|Year : 2022 | Volume
| Issue : 1 | Page : 34-41
Thirty-day morbidity and mortality of bariatric and metabolic surgery in patients with type 2 diabetes mellitus: A subset analysis of the GENEVA cohort study
Rishi Singhal1, Victor Roth Cardoso2, Christian Ludwig3, Jonathan Super4, Yashasvi Rajeev5, Gavin Rudge6, Georgios V Gkoutos7, Kamal Mahawar8, GENEVA collaborators9
1 Department of General Surgery, Upper GI Unit, University Hospital Birmingham NHS Foundation Trust, West Midlands, United Kingdom
2 Institute of Cancer and Genomic Sciences, University of Birmingham, West Midlands; Health Data Research UK Midlands, Birmingham, United Kingdom
3 Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
4 Department of General Surgery, Maidstone and Tunbridge Wells NHS Trust, Royal Tunbridge Wells, Harrow, London, United Kingdom
5 Department of Surgery, London Northwest University Healthcare NHS Trust, Harrow, London, United Kingdom
6 Institute of Applied Health Research, Murray Learning Centre, University of Birmingham, Birmingham, United Kingdom
7 Institute of Cancer and Genomic Sciences, University of Birmingham, West Midlands; Health Data Research UK Midlands; NIHR Biomedical Research Centre; NIHR Surgical Reconstruction and Microbiology Research Centre, Birmingham, United Kingdom
8 Department of General Surgery, Bariatric Unit, South Tyneside and Sunderland NHS Trust, Sunderland, United Kingdom
|Date of Submission||23-Sep-2021|
|Date of Acceptance||16-Dec-2021|
|Date of Web Publication||09-Mar-2022|
Department of General Surgery, Upper GI Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham
Source of Support: None, Conflict of Interest: None
Introduction: There is a paucity of data in the scientific literature on the morbidity and mortality of bariatric and metabolic surgery (BMS) in individuals suffering from Type 2 diabetes mellitus (T2D). The current study is a secondary analysis of the GENEVA dataset to understand this. Materials and Methods: Logistic regressions were performed to investigate the influence of diabetes on complication rates and procedure selection. Ethical approval was not required. Results: One thousand four hundred and seventy-five of these patients were suffering from T2D at the time of the surgery (416 diet-treated type 2 diabetes), 806 oral agent-treated type 2 diabetes, and 253 insulin-treated type 2 diabetes [ITD]). Six hundred and fifty (44.1%) of these patients underwent laparoscopic sleeve gastrectomy (LSG); 487 (33%) underwent Roux-en-Y gastric bypass; 230 (15.6%) underwent a one anastomosis gastric bypass (OAGB); and 108 (7.3%) underwent some other procedures. The 30-day mortality of BMS in those without T2D was 0.07% (4/5609) as compared to 0.4% (6/1475) and 0.8% (2/253) in those with T2D and ITD, respectively. 7.9% of those with T2D developed a 30-day complication compared to 6.5% without T2D (P = 0.0475). There was an increased risk of complications in patients with ITD on univariate and multivariate analysis. Patients with T2D were significantly less likely to undergo an LSG and significantly more likely to undergo an OAGB. Conclusions: ITD patients undergoing BMS experienced significantly higher 30-day morbidity and mortality. Although LSG was the most common procedure in patients with T2D, these patients were less likely to undergo LSG than patients without T2D.
Keywords: Bariatric surgery, coronavirus disease-2019, diabetes surgery, gastric banding, gastric bypass, metabolic surgery, obesity surgery, obesity, pandemic, sleeve gastrectomy, type 2 diabetes mellitus
|How to cite this article:|
Singhal R, Cardoso VR, Ludwig C, Super J, Rajeev Y, Rudge G, Gkoutos GV, Mahawar K, GENEVA collaborators. Thirty-day morbidity and mortality of bariatric and metabolic surgery in patients with type 2 diabetes mellitus: A subset analysis of the GENEVA cohort study. J Bariatr Surg 2022;1:34-41
|How to cite this URL:|
Singhal R, Cardoso VR, Ludwig C, Super J, Rajeev Y, Rudge G, Gkoutos GV, Mahawar K, GENEVA collaborators. Thirty-day morbidity and mortality of bariatric and metabolic surgery in patients with type 2 diabetes mellitus: A subset analysis of the GENEVA cohort study. J Bariatr Surg [serial online] 2022 [cited 2022 Sep 24];1:34-41. Available from: http://www.jbsonline.org/text.asp?2022/1/1/34/339260
| Introduction|| |
Bariatric and metabolic surgery (BMS) for patients suffering from type 2 diabetes mellitus (T2D) and obesity is now supported by many guidelines., This is on the back of high-quality data showing superior efficacy of BMS compared to medical management in the treatment of T2D. However, most of these studies are powered to evaluate the efficacy and there is no randomized controlled trial (RCT) in the scientific literature comparing treatment-related or all-cause morbidity and mortality as the primary endpoints. This makes it difficult for patients and health-care practitioners to make a truly informed choice.
Similarly, though there are many large datasets, that allow us to understand the 30 day morbidity and mortality of BMS in general, there is none that focus on patients with T2D. Studies focussing on patients with T2D tend to examine mortality benefits over prolonged periods,, and do not focus on 30-day morbidity and mortality, a widely recognized outcome measure for examining surgical safety. To the best of our knowledge, there is only one study in the literature that reports on 30-day morbidity and mortality of patients with T2D undergoing either a laparoscopic sleeve gastrectomy (LSG) or Roux-en-Y gastric bypass (RYGB). This analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database in the United States does not include other increasingly popular procedures such as one anastomosis gastric bypass (OAGB), also includes revisional procedures, and is by definition national data.
Patients with T2D and obesity form an especially interesting subset of those undergoing BMS as both their clinical conditions can be expected to improve significantly after surgery. Potentially, therefore, this group stands more to gain from BMS. At the same time, patients with T2D can also be at a higher risk of 30-day morbidity and mortality, when undergoing any surgical procedure. Whether or not this is also true of patients undergoing primary BMS needs to be determined to allow patients and health-care providers to be able to engage in a truly informed discussion.
The GENEVA multinational cohort showed that 30-day morbidity and mortality of BMS during the coronavirus disease-2019 (COVID-19) pandemic were similar to the prepandemic data. The current study is a secondary analysis of the GENEVA data focussing on patients with T2D. This analysis aimed to understand the 30-day morbidity and mortality of primary BMS in patients with T2D and its various subgroups – such as diet-treated type 2 diabetes (DTD), oral agent-treated type 2 diabetes (OATD), and insulin-treated type 2 diabetes (ITD). A secondary aim was to analyze the effect of diabetes and other clinical parameters on the choice of surgical procedure.
| Materials and Methods|| |
Study design and population
We conducted a global, multicentre, observational cohort study of BMS (elective primary, elective revisional, and emergency) in adults (≥18 years) performed between May 1, 2020, and October 31, 2020. The participating centers and surgeons were contacted using personal networks, national societies, and bariatric professionals' networks on social media; this project was registered as a multinational audit.
Data collected and handling
Complications were captured using the Clavien–Dindo (CD) Classification system for reporting surgical complications. This allowed for easier comparison of complication data and captured all complications irrespective of their severity. We further captured individual complications that would be important to the bariatric community such as bleeding and leak rates and complications such as chest infection/pneumonia that would be important in the context of the COVID-19 pandemic. In the case of more than one complication occurring in the same patient, the highest CD score was reported. Study data were collected and managed using research electronic data capture tools.
Continuous data were presented as mean ± standard deviation or median (interquartile range) depending on data distribution. Frequencies were used to summarize categorical variables. Independent t-test or Mann–Whitney U test was used to examine differences between continuous variables depending on data distribution. A Fisher's exact test or Chi-square test was used to compare categorical variables as appropriate. Statistical analysis was performed using Statistical Product and Service Solutions (SPSS; IBM Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp).
Logistic regressions were performed to investigate the effect of T2D on the surgery selection process, where the outcome variable was the specific surgery type against the others, and to investigate the influence of T2D on complications. These regressions included type of diabetes and were adjusted by the following variables: age, sex, body mass index (BMI), smoking status, ethnicity, obstructive sleep apnea (OSA), hypercholesterolemia, hypertension, and “other” comorbidity. Multivariate models were created using a generalized linear model in R. The multivariate model coefficients for each variable were used to calculate the odds ratio (OR) and its confidence interval. The OR was used to assess the likelihood of a patient developing complications perioperatively.
The matching of patients was performed using propensity score matching in a stepwise approach. Patients with ITD were matched with OATD, DTD, and those without T2D independently. The variables used for matching were: age, sex, BMI, smoking status, ethnicity, OSA, hypercholesterolemia, hypertension, and “other” comorbidity. This procedure was performed in R (R Core Team 2021) using the Matchit package., The distance was calculated using Mahalanobis distance, estimating the distribution that is closest to a point, matching on the nearest one. Following this, a multivariate model was created similar to the multivariate model prior to matching.
| Results|| |
A total of 470 surgeons from 179 centers in 42 countries submitted data on 7092 adult patients who underwent primary BMS between May 1, 2020, and October 31, 2020, at the participating centers. Of these, complete 30-day morbidity and mortality data were available for 7084 (99.88%) by December 10, 2020.
One thousand four hundred and seventy-five of these patients had T2D at the time of the surgery (416 DTD, 806 OATD, and 253 ITD). [Table 1] provides basic demographic characteristics and comorbidities for all patients with T2D and its various subgroups. Six hundred and fifty (44.1%) of these patients underwent LSG; 487 (33%) underwent RYGB; 230 (15.6%) underwent a OAGB; and 108 (7.3%) underwent some other procedures.
|Table 1: Basic demographic details of all patients undergoing elective primary BMS described according to their diabetes status|
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Mortality and morbidity
The 30-day mortality of BMS in those without T2D was 0.07% (4/5609) as compared to 0.4% (6/1475) and 0.8% (2/253) in those with T2D or ITD, respectively. This difference was statistically significant (P = 0.0079 and P = 0.0251, respectively; Fisher's exact test).
7.9% of those with T2D developed a 30-day complication compared to 6.5% without T2D (P = 0.0475; Fisher's exact test). [Table 2] provides a full breakdown of different complications according to CD Grade as well as complication type for patients with and without T2D and subgroups of those with T2D.
|Table 2: 30-day morbidity and mortality of elective primary BMS described according to their diabetes status|
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Factors influencing postoperative complications
On univariate analysis, there was a strong association between ITD and postoperative complications (OR = 1.07 [1.04–1.1]; P < 0.0001). This association was not seen with OATD or DTD. On multivariate analysis [Figure 1]a, adjusting for age, sex, and BMI, the increased risk of complications in patients with ITD was maintained (OR = 1.06 [1.02–1.09]; P = 0.001). An increased risk was also identified in patients with increasing age, smokers, patients with hypercholesterolemia, or with OSA not currently on continuous positive airway pressure. Patients undergoing RYGB were also exposed to an increased risk of complications (OR = 1.02 [1–1.03]; P = 0.009). Patients with OATD had an apparent reduction in risk of complications on multivariate analysis (OR: 0.97 [0.96–0.99]; P = 0.03). However, when the data were matched for baseline characteristics [Figure 1]b, this reduction was not seen (OR: 0.99 [0.95–1.05]; P = 0.95).
|Figure 1: Forest plot showing the effect of baseline characteristics on the risk of developing complications before (a) and after (b) matching|
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Choice of procedure
About 44.1% of patients with T2D (n = 649/1470) underwent an LSG as opposed to 59.5% (n = 3334/5600) of those without. Interestingly, only 29.8% (75/252) of ITD patients underwent an LSG. On univariate analysis, if the patient had any type of T2D, there was a tendency to not have LSG (P < 0.00001). On multivariate analysis [Table 3], for patients with T2D, even after adjusting for all other variables, there was still a significant difference in the selection of surgery. Patients with T2D were significantly less likely to undergo an LSG and significantly more likely to undergo an OAGB (OR: 0.89 [0.87–0.92, P < 0.00001). When assessing the choice of RYGB while adjusting for other variables, the tendency to have RYGB was maintained only for ITD (OR: 1.06 [1.002–1.12]; P = 0.04).
|Table 3: Multivariate regression analysis for the factors influencing the choice of procedure|
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Postoperative coronavirus disease-2019
The rate of postoperative symptomatic COVID-19 in patients without T2D (0.5%; n = 30/5609) was similar to patients with T2D (0.5%; n = 8/1475) [Table 4]. Among those with T2D, risk was highest for ITD group (1.6%; n = 4/253). This difference among the four groups (those without diabetes, DTD, OATD, and ITD) was statistically significant (P = 0.039).
|Table 4: Diagnosis of symptomatic postoperative coronavirus disease-2019 according to T2D status|
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| Discussion|| |
This is the first global study reporting on 30-day morbidity and mortality of primary BMS for patients with T2D. We found that 30-day morbidity of BMS in patients with T2D was 6.9% and 30-day mortality was 0.4% (6/1475). Among those with T2D, 30-day morbidity and mortality were highest for ITD patients at 13.0% and 0.8% (2.253), respectively. In comparison, these figures were 6.5% and 0.07% (4/5609), respectively, for those without T2D. 30-day mortality in those without T2D was significantly lower than those with T2D and those with ITD. Patients with T2D were more likely to experience 30-day morbidity or mortality in comparison with those without T2D. On subgroup analyses, the differences were only significant for those with ITD.
There are concerns that BMS is not adequately used for patients with T2D despite data showing its cost-effectiveness, particularly for those needing insulin. One of the potential explanations for lower utilization of BMS could be the morbidity and mortality associated with the surgical procedure itself. Given that patients with T2D are known to be at a higher risk of 30-day morbidity and mortality for many surgical specialties, one could assume that the available data on 30-day morbidity and mortality of BMS do not apply to those with T2D. Our findings would further support this notion.
Leonard-Murali et al. found that 30-day mortality of LSG was 0.15% for ITD patients, 0.09% for OATD patients, and 0.04% for those without T2D. In comparison, corresponding figures in our study were 1.33% (1/75), 0/371, and 0.06% (2/3338), respectively. For RYGB, the 30-day mortality in the study by Leonard-Murali et al. was 0.24% for ITD patients, 0.14% for OATD patients, and 0.1% for those without T2D. In our study, there were no mortalities for RYGB in any of these groups. Just like our study, they also found the complication rate to be higher in those with T2D in comparison with those without T2D. And like us, they found the complication rate to be highest for ITD patients. In modeling from the MBSAQIP database, Wise et al. also found diabetes to be associated with a higher 30-day complication rate with LSG, but this study did not report any real data.
We found that patients with T2D were more likely to undergo OAGB. This is probably because this procedure has been shown to have superior metabolic efficacy in comparison with either RYGB or LSG. RYGB seemed to be preferred over LSG in ITD patients, once again probably because it appears to have a superior metabolic profile in comparison with LSG. Differences in metabolic efficacies of different bariatric procedures are not very obvious from individual RCTs, as they tend to have weight loss as their endpoints and are not sufficiently powered to evaluate differences in diabetes resolution rates.
The postoperative COVID-19 rate in the GENEVA cohort study was very low at 0.5%. In this study, we did not find any difference in postoperative COVID-19 rates in those with diabetes and those without. This is in contrast to Axiotakis et al. who found perioperative infection to be associated with preoperative diabetes (OR: 3.70, P = 0.042). We did however find that patients with ITD were significantly more likely to have postoperative COVID-19 in comparison with other groups [Table 4]. Since in this study we have only focussed on symptomatic postoperative COVID-19, we cannot say if ITD patients are more likely to acquire the virus postoperatively or more likely to develop the clinically apparent infection. Others have also found diabetes to be associated with poorer outcomes with COVID-19.
Strengths and weaknesses
This paper adds to the scarce literature on 30-day morbidity and mortality of BMS in patients with T2D and its various subgroups. The global reach of our data, inclusion of various procedures, a high 30-day data completion rate of 99.5%, and its relevance to the ongoing pandemic make our findings important. Another limitation of the study was that data about the duration of T2D were not captured since the aim of this study was analyzing short-term outcomes of BMS. At the same time, nonrandomized nature of the study and self-reported complication rates mean our findings need further confirmation.
| Conclusions|| |
ITD patients undergoing BMS experience significantly higher 30-day morbidity and mortality. Patients with T2D are significantly more likely to undergo an OAGB and less likely to undergo an LSG.
Financial support and sponsorship
This study was financially supported by Bariatric Unit, University Hospitals Birmingham NHS Foundation Trust.
Conflicts of interest
There are no conflicts of interest.
| Geneva Collaborators|| |
Michał Pędziwiatr1, Piotr Major1, Piotr Zarzycki1, Athanasios Pantelis2, Dimitris P. Lapatsanis2, Georgios Stravodimos2, Chris Matthys3, Marc Focquet3, Wouter Vleeschouwers3, Antonio G Spaventa4, Carlos Zerrweck4, Antonio Vitiello5, Giovanna Berardi5, Mario Musella5, Alberto Sanchez-Meza6, Felipe J Cantu Jr6, Fernando Mora6, Marco A Cantu6, Abhishek Katakwar7, D Nageshwar Reddy7, Haitham Elmaleh8, Mohammad Hassan8, Abdelrahman Elghandour8, Mohey Elbanna8, Ahmed Osman8, Athar Khan9, Laurent layani9, Nalini kiran9, Andrey Velikorechin10, Maria Solovyeva10, Hamid Melali11, Shahab Shahabi11, Ashish Agrawal12, Apoorv Shrivastava12, Ankur Sharma13, Bhavya Narwaria13, Mahendra Narwaria13, Asnat Raziel14, Nasser Sakran14, Sergio Susmallian14, Levent Karagöz15, Murat Akbaba15, Salih Zeki Pişkin15, Ahmet Ziya BALTA16, Zafer Senol16, Emilio Manno17, Michele Giuseppe Iovino17, Ahmed Osman18, Mohamed Qassem18, Sebastián Arana-Garza19, Heitor P. Povoas20, Marcos Leão Vilas-Boas20, Alan Li21, Basil J Ammori22, Hany Balamoun23, Mohammed Salman23, Amrit Manik Nasta24, Ramen Goel24, Hugo Sánchez-Aguilar24, Miguel F Herrera24, Adel ABOU-MRAD25, Lucie CLOIX25, Guilherme Silva Mazzini26, Leonardo Kristem26, Andre Lazaro27, Jose Campos27, Joaquín Bernardo28, Jesús González28, Carlos Trindade29, Octávio Viveiros29, Rui Ribeiro29, David Goitein30, David Hazzan30, Lior Segev30, Tamar Beck30, Hernán Reyes31, Jerónimo Monterrubio31, Paulina García31, Marine Benois32, Radwan Kassir32, Alessandro Contine33, Moustafa Elshafei34, Sueleyman Aktas34, Sylvia Weiner34, Till Heidsieck34, Luis Level35, Silvia Pinango35, Patricia Martinez Ortega36, Rafael Moncada36, Victor Valenti36, Ivan Vlahović37, Zdenko Boras37, Arnaud Liagre38, Francesco Martini38, Gildas Juglard38, Manish Motwani39, Sukhvinder Singh Saggu39, Hazem Al Momani40, Luis Adolfo Aceves López41, María Angelina Contreras Cortez41, Rodrigo Aceves Zavala41, Christine D'Haese RN42, Ivo Kempeneers42, Jacques Himpens42, Andrea Lazzati43, Luca Paolino43, Sarah Bathaei43, Abdulkadir Bedirli44, Aydın Yavuz44, Çağrı Büyükkasap44, Safa Özaydın44, Andrzej Kwiatkowski45, Katarzyna Bartosiak45, Maciej Walędziak45, Antonella Santonicola46, Luigi Angrisani46, Paola Iovino46, Rossella Palma46, Angelo Iossa47, Cristian Eugeniu Boru47, Francesco De Angelis47, Gianfranco Silecchia47, Abdulzahra Hussain48, Srivinasan Balchandra48, Izaskun Balciscueta Coltell49, Javier Lorenzo Pérez49, Ashok Bohra50, Altaf K Awan50, Brijesh Madhok50, Paul C Leeder50, Sherif Awad50, Waleed Al-Khyatt50, Ashraf Shoma51, Hosam Elghadban51, Sameh Ghareeb51, Bryan Mathews52, Marina Kurian52, Andreas Larentzakis53, Gavriella Zoi Vrakopoulou53, Konstantinos Albanopoulos53, Ahemt Bozdag54, Azmi Lale54, Cuneyt Kirkil54, Mursid Dincer54, Ahmad Bashir55, Ashraf Haddad55, Leen Abu Hijleh55, Bruno Zilberstein56, Danilo Dallago de Marchi56, Willy Petrini Souza56, Carl Magnus Brodén57, Hjörtur Gislason57, Kamran Shah57, Antonio Ambrosi58, Giovanna Pavone58, Nicola Tartaglia58, S Lakshmi Kumari Kona59, Kalyan K59, Cesar Ernesto Guevara Perez60, Miguel Alberto Forero Botero60, Adrian Covic61, Daniel Timofte61, Madalina Maxim61, Dashti Faraj62, Larissa Tseng62, Ronald Liem62, Gürdal Ören62, Evren Dilektasli63, Ilker Yalcin63, Hudhaifa AlMukhtar64, Mohammed Al Hadad64, Rasmi Mohan64, Naresh Arora65, Digvijaysingh Bedi65, Claire Rives-Lange66, Jean-Marc Chevallier66, Tigran Poghosyan66, Hugues Sebbag67, Lamia Zinaï67, Saadi Khaldi67, Charles Mauchien68, Davide Mazza68, Georgiana Dinescu68, Bernardo Rea69, Fernando Pérez-Galaz69, Luis Zavala70, Anais Besa71, Anna Curell71, Jose M Balibrea72, Carlos Vaz72, Luis Galindo72, Nelson Silva72, José Luis Estrada Caballero73, Sergio Ortiz Sebastian73, João Caetano Dallegrave Marchesini74, Ricardo Arcanjo da Fonseca Pereira74, Wagner Herbert Sobottka74, Felipe Eduardo Fiolo75, Matias Turchi75, Antonio Claudio Jamel Coelho76, Andre Luis Zacaron76, André Barbosa77, Reynaldo Quinino77, Gabriel Menaldi78, Nicolás Paleari78, Pedro Martinez-Duartez78, Gabriel Martínez de Aragon Ramírez de Esparza79, Valentin Sierra Esteban79, Antonio Torres80, Jose Luis Garcia-Galocha80, MIguel Josa80, Jose Manuel Pacheco-Garcia81, Maria Angeles Mayo-Ossorio81, Pradeep Chowbey82, Vandana Soni82, Hercio Azevedo de Vasconcelos Cunha83, Michel Victor Castilho83, Rafael Meneguzzi Alves Ferreira83, Thiago Alvim Barreiro83, Alexandros Charalabopoulos84, Elias Sdralis84, Spyridon Davakis84, Benoit Bomans85, Giovanni Dapri85, Koenraad Van Belle85, MazenTakieddine86, Pol Vaneukem86, Esma Seda Akalın Karaca87, Fatih Can Karaca87, Aziz Sumer88, Caghan Peksen88, Osman Anil Savas88, Elias Chousleb89, fahad Elmokayed90, islam fakhereldin90, Hany Mohamed Aboshanab90, Talal swelium90, Ahmad Gudal91, Lamees Gamloo91, Ayushka Ugale92, Surendra Ugale92, Clara Boeker93, Christian Reetz93, Ibrahim Ali Hakami93, Julian Mall93, Andreas Alexandrou94, Efstratia Baili94, Zsolt Bodnar95, Almantas Maleckas96, Rita Gudaityte96, Cem Emir Guldogan97, Emre Gundogdu97, Mehmet Mahir Ozmen98, Deepti Thakkar99, Nandakishore Dukkipati99, Poonam Shashank Shah100, Shashank Subhashchandra Shah100, Simran Shashank Shah100, Md Tanveer Adil101, Periyathambi Jambulingam101, Ravikrishna Mamidanna101, Douglas Whitelaw102, Md Tanveer Adil102, Vigyan Jain102, Deepa Kizhakke Veetil103, Randeep Wadhawan103, Antonio Torres104, Max Torres104, Tabata Tinoco104, Wouter Leclercq105, Marleen Romeijn105, Kelly van de Pas105, Ali K. Alkhazraji106, Safwan A. Taha106, Murat Ustun107, Taner Yigit107, Aatif Inam108, Muhammad Burhanulhaq108, Abdolreza Pazouki109, Foolad Eghbali109, Mohammad Kermansaravi109, Amir Hosein Davarpanah Jazi110, Mohsen Mahmoudieh110, Neda Mogharehabed110, Gregory Tsiotos111, Konstantinos Stamou111, Francisco J. Barrera Rodriguez112, Marco A. Rojas Navarro112, Omar MOhamed Torres112, Sergio Lopez Martinez112, Elda Rocio Maltos Tamez113, Gustavo A. Millan Cornejo113, Jose Eduardo Garcia Flores113, Diya Aldeen Mohammed114, Mohamad Hayssam Elfawal114, Asim Shabbir115, Kim Guowei115, Jimmy BY So115, Elif Tuğçe Kaplan116, Mehmet Kaplan116, Tuğba Kaplan116, DangTuan Pham117, Gurteshwar Rana117, Mojdeh Kappus117, Riddish Gadani118, Manish Kahitan118, Koshish Pokharel118, Alan Osborne119, Dimitri Pournaras119, James Hewes119, Errichetta Napolitano120, Sonja Chiappetta120, Vincenzo Bottino120, evelyn dorado121, Axel Schoettler122, Daniel Gaertner122, Katharina Fedtke122, Francisco Aguilar-Espinosa123, Saul Aceves-Lozano123, Alessandro Balani124, Carlo Nagliati124, Damiano Pennisi124, Andrea Rizzi125, Francesco Frattini125, Diego Foschi126, Laura Benuzzi126, CHIRAG PARIKH127, HARSHIL SHAH127, Enrico Pinotti128, Mauro Montuori128, Vincenzo Borrelli128, Jerome Dargent129, Catalin A COPAESCU130, Ionut HUTOPILA130, Bogdan SMEU130, Bart Witteman131, Eric Hazebroek131, Laura Deden131, Laura Heusschen131, Sietske Okkema131, Theo Aufenacker131, Willem den Hengst131, Wouter Vening131, Yonta van der Burgh131, Ahmad Ghazal132, Hamza Ibrahim132, Mourad Niazi132, Bilal Alkhaffaf133, Mohammad Altarawni133, Giovanni Carlo Cesana134, Marco Anselmino134, Matteo Uccelli134, Stefano Olmi134, Christine Stier135, Tahsin Akmanlar135, Thomas Sonnenberg136, Uwe Schieferbein136, Alejandro Marcolini137, Diego Awruch137, Marco Vicentin137, Eduardo Lemos de Souza Bastos138, Samuel Azenha Gregorio138, Anmol ahuja139, Tarun mittal139, Roel Bolckmans140, Tom Wiggins140, Clément Baratte141, Judith Aron-Wisnewsky141, Laurent Genser141, Lynn Chong142, Lillian Taylor142, Salena Ward142, Lynn Chong143, Lillian Taylor143, Michael W Hi143, Helen Heneghan144, Naomi Fearon144, Andreas Plamper145, Karl Rheinwalt145, Helen Heneghan146, Justin Geoghegan146, Kin Cheung Ng146, Naomi Fearon146, Krzysztof Kaseja147, Maciej Kotowski147, Tarig A Samarkandy148, Adolfo Leyva-Alvizo149, Lourdes Corzo-Culebro149, Cunchuan Wang150, Wah Yang150, Zhiyong Dong150, Manel Riera151, Rajesh Jain151, Hosam Hamed151, Mohammed Said151, Katia Zarzar152, Manuel Garcia152, Ahmet Gökhan Türkçapar153, Ozan Şen153, Edoardo Baldini154, Luigi Conti154, Cacio Wietzycoski155, Eduardo Lopes155, Tadeja Pintar156, Jure Salobir156, Cengiz Aydin157, Semra Demirli Atici157, Anıl Ergin158, Huseyin Ciyiltepe158, Mehmet Abdussamet Bozkurt159, Mehmet Celal Kizilkaya159, Nezihe Berrin Dodur Onalan159, Mariana Nabila Binti Ahmad Zuber160, Wei Jin Wong160, Amador Garcia161, Laura Vidal161, Marc Beisani161, Jorge Pasquier162, Ramon Vilallonga162, Sharad Sharma163, Chetan Parmar164, Lyndcie Lee164, Pratik Sufi164, Hüseyin Sinan165, Mehmet Saydam165
12'nd Department of General Surgery, Jagiellonian University Medical College, Krakow, Poland, 24th Surgical Department, Evaggelismos General Hospital of Athens, Athens, Greece, 3A Z Sint Elisabeth Zottegem, Belgium, 4ABC Medical Center Santa Fe, Mexico City, Mexico, 5Advanced Biomedical Sciences Department - Naples “Federico II” University - Italy, 6Advanced Medicine Institute. Reynosa, MEXICO., 7AIG hospital, Hyderabad, India, 8Ain Shams University Hospitals, Cairo, Egypt, 9Al shark hospital fujairah UAE, 10American Medical Clinic, Saint Petersburg, Russia, 11Amin University Hospital, Isfahan, Iran, 12Apoorv Hi Tech at Gokuldas Hospital, 13Asian Bariatrics, Ahmedabad, India, 14Assuta Medical Center, Tel Aviv, Israel, 15Atasam Hospitals,Samsun, Turkey, 16AZBariatrics Obesity Center, Istanbul, 17Bariatric and Metabolic surgery UnitOspedale A.Cardarelli Napoli Italia, 18Bariatric Surgery Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt, 19Bariatric Surgery Experts, Monterrey, Mexico, 20BAROS - Bariatric and Metabolic Surgery, Salvador, Brazil, 21BMI Alexandra Hospital, Manchester, UK, 22Burjeel Hospital, Abu Dhabi, UAE, 23Cairo University, Cairo, Egypt, 24Center of Metabolic Surgery, Wockhardt Hospital, Agripada, Mumbai, India, 24Center of Nutrition and Obesity, ABC Medical Center (Observatorio), Mexico City, 25Centre Hospitalier Regional d'ORLEANS, 26Centro de Obesidade do Instituto do Aparelho Digestivo, Porto Alegre, Brazil, 27Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal, 28Centro Médico de Asturias. Oviedo. Spain, 29Centro Multidisciplinar da Doença Metabólica, Clínica Santo Antonio - Lusiadas, Amadora, Portugal, 30Chaim Sheba Medical Center, Affiliated with Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel, 31Christus Muguerza Sur, Monterrey, Mexico, 32CHU Félix Guyon, la Réunion, France, 33Città di Castello Hospital, Usl Umbria 1, Città di Castello - Italy, 34Clinic for Metabolic Surgery, Krankenhaus Nordwest, Frankfurt, Germany, 35Clínica Santa Sofía, Caracas, Venezuela, 36Clinica Universidad de Navarra. Pamplona. Spain, 37Clinical Hospital Centre Osijek, Osijek, Croatia, 38Clinique des Cedres, Cornebarrieu, France, 39COMS, Apollo Spectra Hospital, New Delhi, India, 40Danat Al Emarat Hospital, Abu Dhabi, UAE, 41Defeat Obesity Bariatric and Metabolic Surgery, CHRISTUS MUGUERZA Hospital Reynosa, Reynosa, Tamaulipas., 42Delta CHIREC hospital, Brussels Belgium, 43Department of General Surgery, Center Hospitalier Intercommunal de Créteil, Paris, France, 44Department of General Surgery, Gazi University Faculty of Medicine, Turkey, 45Department of General Surgery, Military Institute of Medicine, Szaserów 128, 04-141, Warsaw, Poland, 46Department of Public Health, “Federico II” University of Naples, Naples, Italy, 47Division of General Surgery & Bariatric Center of Excellence IFSO-EC, University La Sapienza of Rome, Italy, 48Doncaster and Bassetlaw Teaching Hospitals, 49Dr. Lorenzo, Innovación Cirugía Obesidad y Diabetes, 50East-Midlands Bariatric & Metabolic Institute (EMBMI), Royal Derby Hospital, Derby, UK, 51Elsafa Private Hospital & Mansoura University Hospital & Eldelta Hospital, 52New York Minimally Invasive Surgery PLLC, New York, NY , USA, 53First Department of Propaedeutic Surgery, Hippocration General Athens Hospital, National and Kapodistrian University of Athens, Athens, Greece, 54Fırat University Hospital, Elazığ. Turkey, 55Gastrointestinal, Bariatric & Metabolic Center at Jordan Hospital, Amman, Jordan, 56GASTROMED-Zilberstein Institute, Sao Paulo, Brazil, 57GB Obesitas Skaane, Malmö. Sweden., 58General Surgery, University of Foggia. Italy., 59Glenagles Global Hospital, Lakdikapul, Hyderabad, 60Grammo SAS IPS, Bogotá, Colombia, 61Grigore T. Popa University of Medicine and Pharmacy, Iasi, Romania, 62Groene Hart Hospital in Gouda & Dutch Obesity Clinic The Hague, Netherlands, 62Gürdal Ören Bariatric Surgery Center, İstanbul, Turkey, 63Hayat Hospital, General Surgery, Bariatric & Metabolic Surgery , Bursa , Turkey, 64Healthpoint Hospital, Abu Dhabi, UAE, 65HOPE OBESITY CENTRE, AHMEDABAD, INDIA, 66Hôpital Européen Georges Pompidou, AP-HP, Université de Paris, Paris, France, 67Hôpital Privé de Provence (HPP), Aix-en-Provence, France, 68Hôpital Ste Musse Centre Hospitalier Toulon, 69Hospital Ángeles Lomas, Estado de México, México, 70Hospital Christus Muguerza Sur - Monterrey México, 71Hospital Clínic de Barcelona, Barcelona, Spain, 72Hospital Clínic de Barcelona, Barcelona, Spain, 72Hospital CUF Tejo, Lisbon, Portugal, 73Hospital General Universitario Alicante Spain, 74Hospital Marcelino Champagnat, Curitiba, Brazil, 75Hospital Privado de Comunidad - Mar del Plata - Argentina, 76Hospital Rios D'Or , Rio de Janeiro, Brazil, 77Hospital Unimed Natal, Natal, Brazil, 78Hospital Universitario Austral, Bariatric and Metabolic department. Buenos Aires Argentina, 79Hospital Universitario de Álava, Vitoria- Gasteiz. Spain, 80Hospital Universitario Madrid Monteprincipe. Hospital Clinico San Carlos. Madrid, 81Hospital Universitario Puerta del Mar. Cadiz. Spain, 82Institute of Minimal Access, Metabolic & Bariatric Surgery, Max Super-Speciality Hospital, Saket, New Delhi, India, 83Instituto Campineiro de Tratamento da Obesidade, Campinas, Brazil, 84Interbalcan Medical Center, 85International School Reduced Scar Laparoscopy, Brussels, Belgium, 86Isppc chu -André Vésale , metabolic & Bariatric surgery, 87İstanbul Bilgi University,Turkey,(first author), Department of Pulmonary Medicine, Istanbul Yedikule Chest Diseases and Thoracic Surgery Education and Research Hospital, Zeytinburnu, Turkey(for sekond author), 88Istinye University, School of Medicine, Istanbul,Turkey, 89Jackson North Medical Center, Miami Fl, 90king Abdul aziz hospital, Alhasa,saudi arabia, 91King Abdullah Medical Complex, Jeddah, KSA, 92Kirloskar Hospital, Hyderabad, India, 93Klinikum Region Hannover- Klinikum Nordstadt, 94Laiko General Hospital, National and Kapodistrian University of Athens, Greece, 95Letterkenny University Hospital, Letterkenny, Ireland, 96Lithuanian University of Health Sciences, Surgery Department, Kaunas, Lithuania, 97Liv Hospital Ankara, Turkey, 98Liv Hospital Ankara, Turkey (Istinye University School of Medicine), 99Livlife Hospitals, Hyderabad, India, 100LOC Healthcare LLP, Pune, India, 101Luton and Dunstable Hospital, 102Luton and Dunstable University Hospital, 103Manipal Hospital, New Delhi, India, 104Max Medical, centro de cirugía bariátrica/robótica, Hospital Metropilitano de Quito/Ecuador, 105Máxima Medical Center, Veldhoven, The Netherlands, 106Mediclinic Hospital Airport Road, Abu Dhabi, UAE., 107Memorial Hospital, Istanbul, Turkey, 108Metabolic, Thoracic & General Surgery Team III, Department of General Surgery , Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan., 109Minimally Invasive Surgery Research Center, Division of Minimally invasive and Bariatric surgery, Department of Surgery, Rasool-e Akram Hospital, Iran University of Medical Sciences, Tehran, Iran, 110Minimally Invasive Surgery Research Center, Isfahan University of Medical Sciences, Isfahan, Iran, 111MITERA Hospital, Athens, Greece, 112Monterrey Gastro & Bariatric Group, Monterrey Mexico, 113MtyBariatrics, Monterrey, Nuevo Leon, Mexico, 114Najjar Hospital,Beirut, Lebanon, 115National University Hospital Singapore, 116NCR International Hospital, Gaziantep, Turkey, 117Niagara Falls Memorial Medical Center, Niagara Falls, NY, USA, 118NOBESITY BARIATRIC CENTRE, K D HOSPITAL, AHMEDABAD, INDIA, 119North Bristol NHS Trust, 120Obesity and Metabolic Surgery Unit, Ospedale Evangelico Betania, Naples, Italy, 121Obesity and stethic surgery clinic clinica med cali colombia, 122Obesity Center, Municipal Hospital Karlsruhe, Germany, 123Obesity Clinic:Los Altos Obesity Surgery, Tepatitlan, Mexico, 124Ospedale di Gorizia, Italy. Struttura Complessa Chirurgia Generale, 125Ospedale Galmarini Tradate, Varese, Italy, 126Ospedale San Giuseppe IRCCS Multimedica, University of Milan, Milan, Italy, 127Parul Institute of Medical Sciences & Research, Parul Uiversity, Waghodia, Vadodara, India, 128Policlinico San Pietro, Bergamo, Italy, Unitá di Chirurgia Bariatrica, 129Polyclinique Lyon-Nord, 69140 Rillieux, France, 130Ponderas Academic Hospital, Bucharest, Romania, 131Rijnstate Hospital/Vitalys Clinics, Arnhem, the Netherlands, 132Saint Louis Hospital - Aleppo,Syria, 133Salford Royal NHS Foundation Trust, 134San Marco Hospital GSD, Zingonia (BG), Italy, 135Sana Obesity Center Northrhine Westphalia, Clinic for General, Visceral, and Transplantation Surgery, RWTH University Aachen., 136Sana Obesity Center Northrhine Westphalia, 137Sanatorio Britanico de Rosario, Rosario, Santa Fe, Argentina, 138Santa Casa de Marilia, Marilia, Brazil, 139sir ganga ram hospital delhi india, 140Somerset NHS Foundation Trust, 141Sorbonne Université, Institute of Cardiometabolism and Nutrition ICAN, Assistance Publique-Hôpitaux de Paris, Departments of Digestive surgery and Nutrition, Pitié-Salpêtrière University Hospital, Paris, France., 142St Vincent's Hospital Melbourne, 143St Vincent's Hospital, Melbourne, Australia, 144St Vincent's University Hospital, Dublin, Ireland, 145St. Franziskus Hospital, Cologne, Germany, 146St. Vincent's University Hospital, Dublin, Ireland, 147State Clinical Hospital No 2 of the Pomeranian Medical University in Szczecin, Poland, 148Sutter Gould Medical Foundation, Dameron Hospital - Ca, USA, 149Tecnologico de Monterrey, Monterrey, MX, 150The First Affiliated Hospital of Jinan University, Guangzhou, China, 151The Shrewsbury and Telford Hospital, Shrewsbury, UK, 151Truelife bariatric and digestive surgery center, Mansoura, Dakahleyya, Egypt, 152Tu Opcion Bariatrica, 153Türkçapar Bariatrics Obesity Center, İstanbul, Turkey, 154U.O. Chirurgia, Ospedale “Guglielmo da Saliceto”, Piacenza, Italy, 155Unimed Vale do Caí Hospital, Montenegro, BR. Maicé Hospital, Caçador, BR, 156University Medical Center Ljubljana, Slovenia, 157University of Health Sciences Tepecik Training and Research Hospital, Department of General Surgery, Izmir, Turkey, 158University of Health Sciences, Fatih Sultan Mehmet Training and Research Hospital, General Surgery Department, Istanbul, Turkey, 159University of Health Sciences, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey, 160University of Malaya Medical Centre, Kuala Lumpur, Malaysia, 161Vall d'Hebron University Hospital, Barcelona, Spain, 162Vall Hebron Hospital Campus - Hospital de Barcelonoa-SCIAS, 163Vinamra Swaraj Hospital, Navi Mumbai, India, 164Whittington Health NHS Trust, London, United Kingdom, 165www.metabolistsurgery.com Istanbul Turkey
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[Table 1], [Table 2], [Table 3], [Table 4]