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   2022| May-August  | Volume 1 | Issue 1  
    Online since April 9, 2022

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Leaks after sleeve gastrectomy – A narrative review
Nikhil Jain, Rajesh Bhojwani, Kamal Mahawar
May-August 2022, 1(1):2-9
Background: Laparoscopic sleeve gastrectomy has become a standalone procedure for the treatment of severe obesity with excellent short- and mid-term outcome. Staple-line leak is one of the most dreaded complications of this procedure. Following a standardized sequence of critical steps can help decrease the incidence of leaks. In this review, we examine the etiopathogenesis of leaks after laparoscopic sleeve gastrectomy and important implicated technical considerations. Materials and Methods: A comprehensive literature search of various databases was performed with relevant keywords. The published scientific literature was critically appraised. Results: Patient-, surgery-, and surgeon-related risk factors should be recognized and modifiable risk factors should be addressed. There are anatomical, physiological, and technical considerations that contribute to the pathogenesis of leaks, based on which a multitude of precautions need to be taken to prevent staple-line leak. Conclusion: The correct bougie size, distance from the pylorus, stapler size, orientation of staple line, and distance from angle of His and an intraoperative leak test are some of the crucial aspects for a successful outcome after sleeve gastrectomy. Staple size less than that of 1.5 mm should not be used on the stomach, stapling should be initiated at least 5 cm from pylorus and calibrated on a bougie that should not be <32 Fr size. Reinforcing the staple line reduces the incidence of hemorrhage, and current evidence indicates the incidence of leak. Performing a leak test, though offers less sensitivity to predict a leak, does help in detecting the immediate mechanical failure of staple line.
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A journey of a thousand miles begins with a single step
Pradeep Chowbey, Ramen Goel, Kamal Mahawar
May-August 2022, 1(1):1-1
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Gastric bypass: Historical evolution and technical development of a time-honored bariatric procedure
Eduardo Lemos de Souza Bastos, Dênis Pajecki
May-August 2022, 1(1):10-15
Gastric bypass (GB) was originally described over 50 years ago as an alternative to jejunoileal bypass in the surgical approach to morbid obesity. Since then, several technical improvements and modifications have been proposed over time to simplify technical execution, enhance outcomes, and minimize the risk of complications and/or adverse effects. After half a century of robust and sustained results, the technical drawing of the GB still undergoes improvements, mainly to ensure even more safety for obese patients and encompass modern concepts of metabolic surgery. This review aims to outline the main technical changes proposed for GB from its original description to the current times.
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Gastric remnant shape following laparoscopic sleeve gastrectomy correlates with weight loss: A retrospective cohort study
Dale Jobson, Julia Freckelton, Melanie Seale, Lynn Chong, Nicole N Winter, Matthew Read, Salena Ward, Michael W Hii
May-August 2022, 1(1):24-29
Background: Laparoscopic sleeve gastrectomy (LSG) is a safe and effective bariatric surgical procedure. Sleeve configuration is believed to be an important outcome of good operative technique, yet the relationship of sleeve shape to clinical outcomes including weight loss and postoperative symptoms is not clearly defined. This study aims to identify whether gastric remnant anatomical shape is associated with short-term postoperative weight loss or symptoms of reflux, regurgitation, or dysphagia. Methods: 207 LSG patients were identified from a prospective, multicentre unit database who had surgery between June 2015 and June 2019. Routine postoperative upper gastrointestinal gastrograffin contrast studies were performed between postoperative days one to five and analyzed using a standardized protocol. Gastric remnant shape was classified as either tubular, proximal pouch or distal pouch consistent with previous studies. ANOVA Kruskal − Wallis and Mann − Whitney U-tests were performed to determine the effect of gastric remnant anatomy on weight loss. Descriptive statistics examined the symptoms of reflux, regurgitation, and dysphagia. Results: Gastric remnant anatomy was classified as tubular in 159/207 (78%), proximal pouch in 15/207 (7%), and distal pouch in 33/207 (16%). Patients with a tubular shape had a significantly greater reduction in median body mass index at 12 months postoperatively compared to those with a proximal pouch (11.3 kg/m2 vs. 10.2 kg/m2, P = 0.01). There was no relationship identified between gastric remnant shape and postoperative reflux, regurgitation, or dysphagia. Conclusion: A tubular-shaped gastric remnant is associated with increased weight loss. This suggests that tubular shape should be considered the desired LSG shape for greatest weight loss.
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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 Singhal, Victor Roth Cardoso, Christian Ludwig, Jonathan Super, Yashasvi Rajeev, Gavin Rudge, Georgios V Gkoutos, Kamal Mahawar, GENEVA collaborators
May-August 2022, 1(1):34-41
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.
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Early weight loss: A determinant of total weight loss after bariatric surgery
Sigin Satheesh, Aashik Shetty, Amrit Manik Nasta, Madhu Goel, Ramen Goel
May-August 2022, 1(1):30-33
Background: Bariatric surgery is the most effective weight loss intervention for patients with severe obesity. Several studies have shown wide variability in weight loss response between patients. The aim of the study is to identify comparative poor responders based on weight loss in the early postoperative period. Methods: A retrospective analysis of 125 patients who underwent primary bariatric surgery by a single surgeon and completed 1 year of follow-up was performed. Patients were divided into two groups based on % Total Weight loss (%TWL) at 1 month after surgery: Group 1-who lost <10% TWL and Group 2-who lost >10% TWL. The comparison of factors in both groups at different time points was executed using paired t-tests or analysis of variance. The relationships between Group 1 and Group 2 after 1 year follow-up period were assessed through linear regression analyses. Results: Seventy (56%) patients lost <10% TWL and 55 (44%) patients lost more than 10% TWL in 1 month after surgery. Mean weight loss at 1 month and 1 year after surgery was 9 ± 5.5 kg and 37 ± 13.3 kg in Group 1 compared to 16 ± 5.2 and 46 ± 16.4 kg in Group 2, respectively. Patients with >10%TWL at 1 month had significantly greater %TWL at 1 year (P = 0.001). Linear regression analysis showed a positive correlation between patients who lost >10%TWL 1 month after surgery and weight loss at 1 year. Conclusion: Postoperative percentage TWL of <10% at 1 month can be used as an early determinant of comparatively poor weight loss at 1 year. Early initiation of aggressive and multimodal treatment strategies is likely to improve overall weight loss outcomes after surgery.
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Medium-Term outcomes after Roux-en-Y-Gastric Bypass: Experience from a Tertiary Healthcare Center from India
Prasanna Ramana Arumugaswamy, Vitish Singla, Sandeep Aggarwal
May-August 2022, 1(1):16-23
Background: Roux en Y gastric bypass (RYGB) has been highly effective in weight loss and it has been the procedure of choice for patients suffering from diabetes. There is a high attrition rate in long-term follow-up. Hence, limited long-term data are available. Methodology: We collected retrospectively data from a prospectively maintained institutional database. To increase the long-term follow-up rate, a telephonic interview was conducted with patients who had not come for long-term follow-up. Standard definitions were used for weight loss, weight regain, comorbidities, comorbidity resolution, and nutritional parameters. Results: Of 142 patients who underwent laparoscopic RYGB between 2008 and 2018, 125 patients (M: 33, F: 92; Age: 42.4 ± 5.2 years) were included in the study. The mean % weight loss at 1, 3, 5, and 7 years was 28.9, 31.8, 31.3, and 31.7, respectively. Mean % excess body mass index loss (% EBMIL) at 1, 3, 5, and 7 years was 67.6 ± 18, 73.7 ± 17.9, 71.7 ± 20.7, and 69.5 ± 24.6, respectively. Median weight regain at 3, 5, and 7 years was 8.4%, 12.7%, and 24% of weight lost. Significant weight regain was seen in 1 patient at 3 years and 3 patients at 5 and 7 years of follow-up. Among patients suffering from diabetes, 50.9% had remission and 45.3% had improvement at 1 year. At 5 years, this was 56% and 40%, respectively. Among patients suffering from hypertension, at 5 years, remission was seen in 11 (64.7%) out of 17. Significant improvements were seen in hypothyroidism, OSA, gastroesophageal reflux disease, and lipid profile. There was a statistically significant decrease in mean levels of fasting blood sugar, glycated hemoglobin (HbA1c), hemoglobin, serum calcium, insulin, c-peptide, serum albumin, and total protein and there was an increase in mean Vitamin D levels at 1 year follow-up. There was a decrease in mean levels of folate, total iron-binding capacity, parathyroid hormone, and alkaline phosphatase and an increase in mean Vitamin B12, iron, and ferritin postsurgery. However, this was statistically not significant. Nutritional deficiencies were noted. Seven complications were noted out of 142 procedures and no surgery-related mortality. Three patients had significant weight regain beyond 5 years. Conclusion: RYGB is a safe and effective bariatric procedure with well-sustained results in long run. Nutritional supplementation is required to correct deficiencies.
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Management of gastrojejunostomy anastomotic leak post one anastomosis gastric bypass with a covered stent alone
Parveen Bhatia, Harsh Sheth, Shubham Bhatia, Sarfaraz Baig
May-August 2022, 1(1):55-58
Leaks after one anastomosis gastric bypass are managed based on the timing of presentation and the presence or absence of peritonitis. Reoperation is strongly advocated because of the potential severity of biliary peritonitis. Recently, nonoperative treatment is being increasingly employed, especially for staple line disruptions or unspecified leaks. We report successful usage of a covered esophageal stent in a gastrojejunostomy anastomosis leak with a favorable outcome.
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Revision of Roux-en-Y-Gastric bypass – Our experience in Indian patients
Naveen Verma, Randeep Wadhawan, Lalit Sehgal, Deepa Kizhakke Veetil, Muneendra Gupta
May-August 2022, 1(1):49-54
Background: The indications for revision bariatric surgery include inadequate weight loss, weight regain, failure to resolve comorbidities, and complications associated with primary surgery. Objectives: The objective is to evaluate the outcome of revision of Roux-en-Y gastric bypass (RYGB) and compare the efficacy of different revision procedures for weight regain, resolution of comorbidities, and complications, if any. Methods: Revision cases performed between May 2017 and April 2021 were included. The analysis of collected data was carried out for weight loss, resolution of comorbidities, and adverse outcomes. Results: Twenty three revision procedures were performed. Two patients were lost to follow-up. The overall complication and reoperation rates were 14.29% and 4.76%, respectively. The follow-up duration was at 6, 12, and 36 months. Twenty-one (91.3%) patients completed 6-month, 18 (78.3%) 12-month, and nine (39.1%) completed 36-month follow-up. The mean postoperative body-mass index at 6, 12, 36 months were 33.07+/−4.15, 33.11+/−4.05, 34.5 ± 8.81, respectively. The mean %excess weight loss (EWL) at 6, 12, 36 months were 39.47+/−13.76, 43.70+/−13.70, 41.14+/−8.48%, respectively. The patients were divided into three groups. Group A - lengthening of biliopancreatic limb (BPL) by 100 cm (n = 6); Group B - placement of ring with a diameter of 7.5 cm in addition to BPL lengthening (n = 12); and Group C - pouch trimming with BPL lengthening by 100 cm (n = 3). %EWL at 6 months was 31.86, 47.69, and 53.49, in Groups A, B, and C, respectively. Similar trends in %EWL were observed in three groups at 12 and 36 months. Conclusion: Revision bariatric surgeries are complex procedures. In our study, banded RYGB with BPL lengthening had better outcomes, though a statistical significance could not be established due to the small sample size and retrospective nature of the study.
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Outcomes of 75 consecutive cases of laparoscopic one-anastomosis gastric bypass: A prospective study
Dhananjay Pandey, Lokesh Yadav, Kona S Lakshmi, Ramalingam Trivikraman
May-August 2022, 1(1):42-48
Background: Obesity is increasing at an alarming rate in India along with rest of the world. In the National Family and Health survey - IV conducted in 2015-16; 31.3% women and 26.6% men in urban area were obese or over weight. Bariatric surgery has long been introduced for weight control and is well established measure and superior to other weight control measures. Procedures like laparoscopic Roux en Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are more commonly performed than Laparoscopic One Anastomosis Gastric Bypass (LOAGB). Although sufficient data has accumulated in literature regarding the safety and efficacy of LOAGB, some of standard textbooks still mention it as an experimental procedure and not the mainstream procedure. Aims and Objective: The present study was conducted with objective to find out changes in pre-operative and post-operative status of diabetes mellitus, hypertension, dyslipidemia, obstructive sleep apnoea, osteoarthritis, GERD and quality of life after laparoscopic one anastomosis gastric bypass along with its safety and efficacy in Indian population. Material and Methods: The study was conducted at a tertiary care bariatric surgical centre and included 75 consecutive individual operated between January 2016 to December 2017 who underwent Laparoscopic One Anastomosis Gastric Bypass and followed prospectively for minimum 1 year (mean 18 months) and statistical analysis was done using SPSS 21 software. Result: One Anastomosis Gastric Bypass was completed laparoscopically in all the patients without need for conversion to an open procedure. The overall complication with Laparoscopic One Anastomosis Gastric Bypass was 1.3% without any mortality. Mean percentage of excess weight loss (% EWL) achieved was 72.73. 93.9 % patients with diabetes, 67.43% patients with hypertension, 87.1% patient with hyperlipidemia, all the patient with obstructive sleep apnoea and osteoarthritis of knee showed improvement in their disease status. None of the patient showed worsening of gastroesophageal reflux or development of new symptoms of gastro esophageal reflux. All patients had improvement in their quality of life as seen in the improvement of their SF 36 scores. Conclusion: Laparoscopic One Anastomosis Gastric Bypass is a safe and effective bariatric procedure. The post procedure improvement in diabetes, hypertension, hyperlipidemia, obstructive sleep apnoea, osteoarthritis of knee and quality of life is significant in Indian context.
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