable analyses were used to evaluate the outcome in each diabetic cohort., Results: Multivariable analysis of patients who underwent LSG (with NDM patients as reference) showed higher 30-day mortality (NIDDM AOR = 1.52, p = 0.043; IDDM AOR = 1.91, p = 0.007) and risk of serious adverse events (NIDDM AOR = 1.15, p < 0.001; IDDM AOR = 1.58, p < 0.001) in the diabetic versus NDM groups. Multivariable analysis of patients who underwent LRYGB (with NDM patients as reference) showed higher risk of serious adverse events (NIDDM AOR = 1.09, p = 0.014; IDDM AOR = 1.43, p < 0.001) in the diabetic versus NDM groups., Conclusions: Diabetics who underwent LSG and LRYGB had higher rates of several perioperative complications compared with non-diabetics. IDDM had a stronger association with several perioperative complications compared with NIDDM. This increase in morbidity and mortality is modest and should be weighed against the real benefits of bariatric surgery in patient with obesity and diabetes mellitus.

Purpose: Bariatric procedures are technically complex and skill demanding. In order to standardize the procedures for research and training, a Delphi analysis was performed to reach consensus on the practice of the laparoscopic gastric bypass and sleeve gastrectomy in the Netherlands., Methods: After a pre-round identifying all possible steps from literature and expert opinion within our study group, questionnaires were send to 68 registered Dutch bariatric surgeons, with 73 steps for bypass surgery and 51 steps for sleeve gastrectomy. Statistical analysis was performed to identify steps with and without consensus. This process was repeated to reach consensus of all necessary steps., Results: Thirty-eight participants (56%) responded in the first round and 32 participants (47%) in the second round. After the first Delphi round, 19 steps for gastric bypass (26%) and 14 for sleeve gastrectomy (27%) gained full consensus. After the second round, an additional amount of 10 and 12 sub-steps was confirmed as key steps, respectively. Thirteen steps in the gastric bypass and seven in the gastric sleeve were deemed advisable. Our expert panel showed a high level of consensus expressed in a Cronbach's alpha of 0.82 for the gastric bypass and 0.87 for the sleeve gastrectomy., Conclusions: The Delphi consensus defined 29 steps for gastric bypass and 26 for sleeve gastrectomy as being crucial for correct performance of these procedures to the standards of our expert panel. These results offer a clear framework for the technical execution of these procedures.

Background: According to recent American Society for Metabolic and Bariatric Surgery estimates, sleeve gastrectomy (SG) is now the most commonly performed procedure in the United States (~53.8% of all bariatric procedures), followed by Roux-en-Y gastric bypass (RYGB; 23.1% of all procedures)., Objectives: The objective of this study was to evaluate outcomes and safety of these 2 procedures in the first 30 days postoperatively using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry., Setting: University health network, United States., Methods: We reviewed all SG and RYGB cases entered between January 1 and December 31, 2015 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry. Demographic characteristics and 30-day outcomes were analyzed based on separate Mann-Whitney rank sums tests, χ 2 , or Fisher's exact tests as appropriate, with P<.05 denoting statistical significance and no adjustment for multiple testing., Results: A total of 141,646 patients were analyzed; 98,292 underwent SG and 43,354 underwent RYGB. Average age was 44.5 and 45.4 years for SG and RYGB, respectively. Preoperative body mass index was 45.1 and 46.1 for SG and RYGB, respectively. The 30-day mortality was .1% for SG and .2% for RYGB (P<.05). The incidence of unplanned intensive care unit admission after RYGB was twice as high compared with SG (1.3% versus .6%, respectively, P<.05). The incidence of at least 1 intervention or reoperation after RYGB was significantly higher compared with SG (2.8% and 2.5% for GB versus 1.2% and 1% for SG, P<.05). After RYGB, .4% of patients had a drain left in place at 30 days postoperatively versus .3% for SG (P<.05). The incidence of readmission was 2.8% for RYGB and 1.2% for SG (P<.05)., Conclusions: The incidence of postoperative complications in the first 30 days after surgery is low for both RYGB and SG. However, SG seems to have a better safety profile in the first 30 days postoperatively compared with RYGB. These findings should be considered in the preoperative evaluation and counseling of bariatric patients. Long-term follow-up is needed to compare safety and efficacy of SG versus RYGB., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The preferred surgical procedure for treating morbid obesity is debated. Patient-reported outcome measures (PROMs) are relevant for evaluation of the optimal bariatric procedure., Methods: A total of 113 patients with BMI from 50 to 60 were randomly assigned to standard (n = 57) or distal (n = 56) Roux-en-Y gastric bypass (RYGB). Validated PROMS questionnaires were completed at baseline and 2 years after surgery. Data were analyzed using mixed models for repeated measures and the results are expressed as estimated means and mean changes., Results: Obesity-related quality of life improved significantly after both procedures, without significant between-group differences (- 0.4 (95% CI = - 8.4, 7.2) points, p = 0.88, ES = 0.06). Both groups had significant reductions in the number of weight-related symptoms and symptom distress score, with a mean group difference (95% CI) of 1.4 (- 0.3, 3.3) symptoms and 5.0 (2.9. 12.8) symptom distress score points. There were no between-group differences for uncontrolled eating (22.0 (17.2-26.7) vs. 28.9 (23.3-34.5) points), cognitive restraint (57.4 (52.0-62.7) vs. 62.1 (57.9-66.2) points), and emotional eating (26.8 (20.5-33.1) vs. 32.6 (25.5-39.7) points). The prevalence of anxiety was 33% after standard and 25% after distal RYGB (p = 0.53), and for depression 12 and 9%, respectively (p = 0.76)., Conclusions: There were no statistically significant differences between standard and distal RYGB 2 years post surgery regarding weight loss, obesity-related quality of life, weight-related symptoms, anxiety, depression, or eating behavior., Trial Registration: Clinical Trials.gov number NCT00821197.

Background: An increasing number of surgeons worldwide are now performing one anastomosis/mini gastric bypass (OAGB/MGB). Lack of a published consensus amongst experts may be hindering progress and affecting outcomes. This paper reports results from the first modified Delphi consensus building exercise on this procedure., Methods: A committee of 16 recognised opinion-makers in bariatric surgery with special interest in OAGB/MGB was constituted. The committee invited 101 OAGB/MGB experts from 39 countries to vote on 55 statements in areas of controversy or variation associated with this procedure. An agreement amongst ≥ 70.0% of the experts was considered to indicate a consensus., Results: A consensus was achieved for 48 of the 55 proposed statements after two rounds of voting. There was no consensus for seven statements. Remarkably, 100.0% of the experts felt that OAGB/MGB was an "acceptable mainstream surgical option" and 96.0% felt that it could no longer be regarded as a new or experimental procedure. Approximately 96.0 and 91.0% of the experts felt that OAGB/MGB did not increase the risk of gastric and oesophageal cancers, respectively. Approximately 94.0% of the experts felt that the construction of the gastric pouch should start in the horizontal portion of the lesser curvature. There was a consensus of 82, 84, and 85% for routinely supplementing iron, vitamin B 12 , and vitamin D, respectively., Conclusion: OAGB/MGB experts achieved consensus on a number of aspects concerning this procedure but several areas of disagreements persist emphasising the need for more studies in the future.

Background: The previous popularity of adjustable gastric banding (AGB), along with inconsistent long-term results, has resulted in the need for conversion to other procedures. The perioperative safety of laparoscopic sleeve gastrectomy (SG) and gastric bypass (RYGB) as single-stage conversion procedures is unclear., Objectives: To compare the early safety of SG and RYGB when performed as single-stage conversion procedures at the time of AGB removal., Setting: Nationwide analysis of accredited centers., Methods: The Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program public use file for 2015 was queried for all patients who underwent single-stage conversion to SG or RYGB. Multivariable logistic regression was performed to control for baseline differences, and odds ratios (ORs) with 95% confidence intervals are reported., Results: There were 4865 patients who underwent a single-stage AGB conversion. SG was performed in 3364 (69.1%). The 30-day reoperation (1.6% versus 2.7%, P = .008), readmission (4% versus 5.7%, P = .006), reintervention (1.7% versus 2.7%, P = .024), and overall morbidity (2.9% versus 6.5%, P<.0001) were significantly less common in the SG group. After controlling for baseline characteristics, RYGB was independently associated with higher overall 30-day reoperation (OR 1.81, 1.19-2.75), readmission (OR 1.42, 1.07-1.88), reintervention (OR 1.59, 1.06-2.4), and overall morbidity (OR 2.17, 1.62-2.9)., Conclusions: AGB conversions are associated with low overall 30-day event rates. Patients undergoing RYGB as a single-stage conversion experience higher complication rates and the need for additional early procedures compared with SG., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Gastric bypass versus sleeve, pros and cons  The most commonly performed bariatric procedure today is gastric bypass, while sleeve gastrectomy has become more common in recent years. Little is known about the long-term effects of sleeve gastrectomy and despite several randomized trials it is still unknown which procedure is the most favourable. Two recently published randomized trials show that the two procedures result in comparable weight loss in the short term while gastric bypass could possibly result in better weight loss in the long term. However, gastric bypass tends to lead to a higher incidence of post-operative complications compared to sleeve gastrectomy.

Purpose: We aimed to evaluate the safety and effectiveness of fluoroscopy-guided gastroduodenal metallic stent placement with different approaches in malignant obstruction., Methods: We retrospectively assessed 53 patients (33 men and 20 women; mean age, 58.7±15 years) who underwent stent placement between February 2004 and April 2014. All patients had unresectable tumors. The most common causes of obstruction were gastric (38%) and pancreatic cancers (36%). Uncovered self-expandable metallic stents (SEMS) were placed under fluoroscopic guidance. In addition to transoral approach in 46 patients (86.7%), transgastric and transhepatic approaches were used in six patients (11.3%) and one patient (1.8%), respectively. Gastric outlet obstruction scoring system (GOOSS) was used to evaluate oral intake before and after stenting. Patients were followed until death or the end of the study., Results: Technical and clinical success rates were 100% and 92%, respectively. The median stent patency was 76 days (range, 4-985 days). Mean preprocedural GOOSS score of 0.1 increased to postprocedural GOOSS score of 2.42 (P < 0.001). Afferent loop decompression was achieved in one symptomatic patient. Neither mortality nor major complications occurred due to stenting. Stent migration occurred in one patient (2%) and stent obstruction occurred in two patients (4%). Combined biliary and duodenal stenting were performed in 21 patients (40%). Post-stenting GOOSS scores were predictive of survival (P = 0.003)., Conclusion: Fluoroscopic metallic stent placement for palliation of malignant gastroduodenal obstruction is safe and effective with high technical and clinical success rates and minimal complications. High technical success rates can be achieved using different approaches.

Background: The purpose of this study is to compare sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGBP) performed in Institutions participating in IFSO-European Chapter, Center of Excellence (COE) program., Methods: Since the initiation of the program in January 2010, 6413 SGs and 10,622 RYGBPs performed as primary procedures by December 31, 2014, with at least 12-month follow-up, were retrospectively compared., Results: There were steadily increasing numbers of patients underwent SG from 2010 to 2015. Early (<30 days) postoperative complication rate of 3.02 % for RYGBP was significantly higher than 2.12 % seen after SG (p = 0.0006). Only two patients, one in each group, died in the first 30 postoperative days (0.016 % mortality for SG vs 0.009 % for RYGBP-NS). From SG group, 103 patients, 1.61 %, and 206 patients, 1.94 %, from RYGBP group required readmission following hospital discharge in the first 30 days following bariatric surgery-NS. From the readmitted patients in the SG group, 75.72 % were reoperated vs 50.50 % in the RYGBP group (p < 0.0001). SG patients were heavier (BMI 44.93 vs 43.96 kg/m 2 , p < 0.0001). However, significantly better % excess weight loss were seen following RYGBP in all postoperative years (60.36 vs 67.72 %, p = 0.002 at fifth year). Better remission rates were seen for diabetes, arterial hypertension, dyslipidemia, and sleep apnea syndrome after RYGBP in the first postoperative year., Conclusions: Both procedures were performed with very low complications, mortality, readmissions, and reoperations rate. Better weight loss was observed following RYGBP, the first five postoperative years.

Background: The quality of narrative operative notes is poor. No investigation has previously addressed operative reporting specifically in bariatric surgery., Objectives: To evaluate surgeons' perceptions of the quality of operative reporting in bariatric surgery and compare this to an audit of Roux-en-Y gastric bypass (RYGB) narrative reports using validated quality indicators., Setting: University hospital, Canada., Methods: A Web-based survey was distributed to bariatric surgeons across Canada. Perceptions regarding the quality of reporting were gathered using a Likert scale (modified Structured Assessment Format for Evaluating Operative Reports) and free text fields. Forty RYGB narrative reports were analyzed against established quality indicators and compared to respondent's perceptions based on themes., Results: Twenty-four of 34 bariatric surgeons (71%) completed the survey. The most commonly performed procedures were RYGB and sleeve gastrectomy (96% and 100%, respectively). Currently, 70.8% perform a traditional narrative report. The average Structured Assessment Format for Evaluating Operative Reports score for narrative dictations by bariatric surgeons was neutral (27.9/40). The lowest scoring items were the "description of indications" (2.9/5) and "succinctness" (3.3/5). Opinions reflected a need for an immediately generated, standardized, template-based report to improve the quality and accessibility of operative documentation. The quality audit reinforced respondents' perceptions. Reports included only 62.0%±6.6% of quality indicators, with the lowest scoring areas being "patient details," "preoperative events," and "postoperative details" (41.1%, 32.4%, and 31.7%, respectively)., Conclusion: This survey revealed a perception of mediocre quality of narrative dictations. This was reinforced by an audit of RYGB operative reports. Future investigations should focus on improving this form of operative communication., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Synoptic operative reporting is a solution to the poor quality of narrative reports., Objective: To develop operative report quality indicators (QI) for laparoscopic Roux-en-Y gastric bypass (LRYGB) to generate validated parameters by which these reports can be evaluated and improved., Setting: University hospital in Canada., Methods: A Delphi protocol was used to determine QIs for LRYGB reporting. Bariatric surgeons across Canada were recruited along with key physician stakeholders to participate via a secure web-based platform. Participants initially submitted potential QIs. These were grouped by theme. Items were rated on 9-point Likert scales in subsequent rounds. Scores of 70% or greater were used for inclusion consensus, and 30% or less denoted exclusion. Elements scoring 30% to 70% were recirculated by runoff in subsequent rounds to generate the final list of QIs., Results: Four community and 4 academic bariatric surgeons were invited, representing all provinces performing LRYGB. The 4 multidisciplinary invitees included 1 minimally invasive/acute care surgeon, 1 tertiary abdominal radiologist, 1 gastroenterologist performing advanced endoscopy, and 1 general surgeon with expertise in synoptic reporting. Round 1 achieved an 83.3% (10/12) response and identified 91 potential items for consideration. Round 2 had a 100% response, and 69 items reached inclusion consensus. The third round achieved a 100% response and resulted in 75 QIs reaching final inclusion consensus., Conclusion: This study established consensus-derived multidisciplinary QIs for LRYGB operative reports. This will allow further assessment of the quality of narrative reports and afford the development of a synoptic operative report that may ameliorate identified deficiencies., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Percentile charts would be ideal for assessing sufficient weight loss in bariatric surgery. They allow comparing individual results to the outcome of many others, at any postoperative time. Unfortunately, percentile charts can be problematic when comparing unequally heavy peers, a circumstance not uncommon among bariatric patients. We investigate the relevance of this disadvantage and combine new insights to improve the practical use of percentile charts in bariatric surgery., Methods: Laparoscopic Roux-en-Y gastric bypass outcome expressed with body mass index (BMI), excess weight loss (%EWL), total weight loss (%TWL), and alterable weight loss (%AWL), a new metric rendering outcome independent of baseline BMI, is used to build percentile curves p97/p90/p75/p50/p25/p10/p03 with the lambda-mu-sigma method. We used the %AWL p25 curve as baseline BMI-independent reference for sufficient weight loss and compared it to p25 curves based on common metrics and to traditional criteria ≥50 % EWL, <25 % EWL, and BMI < 35 kg/m 2 ., Results: We operated 2880 patients, with baseline BMI of 43.4 kg/m 2 , follow-up 71 %, and mean of 23.3 (0-87.6) months. Independent %AWL outcome is presented in one percentile chart. Percentile curves p25/p50/p75 show 40/48/57 % AWL at nadir 15/16/19 months, 35/45/54 % AWL at 3 years, and 30/38/47 % AWL at 7 years. Traditional criteria and p25 curves based on %EWL and BMI match with most sufficient results (high sensitivities), but overlook many insufficient results (low specificities)., Conclusions: We present the first baseline BMI-independent bariatric weight loss percentile chart. It allows comparing heavier patients to lighter peers and vice versa, at any postoperative time, up to 7 years. With these advantages, we compared it to traditional bariatric criteria like ≥50 % EWL and found that they are weak in recognizing insufficient weight loss. The visual aspect of consecutive results plotted on a chart among the percentile curves of peers conveys a strong, intuitive message on the personal progress of postoperative weight loss.

Background: Bariatric surgery is associated with improved co-morbidities, quality of life, and survival in severely obese patients. Common bariatric surgery procedures include Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric band (LAGB), and sleeve gastrectomy (SG). Currently, literature studying comparative effectiveness on different bariatric surgery procedures in veterans is limited., Objectives: To compare effectiveness of 3 bariatric surgery procedures performed in veterans., Setting: Veterans Affairs Loma Linda Healthcare Systems (VALLHS), Loma Linda, California, United States., Methods: This study was a single-institution, retrospective cohort study. Primary outcome was weight reduction, expressed as kilograms lost, body mass index (BMI) reduction, percentage weight loss (%WL), and percentage excess weight loss (%EWL) after 12 months of bariatric surgery. Secondary outcomes were reduction in number of medications and laboratory markers for obesity-related chronic conditions. Inverse-probability weighting propensity score method was used to balance baseline characteristics among the procedures., Results: A total of 162 patients were included in the study. At 12 months, the kilograms lost, BMI reduction, %WL, and %EWL were 40.7±14.5 kg, 13.4±4.1 kg/m(2), 31.5±8.5%, and 41.4±11.6% for RYGB; 24.4±22.1 kg, 7.9±7.3 kg/m(2), 20.2±21.5%, and 26.7±27.6% for SG; and 15.3±15.7 kg, 5.0±5.0 kg/m(2), 12.0±11.7%, and 16.1±15.9% for LAGB, respectively (RYGB versus SG, RYGB versus LAGB, and SG versus LAGB, all P<.01). The reduction in number of medications, total cholesterol, and low-density lipoprotein (LDL) also showed significant improvement with RYGB., Conclusion: For the short term, RYGB appears to achieve better weight reduction and management of obesity-associated co-morbid conditions compared with the SG and LAGB procedures in veteran patients. SG could be the next alternative over LAGB for the bariatric surgery procedure in patients who are not candidates for RYGB., (Copyright © 2016 American Society for Bariatric Surgery. All rights reserved.)

Background: Gastric bypass surgery is the recommended treatment for severely obese patients. However, postoperative symptomatic gastrointestinal (GI) episodes are common complaints., Objectives: To determine if administration of probiotics improves symptomatic GI episodes after gastric bypass surgery., Setting: Hospital-based bariatric center., Methods: This double-blind, randomized trial was conducted between March 2010 and September 2010 with 60 patients who underwent gastric bypass for severe obesity and experienced postoperative symptomatic GI episodes. Patients were randomly assigned to the probiotics group A (n = 20; 1 g Clostridium butyricum MIYAIRI twice daily); probiotics group B (n = 20; Bifidobacterium longum BB536 twice daily); or digestive enzymes group (n = 20; Aczym, containing 100 mg takadiastase N, 20 mg cellulase AP, 50 mg lipase MY, and 100 mg pancreatin, twice daily). Quality of life was measured using the modified Gastrointestinal Quality of Life Index (mGIQLI) before and after the 2-week intervention., Results: Preintervention patient characteristics and mGIQLI scores were similar among the 3 groups. After the 2-week intervention, the mean mGIQLI score improved from 57.4 to 63.9 points in the entire sample and also within each group for 7 items specifically for 7: excessive passage of gas, foul smell of flatulence, belching, heartburn, abdominal noises, abdominal bloating, and abdominal pain., Conclusions: Administration of probiotics or digestive enzymes may improve symptomatic GI episodes after gastric bypass surgeries and improve quality of life, at least initially., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Most population-based studies lack long-term data, making the reporting of true mortality and outcome rates difficult. An accurate estimate of these rates in a high-risk population is critical for obtaining informed consent, especially for an elective procedure such as Roux-en-Y gastric bypass (RYGB)., Objectives: To examine the longitudinal outcomes of RYGB., Setting: The California Office of Statewide Health Planning and Development (OSHPD) longitudinal database., Methods: The OSHPD longitudinal database was queried for patients who underwent RYGB between 1995 and 2009. The primary outcome was mortality rates at 1, 5, and 10 years. Secondary outcomes were marginal ulcer and reoperation. The Cox hazard proportional analysis was used to determine adjusted survival and long-term outcomes for laparoscopic RYGB compared with open RYGB., Results: The study included 129,432 RYGB patients. Rates of laparoscopy increased from 3% to 35% from 1995 to 2004 and then steeply increased to 80% in 2005 and to 93% in 2009. Overall mortality rate at 1, 5, and 10 years was 2.2%, 4.4%, and 8.1%, respectively; the rates of marginal ulcer were .3%, .7%, and 1%, respectively; and the reoperation rates were .3%, .8%, and 1.2%, respectively. Predictors of poor outcomes were male gender, age, smoking, alcohol, Medicare, Medi-Cal insurance, and Asian or Native American race. The laparoscopic approach was protective against death (hazard ratio [HR] 95% confidence interval [95%CI]: .63[.58-.69]) and long-term complications (HR .78[.72-.85])., Conclusions: This longitudinal population study showed high rates of mortality following RYGB, with improved long-term outcomes when the laparoscopic approach was used., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Multi-centre randomised controlled trials (RCTs) in surgery are challenging. It is particularly difficult to establish standards of surgery and ensure that interventions are delivered as intended. This study developed and tested methods for identifying the key components of surgical interventions and standardising interventions within RCTs. Qualitative case studies of surgical interventions were undertaken within the internal pilot phase of a surgical RCT for obesity (the By-Band study). Each case study involved video data capture and non-participant observation of gastric bypass surgery in the operating theatre and interviews with surgeons. Methods were developed to transcribe and synchronise data from video recordings with observational data to identify key intervention components, which were then explored in the interviews with surgeons., Results: Eight qualitative case studies were undertaken. A novel combination of video data capture, observation and interview data identified variations in intervention delivery between surgeons and centres. Although surgeons agreed that the most critical intervention component was the size and shape of the gastric pouch, there was no consensus regarding other aspects of the procedure. They conceded that evidence about the 'best way' to perform bypass was lacking and, combined with the pragmatic nature of the By-Band study, agreed that strict standardisation of bypass might not be required., Conclusions: This study has developed and tested methods for understanding how surgical interventions are designed and delivered delivered in RCTs. Applying these methods more widely may help identify key components of interventions to be delivered by surgeons in trials, enabling monitoring of key components and adherence to the protocol. These methods are now being tested in the context of other surgical RCTs., Trial Registration: Current Controlled Trials ISRCTN00786323 , 05/09/2011.

Background: Health care in the United States is expensive and quality is variable. The aim of this study was to investigate whether our integrated health system, composed of academic hospitals, a practice plan, and a managed care payer, could reliably implement an evidence-based program for gastric bypass surgery. A secondary aim was to evaluate the impact of the program on clinical outcomes., Study Design: A standardized program for delivery of clinical best-practice elements for patients undergoing initial open or laparoscopic Roux-en-Y gastric bypass was implemented in 2008. Best-practice elements were embedded into the workflow. The best-practice elements were refined after reviewing failures observed during the early implementation period. The study period was divided into 3 groups: group α = year preceding program implementation (control), group β = first year of implementation (unreliable), and group Ω = 2nd to 4th years of implementation (reliable). Outcomes data were collected for all patients who had undergone Roux-en-Y gastric bypass between May 2008 and April 2012 and were compared with a control group from the preceding year using multiple logistic regression analysis., Results: Two thousand and sixty-one patients were studied, with no significant demographic differences between study groups. Best-practice elements delivery was 40% in group β, but was >90% for group Ω (p < 0.001). Length of stay for group α was 3.5 days and improved to 2.2 days (p < 0.001) for group Ω. Complications and readmission rates improved considerably with reliable delivery of best-practice elements., Conclusions: Standardization of evidence-based care delivery for Roux-en-Y gastric bypass was feasible and reliable delivery of this pathway improved clinical outcomes., (Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Obesity is a risk factor for the development of diseases such as type 2 Diabetes Mellitus. Bariatric surgery with laparoscopic single anastomosis gastric bypass is an effective treatment for morbid obesity and diabetes type 2 complete remission, and it has been proven to generate an improvement in glycemic levels and glycosylated hemoglobin (HbA1c) keeping the weight loss for a long time., Material and Methods: In a period of time between June 2002 until May 2012, 2070 patients underwent surgery with LOAGB technique. Between January 2010 an May 2012, 415 patients were included in the European Accreditation Council for Excellence Centers for Bariatric Surgery (EAC-BS) database, from which 79 patients with a glycemic level disturbance in the preoperative blood sample where chosen. Of this group, 47 patients were pre-diabetic (fast plasma glucose ≥ 110 mg/dl ≤ 125 mg/dl) and glycosylated hemoglobin (HbA1c) levels between 5.7-6.4% and 32 were diabetic (fast plasma glucose ≥ 126 mg/dl) and glycosylated hemoglobin (HbA1c) levels ≥ 6.5%. We described the weight evolution, the excess body mass index lost percentage (%EBMIL) the glycemia and the glycosylated hemoglobin levels; and we reported regular laboratory controls during the first year after surgical intervention., Results: Both patient groups achieved their lowest mean weight loss 12 months after surgery, being average weight in the pre-diabetic group 62,41 ± 10,93 and 68,36 ± 11,16 in the diabetic group. Since 3 months after surgery, pre-diabetic patients achieve a mean BMI < 30, according to the Spanish Society for Obesity Study (SEEDO 2007) this amount is outside of the definition of obesity. Not being the case of the diabetic patients who don´t achieve this result until 6 months after surgery. The weight loss was excellent in both study groups, achieving an excess body mass index loss percentage (% EBMIL) greater than 65%, since the first three-month postoperative control. Glycemia levels descend in both groups, achieving the pre-diabetic group a mean glycemia level of < 110 mg/ dl in the second day after LOAGB surgery. Pre-diabetic patients maintain more stable glycemia with better controls, and very favorable outcomes 12 months after surgery. The diabetic patients achieve the mean glycemia level of < 110 mg/dl at the first month after surgery and maintained it 12 months after surgery which is the time of this study. The glycosylated hemoglobin levels descended in both groups, achieving levels of 4% three months after surgery in the prediabetic group and 4.8% at six months in the diabetic group., Conclusion: LOAGB proved to be an efficient bariatric technique for complete remission of pre-diabetes and diabetes mellitus type 2 and also with the excess weight loss resolution. We showed that the excess weight loss, the glycemia and glycosylated hemoglobin levels continue being normal after one year of follow up after surgery. The best results are obtained in pre-diabetic patients who underwent LOAGB, this group is integrated with people who are at high risk of suffering a deterioration of their obesity and a rapid advance of the diabetes and the associated comorbidities, that's why surgery has to be performed as soon as possible when the medical exam continues being favorable., (Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.)

Background: Since 1 January 2005, bariatric surgery has been monitored in Germany. All related data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University Magdeburg., Methods: Data collection regarding obesity and metabolic surgery was started in an online database in 2005. Follow-up data are collected once a year. Participation in the quality assurance study is voluntary., Results: Since 2005, 10,330 Roux-en-Y gastric bypass (RYGB) procedures have been performed in Germany. In total, 8,013 patients were female and 2,317 were male. Male patients suffered significantly more comorbidities than female patients. The men also had higher body mass indexes (BMIs) and ages than the women at the time of operation. Data on the gender-specific aspects of RYGB from the Nationwide Survey of Bariatric Surgery in Germany (GBSR) showed a significant difference in anastomotic insufficiency at the gastro-entero-anastomosis. The leakage rate was 2.37 % (55/2,317) in men and 1.68 % (135/8,013) in women. Additionally, specific complication and mortality rates were significantly higher in male than in female patients., Conclusions: Metabolic and obesity surgery is becoming increasingly popular in Germany. Data from the GBSR show significant differences in preoperative comorbidities and postoperative complication and mortality rates between male and female patients. There is a need for further evaluation of gender-specific aspects to optimize patient selection and reduce specific postoperative complications.

Background: Surgical error analysis is essential for investigating mechanisms of errors, events and adverse outcomes. Furthermore, it provides valuable information for formative feedback and quality control. The aim of the present study was to design and validate a technical error rating tool in laparoscopic surgery., Methods: The framework consisted of nine task groups and four error modes. Unedited videos of laparoscopic Roux-en-Y gastric bypass procedures were rated and analysed. The Objective Structured Assessment of Technical Skill (OSATS) global rating scale was used to assess technical skills. The incidence of errors and of injuries (events) were the main outcome measures, and were used to calculate the reliability, and construct and concurrent validity of the instrument., Results: Two observers analysed 25 procedures. Inter-rater reliability was high regarding total number of errors (intraclass correlation coefficient (ICC) 0·90) and events (ICC 0·85). The median (interquartile range) error rate was 35 (26-44) and the event rate 3 (2-3) per procedure. Error frequencies and OSATS scores correlated significantly in all operative steps (rs = -0·75 to -0·40, P = <0·001-0·046). Surgeons demonstrating high OSATS scores had lower median (i.q.r.) error rates than surgeons with low scores in three of four steps: measuring bowel (4 (2-7) versus 10 (9-11); P = 0·004), jejunojejunostomy formation (5 (2-6) versus 10 (9-11); P = 0·001) and pouch formation (4 (3-6) versus 9 (5-12); P = 0·004)., Conclusion: The proposed error rating tool allows an objective and reliable assessment of operative performance in laparoscopic gastric bypass procedures., (© 2013 British Journal of Surgery Society Ltd. Published by John Wiley & Sons Ltd.)

Background: There is no objective scale for assessment of operative skill in laparoscopic gastric bypass (LGBP). The objective of this study was to develop and demonstrate feasibility of use, validity, and reliability of a Bariatric Objective Structured Assessment of Technical Skill (BOSATS) scale., Study Design: The BOSATS scale was developed using a hierarchical task analysis (HTA), a Delphi questionnaire, and a panel of international experts in bariatric surgery. The feasibility of use, reliability, and validity of the developed scale were demonstrated by reviewing 52 prospectively collected video recordings of LGBP performed by novice and experienced surgeons., Results: A total of 214 discrete steps were identified in HTA. A total of 12 and 17 panel members completed the first and second round of the Delphi questionnaire, respectively. Consensus among the panel was achieved after the second round (Cronbach's alpha = 0.85). The BOSATS scale demonstrated high inter-rater (intraclass correlation coefficient [ICC] = 0.954; p < 0.001) and test-retest reliability (ICC = 0.99; p < 0.001). Significant differences between BOSATS scores of experienced and novice surgeon groups were noted for the creation of jejunojejunostomy (JJ), gastric pouch, linear stapled gastrojejunostomy (GJ), circular stapled GJ, and hand-sewn GJ. Moderate to high correlations between BOSATS scale and Objective Structured Assessment of Technical Skills Global Rating Scale (OSATS GRS) were seen for JJ (rho = 0.59; p = 0.001), gastric pouch (rho = 0.48; p = 0.0004), linear stapled GJ (rho = 0.70; p = 0.0001), and hand-sewn GJ (rho = 0.96; p < 0.0001)., Conclusions: The BOSATS scale is a feasible to use, reliable, and valid instrument for objective assessment of operative performance in LGBP. Implementation of this scale is expected to facilitate deliberate practice and provide a means for future certification in bariatric surgery., (Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Since January 1st 2005, the situation of bariatric surgery has been examined in Germany. All data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg., Methods: The voluntary data registration occurs in an internet online data bank. All primary bariatric procedures as well as re- and redo-procedures are documented. Follow-up data were collected once a year. Participation in the quality assurance study is obligatory for certificated centres., Results: Since 2005 13,879 bariatric procedures have been performed at 83 hospitals. The number of primary procedures has increased from 596 in 2005 to 11,835 in 2010. Revisional surgery has been performed in 1,438 patients since 2005. Sleeve gastrectomy (SG) is the major procedure with 1,564 operations in 2010. The mean BMI was 48.8 kg/m². The incidence of comorbidities was 84.8%., Conclusion: Bariatric surgery has become more accepted in Germany. Beside the Roux-en-Y gastric bypass, sleeve gastrectomy is the most frequently performed operation. BMI and incidence of comorbidities are still high in comparison with literature values. Due to the lack of evidence, more randomised studies are necessary to standardise operative techniques and evaluate patient selection criteria. Quality assurance studies support a detailed analysis of these parameters., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: With the advent of clinical fellowships in general surgery, there has been a continual debate over the effect on general surgical resident training. Will a fellowship interfere with a chief resident's experience or case volume? The aim of this study was to test the hypothesis that the presence of an advanced laparoscopic fellow in a tertiary care hospital and residency has had no deleterious effect on chief resident laparoscopic case volume., Methods: The operative case logs of graduating residents and fellows from 2001 to 2011 were reviewed, focusing on laparoscopic basic and complex cases and comparing between those 2 groups and comparing residents' case numbers with the national average published by the Accreditation Council for Graduate Medical Education., Results: Residents graduating from 2001 to 2011 (4-6 chief residents per year) performed an average of 989 ± 76.2 laparoscopic cases per graduating chief class, with each chief averaging 207.7 ± 10.7. The average number of laparoscopic basic cases per graduating chief year was 555.3 ± 42.1, with each chief averaging 116.2 ± 4.9. The average number of laparoscopic complex cases per graduating chief year was 434.4 ± 39.2, with each chief averaging 91.5 ± 7.2. Over the same period of time (1 or 2 fellows per year), fellows performed an average of 336 ± 23.3 cases per year. When comparing residents' total average cases with the national data, the residents performed a similar number of cases (209.9 ± 11.9 vs 195.0 ± 19.5, P = .53). When comparing years when there were 2 clinical fellows vs years with 1 fellow, there was no change in the total number of laparoscopic cases per chief (224.2 vs 195.6, P = .26) and no change in the number of complex laparoscopic cases (97.1 vs 88.7, P = .63). There was a significant difference for basic laparoscopic cases, with a slight decrease when there were 2 fellows (127.8 vs 106.9, P = .04)., Conclusions: A laparoscopic fellowship has not had an adverse impact on the complex or basic laparoscopic case experience of surgical residents. In a busy academic practice, laparoscopic fellowships and general surgical residency can coexist., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) requires specialized training commonly acquired during a fellowship. We hypothesized that fellows affect patient outcomes and this effect varies during training., Methods: We included all LRYGB from the 2005 to 2009 American College of Surgeons-National Surgical Quality Improvement Program database. Cases without trainees (attending) were compared to those with trainees of ≥6 years (fellow). Outcomes were pulmonary, infectious, and wound complications and deep venous thrombosis (DVT). Multivariable regression controlled for age, BMI, and comorbidities., Results: Of the 18,333 LRYGB performed, 4,349 (24%) were fellow cases. Fellow patients had a higher BMI (46.1 vs. 45.7, p < 0.001) and fewer comorbidities. Mortality was 0.2 and 0.1% and overall morbidity was 4.8 and 6.0% for attending and fellow groups, respectively. On adjusted analysis, mortality was similar, but fellow cases had 30% more morbidity (p = 0.001). Specifically, fellows increased the odds of superficial surgical site infections (SSSIs) [odds ratio (OR) = 1.4, p = 0.01], urinary infections (UTIs) (OR = 1.7, p = 0.002), and sepsis (OR = 1.5, p = 0.05). During the first 6 months, fellows increased the odds of DVT (OR = 4.7, p = 0.01), SSIs (OR = 1.5, p = 0.001), UTIs (OR = 1.8, p = 0.004), and sepsis (OR = 1.9, p = 0.008). By the second half of training, fellow cases demonstrated outcomes equivalent to attending cases., Conclusions: Involving fellows in LRYGB may increase DVT, SSIs, UTIs, and sepsis, especially early in training. By completion of their training, cases involving fellows exhibited outcomes similar to cases without trainees. This supports both the need for fellowship training in bariatric surgery and the success of training to optimize patient outcomes.

Background: As a result of increasing numbers of patients with morbid obesity there is a worldwide demand for bariatric surgeons. The Roux-en-Y gastric bypass, nowadays performed mostly laparoscopically (LRYGB), has been proven to be a highly effective surgical treatment for morbid obesity. This procedure is technically demanding and requires a long learning curve. Little is known about implementing these demanding techniques in the training of the surgical resident. The aim of this study was to evaluate the safety and feasibility of the introduction of LRYGB into the training of surgical residents., Methods: All patients who underwent LRYGB between March 2006 and July 2010 were retrospectively analyzed. The procedure was performed by a surgical resident under strict supervision of a bariatric surgeon (group I) or by a bariatric surgeon (group II). The primary end point was the occurrence of complications. Secondary end points included operative time, days of hospitalization, rate of readmission, and reappearance in the emergency department (ED) within 30 days., Results: A total of 409 patients were found eligible for inclusion in the study: 83 patients in group I and 326 in group II. There was a significant difference in operating time (129 min in group I vs. 116 min in group II; p < 0.001) and days of hospitalization. Postoperative complication rate, reappearance in the ED, and rate of readmission did not differ between the two groups., Conclusions: Our data suggest that under stringent supervision and with sufficient laparoscopic practice, implementation of LRYGB as part of surgical training is safe and results in only a slightly longer operating time. Complication rates, days of hospitalization, and the rates of readmission and reappearance in the ED within 30 days were similar between the both groups. These results should be interpreted by remembering that all procedures in group I were performed in a training environment so occasional intervention by a bariatric surgeon, when necessary, was inevitable.

Objective: The present meta-regression pools data from reports of long-term follow-up (>2 years) to assess durability of the efficacy associated with Roux-en-Y gastric bypass (RYGB) surgery., Data Sources: Medline and PubMed searches for articles pertaining to long-term weight loss after RYGB surgery were performed., Background: Various studies have consistently shown short-term (<2 years) efficacy of RYGB surgery for morbid obesity, corroborated by meta-analytic techniques. Relatively few studies have assessed efficacy over longer periods of time. This is the first meta-analysis to analyze long-term effects of RYGB surgery on weight loss., Methods: Twenty-two reports with a total of 4206 patient cases were included. Sixteen of the 22 studies had multiple follow-up times, ranging from 2 to 12.3 years (mean: 3.6 years). An inverse variance weighted model and meta-regression were used to generate the pooled percent mean excess weight loss (EWL) and the durability of EWL over time, respectively., Results: Meta-regression did not reveal any significant change in EWL over time. Pooled mean EWL was 66.5%, and there was no significant association between EWL and length of follow-up., Conclusions: Pooling data from multiple studies meta-analytically revealed that weight loss after RYGB is maintained over the long-term. Further investigation would be necessary to ascertain similar durability in comorbidity reduction after RYGB surgery.

Background: Ex vivo simulation-based technical skills training has been shown to improve operating room performance and shorten learning curves for basic laparoscopic procedures. The application of such training for laparoscopic Roux-en-Y gastric bypass (LRYGBP) has not been reviewed., Methods: Relevant studies were identified by one author from a search of MEDLINE and Embase databases from 1 January 1994 to 30 November 2010. Studies examining the learning curves and ex vivo training methods for LRYGBP were included; all other types of bariatric operations were excluded. A manual search of the references was also performed to identify additional potentially relevant papers., Results: Twelve studies (5 prospective and 7 retrospective case series) were selected for review. The learning curve for LRYGBP was reported to be 50-100 procedures. Bench-top laparoscopic jejunojejunostomy, anaesthetized animals and Thiel human cadavers made up the bulk of the reported models for ex vivo training. Most studies were of relatively poor quality. An evidence-based ex vivo training curriculum for LRYGBP is currently lacking., Conclusion: Better quality studies are needed to define the learning curve for LRYGBP. Future studies should focus on the design and validation of training models, and a comprehensive curriculum for training and assessment of cognitive, technical and non-technical components of competency for laparoscopic bariatric surgery., (Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Background: Robot-assisted Roux-en-Y gastric bypass (RYGBP) is rapidly evolving as an important surgical approach in the bariatric field. However, the specific learning curve associated with this new approach remains poorly investigated. This study aimed to evaluate the learning curve for robot-assisted RYGBP., Methods: A series of 64 consecutive robot-assisted RYGBP procedures were performed between December 2008 and December 2010 by a single surgeon already experienced in advanced laparoscopic procedures but not in bariatric surgery. All data were collected prospectively in a database and reviewed retrospectively. The learning curve was evaluated using the cumulative sum (CUSUM) method., Results: Women comprised 76.6% and men 23.4% of this series. These patients had a mean age of 43 years and a mean body mass index (BMI) of 44.5 kg/m(2). The mean operative time (OT) was 238.1 min (range, 150-400 min). A total of six complications occurred (9.4%). The CUSUM learning curve consisted of two distinct phases: phase 1 (the initial 14 cases; mean OT, 288.9 min) and phase 2 (the subsequent cases; mean OT, 223.6 min), which represented the mastery phase, with a decrease in OT (P = 0.0001). The two groups were similar in terms of gender, age, and BMI. The two phases did not differ in terms of complications or hospital stay., Conclusions: This series confirms previous study findings concerning the feasibility and the safety of robotic RYGBP even after a limited experience with laparoscopic RYGBP. The data reported in this article suggest that the learning phase for robot-assisted RYGBP can be achieved with 14 cases.

Background: Obesity surgery is the most effective treatment for morbid obesity and the fastest growing area in surgery. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the gold standard procedure in many countries. Optimization of the treatment process is important in order to keep the morbidity rate down and cost of treatment as low as possible., Methods: In September 2005, we established a bariatric surgery program. Until December 2010, 2,000 patients underwent LRYGB. Clinical pathways were established, with focus on safety, fast-track methodology and training of surgeons. Time recordings from all parts of the treatment, as well as clinical outcome, were prospectively registered., Results: Time consumption for the total procedure in the operating theater was reduced from 102 to 54 min (P < 0.001). With only 11 min turnover between patients, the total time for one patient has been reduced to 65 min, enabling us to perform six operations in a single operating theater during ordinary daytime. Early complication rate was 2.8%, and mean hospital stay was 2.3 days. We were able to double the patients treated in 2010 compared to 2007 with only 10% increase in staff. Three surgeons were trained during the period into fully qualified senior bariatric surgeons., Conclusions: Multimodal evidence-based care within the fast-track methodology and routine time recordings was successful in order to increase the production volumes and reduce costs, without compromising the safety or quality for the patients. This kind of approach may be transferred to other types of standardized surgery.

Objective: In a prospective observational cohort study, the biochemical profile of bariatrically managed diabetes was documented, aiming to assess its association with clinical outcome., Methods: The population (n = 82; age, 50.7 +/- 10.3 years; 92.7% women; followed up for 93 +/- 34 months) was stratified as responsive diabetes (Group I) (36.6%, 30 of 82) and controls without diabetes (Group II) (57.3%, 47 of 82). A few refractory subjects were identified in this cohort (Group III [refractory diabetes], 6.3%, five of 82). Nonbariatric overweight and obese diabetes subjects with similar follow-up (n = 21) were documented as well. Main outcome measures were diabetes regression, body mass índex (BMI), glucose, glycosylated hemoglobin A1c (HbA1c), serum lipids, and white blood cell count (WBC) count., Results: Preoperative BMI was somewhat discrepant among operated groups but leveled off from 2 years on. Baseline WBC count, total cholesterol, low-density lipoprotein-cholesterol, blood glucose, and HbA1c were higher in responsive subjects, but a downward shift occurred, without differences regarding controls, in the subsequent period. Conservatively managed diabetes displayed favorable changes of some lipid fractions, but not glucose, HbA1c, total cholesterol, or WBC count., Conclusions: Diabetes regression rate was 94.3% at 5 years and 84.7% at around 8 years. In responsive patients, both BMI and biochemical indices normalized in the first 2 years and followed a stable path thereafter. Nonoperative treatment was unable to reduce HbA1c, glucose, or WBC count, and HbA1c was a clear prognostic marker of persistent disease in surgical cases. Further studies emphasizing the metabolic and inflammatory signature of obesity-related diabetes are worthwhile.

Background: The stomach can either be divided or undivided in performing Roux-en-Y gastric bypass (RGB) for morbid obesity. We evaluated whether surgical technique is the sole contributing factor to the formation of gastrogastric fistula (GGF)., Methods: A retrospective analysis of 1,036 consecutive patients was evaluated. RGB was performed as open undivided, open divided, and laparoscopic (divided). Incidence of GGF was identified for each technique and its relationship to surgical experience was assessed., Results: Overall incidence of GGF was 1.3%. All fistulae occurred in patients who received undivided open RGB. There was a significant difference between the undivided open group and the divided open+laparoscopic groups (2.1% vs 0%, P<.01). Incidence of GGF decreased over time with increasing open undivided RGB volume., Conclusions: GGF was only identified in undivided RGB. The occurrence decreased with increasing surgical experience. Together, overall surgical technique in addition to gastric division must play a role in fistula formation., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Background: Bariatric surgery is expanding and the increasing workload needs to be undertaken safely in new surgical centres with no previous bariatric experience. The laparoscopic Roux-en-Y gastric bypass (LRYGB) has a steep learning curve with documented high risk. We present the results for the first 300 cases of LRYGB in a new centre., Methods: Three hundred consecutive patients underwent LRYGB performed by a single surgeon. Four external surgeons mentored eight cases in the first 50. Demographic characteristics, body mass index (BMI) and operative time were collected prospectively and the Obesity Surgery Mortality Risk Score was used for risk stratification., Results: The mean BMI of the patients increased during the series from 49.0 for the first group to 50.2 for the second group and to 51.0 for the third group (p < 0.05). The number of high-risk patients measured with the OS-MRS was 19/300 (6.3%) in the whole series. The mean operative time decreased from 163 min for the first 100 patients to 119 min for the second 100 and 94 for the third (p < 0.0001). In the first group, there were nine reoperations and two conversions to open surgery, compared to two reoperations and one conversion in the second group (p < 0.05). In the whole series, there were 12 early complications requiring re-operation, four conversions to open surgery and one mortality (patient 110, heart failure within 24 h)., Conclusions: A mentoring process ensures that LRYGB can be done safely in a newly established bariatric centre. The operative time reduces markedly after the learning curve.

Background: Payers and professional organizations are expanding accreditation and "centers of excellence" programs in bariatric surgery. Rather than directly measuring outcomes, most programs rely on procedure volume. We sought to determine whether risk-adjusted outcomes or hospital volume were better at predicting future hospital morbidity with bariatric surgery., Study Design: We identified all patients who underwent gastric bypass in the New York State Inpatient database (n = 32,381 patients, n = 105 hospitals). Morbidity was ascertained using a previously validated combination of diagnostic and procedure codes. We first calculated the risk-adjusted morbidity and volume at each hospital during a 2-year period (2003 to 2004). We then ascertained the proportion of hospital-level variation explained by each measure using hierarchical modeling techniques. Finally, we compared the ability of each measure to predict future performance, as assessed with risk-adjusted morbidity, in the next 2 years (2005 to 2006)., Results: Risk-adjusted morbidity explained 83% of future hospital-level variation in morbidity compared with only 21% for hospital volume. When comparing the "best" with the "worst" hospital quartiles, risk-adjusted morbidity predicted a more than fourfold difference in future performance (1.7% versus 7.2%; odds ratio [OR]: 4.5; 95% CI, 3.5 to 5.9). Hospital volume predicted only a twofold difference (2.5% versus 4.5%; OR: 1.9; 95% CI, 1.5 to 2.4) from the best to worst quartile., Conclusions: Risk-adjusted morbidity is much better than hospital volume at predicting future performance with bariatric surgery. Rather than focusing on volume, accreditation and centers of excellence programs should focus more on directly measuring outcomes.

Background: Various techniques of laparoscopic Roux-en-Y gastric bypass have been described. We completely standardized this procedure to minimize its sometimes substantial morbidity and mortality. This study describes our experience with the standardized fully stapled laparoscopic Roux-en-Y gastric bypass (FS-LRYGB) and its influence on the 30-day morbidity and mortality., Methods: We retrospectively analyzed 2,645 patients who underwent FS-LRYGB from May 2004 to August 2008. Operative time, hospital stay and readmission, re-operation, and 30-day morbidity/mortality rates were then calculated. The 30-day follow-up data were complete for 2,606 patients (98.5%)., Results: There were 539 male and 2,067 female patients. Mean age was 39.2 years (range 14-73), mean BMI 41.44 kg/m(2) (range, 23-75.5). The mean hospital stay was 3.35 days (range 2-71). Mean total operative time was 63 min (range 35-150). One patient died of pneumonia within 30 days of surgery (0.04%). One hundred and fifty one (5.8%) patients had postoperative complications as follows: gastrointestinal hemorrhage (n = 89, 3.42%), intestinal obstruction (n = 9, 0.35%), anastomotic leak (n = 5, 0.19%) and others (n = 47, 1.80%). In 66 patients, the bleeding resolved without any surgical re-intervention. One hemorrhage resulted in hypovolemic shock with subsequent renal and hepatic failure., Conclusion: The systematic approach and the full standardization of the FS-LRYGB procedure contribute highly to the very low mortality and the low morbidity rates in our institution. Gastrointestinal bleeding appears to be the commonest complication, but is self-limiting in the majority of cases. Our approach also significantly reduces operative time and turns the technically demanding laparoscopic Roux-en-Y gastric bypass procedure into an easy reproducible operation, effective for training.

Introduction: Super-morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) present unique technical challenges. In our experience the ease of the operation and the operative time seem to be more dependent on body habitus than body mass index (BMI). We hypothesized that the distance between the xyphoid process and the umbilicus (the XU distance) correlated with surgical difficulty and described an original modification of trocar placement based on this measurement to improve the ease of the operation., Methods: Seven hundred and seventy-four patients underwent LRYGB, and the XU distance was measured in a subset of 38 patients midway through the experience. The need for additional trocars was assessed intraoperatively and the relationship between the XU distance and the need for extra trocars was subsequently analyzed. A standardized approach for trocar placement was implemented in the second half of our series. The operative time was compared between the standardized and nonstandardized groups., Results: Fifty percent of the patients required a five-trocar technique. Median XU distance in this group was 21.4 cm (range 17-25 cm). In the remaining 19 patients additional trocars were added; median XU distance was 27.3 cm (range 24-33 cm). From the 774 patients included in the study period, the operative time for the first 322 patients who were completed with a nonstandardized trocar approach was significantly longer than the subsequent 452 cases in which the standardized trocar approach was used (210 versus 173 min, p < 0.001)., Conclusions: We define XU distance as the key element in determining the choice of trocar placement. When XU distance is less then 25 cm, the basic approach should be used and if it is greater than 25 cm, the advanced trocar approach is recommended. This standardized technique leads to decreased operative time and improved ease of operation.

Background: One strategy to reduce the consumption of resources associated to specific procedures is to utilize clinical pathways, in which surgical care is standardized and preset by determination of perioperative in-hospital processes. The aim of this prospective study was to establish the impact of clinical pathways on costs, complication rates, and nursing activities., Method: Data was prospectively collected for 171 consecutive patients undergoing laparoscopic cholecystectomy (n = 50), open herniorrhaphy (n = 56), and laparoscopic Roux-en-Y gastric bypass (n = 65)., Results: Clinical pathways reduced the postoperative hospital stay by 28% from a mean of 6.1 to 4.4 days (p < 0.001), while the 30-day readmission rate remained unchanged (0.5% vs. 0.45%). Total mean costs per case were reduced by 25% from euro 6,390 to euro 4,800 (p < 0.001). Costs for diagnostic tests were reduced by 33% (p < 0.001). Nursing hours decreased, reducing nursing costs by 24% from euro 1,810 to euro 1,374 (p < 0.001). A trend was noted for lower postoperative complication rates in the clinical pathway group (7% vs. 14%, p = 0.07)., Conclusions: This study demonstrates clinically and economically relevant benefits for the utilization of clinical pathways with a reduction in use of all resource types, without any negative impact on the rate of complications or re-hospitalization.

Background: The incidence of morbid obesity is increasing and gastric bypass is the most effective surgical treatment., Aim: To assess the long term results of resection gastric bypass among morbidly obese patients aged less than 18 and over 65 years in terms of weight loss and correction comorbidities., Material and Methods: From August 1999 to December 2006, 712 patients with morbid obesity were subjected to open resection gastric bypass. A group of 12 patients, aged less than 18 years and a second group of 8 patients aged more 65 years were selected to prospectively assess weight loss, complications and correction of associated comorbidities., Results: In the first group body mass index (BMI) decreased from 45+/-6.7 kg/m2 to 27.7+/-3.2 kg/m2, in a follow-up period of 22.9+/-8.4 months. All comorbidities disappeared or improved. A single patient (8.3%) had an incisional hernia. Among the second group, BMI decreased from 40.6+/-5.4 kg/m2 to 28.4+/-4.4 kg/m2, in a follow-up period of 26.6+/-15.9 months. All obesity comorbidities disappeared. Three patients (37.5%) presented incisional hernias. No patient died or had postoperative complications., Conclusions: In both groups resection gastric bypass was safe, obtained an appropriate weight loss and corrected all associated comorbidities to obesity.

Background: Since January 1st 2005, the situation of bariatric surgery in Germany has been examined. The data are registered in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke-University Magdeburg., Methods: The data registration took place prospectively in an internet online data base. All primary bariatric procedures performed since January 1st 2005 were detected as well as re-operations in patients who had been operated before., Results: 629 patients underwent bariatric surgery in 21 hospitals in 2005 and 828 patients were operated in 32 hospitals in 2006. The mostly performed operation was gastric banding with 46.8 %, followed by Roux-Y gastric bypass with 38.5 %. 74.4 % of the patients were female. The medium BMI of all patients was 48.5 kg/m2 in 2005 and 48.4 kg/m2 in 2006. Follow-up data were available for 71.2 % of the patients operated in 2005. These data show a higher reduction of BMI after malabsorptive than after restrictive bariatric procedures., Conclusion: A trend from restrictive bariatric procedures to a malabsorptive approach could be observed. In Germany the BMI of patients undergoing bariatric surgery is higher than in most countries world-wide. No differences could be detected in intraoperative and short-term complications as well in the complication rate in the first year of follow-up in comparison with the literature.

Background: To report the effect of the American Society of Bariatric Surgery or American College of Surgeons-designated Centers of Excellence designation in Michigan on our practice trends and patient populations. As of February 2006, weight loss surgery for Medicare beneficiaries are reimbursed when procedures are performed at American Society of Bariatric Surgery or American College of Surgeons-designated Centers of Excellence., Methods: Patients who underwent laparoscopic Roux-en-Y gastric bypass surgery by an individual surgeon from June 1 to October 31 in 2004, 2005, and 2006 were stratified according to use of private third-party insurance versus Medicare (MC) insurance. The demographic data, body mass index, numbers of medications and co-morbidities, operative time, lengths of stay, morbidity, and mortality were analyzed. Significance was assessed at P <.05., Results: From June 1 to October 31 in 2004, 2005, and 2006, 255 patients with MC or private third-party insurance underwent laparoscopic Roux-en-Y gastric bypass surgery, with the percentage of MC patients increasing from 15.3% and 10.2% in 2004 and 2005 to 30.9% in 2006. The MC patients were older (56.1 +/- 1.3 yr versus 44.1 +/- 0.7 yr; mean +/- standard error of mean), had more co-morbidities (5.1 +/- 0.2 versus 3.5 +/- 0.1), required more medications (10.3 +/- 0.6 versus 5.6 +/- 0.3), had undergone more previous operations (2.1 +/- 0.2 versus 1.3 +/- 0.1), and had longer operative times (148 +/- 11.1 versus 121 +/- 3.1 min) than the private third-party insurance patients; the differences were all significant. The differences in gender, body mass index, and length of stay were not significantly different., Conclusion: The Centers for Medicare and Medicaid Services requirements for Centers of Excellence designation resulted in a significant increase in the Medicare case load within our institution. This population tended to be older and more complex, with longer operative times. The changes present new challenges in patient care, including the coordination of care for the multiple co-morbidities of older obese patients with a multispecialty care team.