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BackgroundThe timing of bleeding after bariatric surgery and subsequent management (characterized as surgical versus non-surgical (i.e., interventions including endoscopic or interventional radiology approaches)) has not been thoroughly studied. As such, we sought to describe the rates of reoperation or non-operative intervention after bleeding following sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB).MethodsThe Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) database was queried between 2015 and 2018 for any bleeding after SG or RYGB and subsequent reoperation or non-operative intervention. Multivariable Fine-Gray models were used to compare the hazard of reoperation/non-operative intervention. Multivariable generalized linear regression models were used to test the number of subsequent reoperations/non-operative interventions depending on initial management.Results6251 patients with bleeding after SG or RYGB were identified, of which 2653 patients underwent subsequent procedures (n = 1375 [51.83%] RYGB index procedure, n = 1278 [48.17%] SG index procedure). 1892 (71.32%) and 761 (28.68%) patients had reoperation and non-operative intervention, respectively. For patients who developed bleeding, SG was associated with significantly higher reoperation risk, while RYGB was associated with significantly higher risk of non-operative intervention. Early bleeding was associated with significantly increased risk of reoperation and decreased risk of non-operative intervention, regardless of initial procedure. The total number of subsequent reoperations/non-operative interventions did not differ significantly depending on whether the patients had non-operative intervention or reoperation first [ratio 1.01, 95% CI (0.75, 1.36), p value 0.9418].ConclusionPatients after SG who experience bleeding are more likely to undergo reoperation than RYGB patients. On the other hand, patients with bleeding after RYGB are more likely to undergo non-operative intervention compared to SG patients. Early bleeding is associated with higher risk of reoperation and lower risk of non-operative intervention both after SG and RYGB. The initial approach did not play a role in the total number of subsequent reoperations/non-operative interventions.

Background Transoral outlet reduction (TORe) is a safe and effective technique for management of weight regain (WR) after Roux-en-Y Gastric Bypass (RYGB). Carriers of a heterozygous variant in the leptin melanocortin pathway (LMP) have been shown to be at high risk for WR in the mid- and long-term after RYGB. Our case series includes four patients with heterozygous LMP variants and presents novel data on their weight loss after TORe. Methods We performed a retrospective study of the Mayo Clinic Biobank and identified adult participants who had been genotyped and found to have or do not have a heterozygous variant in the LMP (“carriers” vs “non-carriers”, respectively) and had undergone a TORe procedure. TBWL% at 1, 3, 6, 9, and 12 months ± 15 days were calculated based on baseline weight at TORe procedure. Results A total of 14 patients were included in the analysis: four patients (mean age 51.0 [5.2] years, 100% females, body mass index [BMI] 40.5 [8.7] kg/m 2 ) with LMP variant and 10 non-carriers (age 55.4 [15.3] years, 90% females, BMI 37.3 [7.7] kg/m 2 ). There were no baseline differences between carriers and non-carriers at time of TORe procedure. After TORE, carriers lost less weight when compared to non-carriers at 3, 6, 9, and 12 months. The difference at 12 months was statistically significant (1.6 vs 12.3%; p = 0.03). Conclusions Patients with a LMP variant and that underwent RYGB showed decreased weight loss after undergoing TORe. Further and larger studies are needed to comprehend the effect of TORe on patients with LMP variants.

BackgroundThe implications of operative time (OT) have been studied in different surgical specialties, showing a correlation with higher incidence rates of postoperative complications. However, the impact of OT on bariatric surgery complications is not well elucidated.MethodsA retrospective review of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database between 2015 and 2019 was performed. A total of 358,382 SG patients and 123,357 RYGB patients were included. The median OT was 68 min (10–720) and 113 min (10–640) for the sleeve gastrectomy (SG) group and the Roux-en-Y gastric bypass group, respectively. The groups were subdivided into two subgroups based on OT in comparison to the median time of each group. The subgroups were compared for surgical complications and outcomes. To reduce selection bias and risk of confounders, we performed a propensity score matching (PSM) for 22 variables.ResultsIn the PSM-matched cohort, 18,915 SG and 6,495 RYGB patients were included in each subgroup. The SG cohort showed higher rates of Clavien–Dindo Class 1, 2, 3a, 4, and 5 complications as well as higher rates of readmission, reoperation, and reintervention in the longer OT group before matching. After PSM, the subgroup with longer times continued to have higher rates of Clavien–Dindo Class 2 complications and higher rates of readmission and reoperation. Similarly, there were higher rates of all Clavien–Dindo class complications as well as readmission, reoperation, and reintervention in the RYGB group with higher OT. After PSM, there were still higher rates of Clavien–Dindo Class 3a complications as well as readmission and reintervention in the RYGB subgroup with prolonged OT.ConclusionIn both SG and RYGB, longer OT was associated with increased rates of complications as well as readmission, reoperation, and reintervention. Surgeons should be cognizant of the increased rates of complications when operative times are longer.

Purpose Metabolic and bariatric surgery (MBS) could improve health-related quality of life (HrQoL) for selected patients with obesity. Although biliopancreatic diversion with duodenal switch (BPD-DS) is regarded as the most effective MBS technique in achieving weight loss, no consensus has been reached on the impact of BPD-DS on HrQoL. The aim of this meta-analysis is to assess the mid-term HrQoL after BPD-DS in the management of patients with obesity. Materials and Methods Cochrane, Embase, APA PsycInfo, PubMed, Scopus, and Web of Science were searched for articles from their inception to August 2022 by two independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) system. The review was registered prospectively with PROSPERO (CRD42022352073). Results From 223 studies screened, twelve studies met the eligibility criteria, with a total of 937 patients with obesity undergoing BPD-DS. Minimal clinically important differences (MCID) were reached for the physical component summary score (PCS) of the 36-Item Short-Form Health Survey (SF-36) (MD = 13.4) and impact of weight on quality of life (IWQOL)-Lite total score (MD = 48.7). Similarly, MCIDs were attained in the Laval questionnaire and SF-36 subscales. Conclusion Our meta-analysis demonstrated an improvement in mid-term HrQoL after BPD-DS. Despite the promising trends demonstrated in this meta-analysis, further studies with large sample sizes are needed to evaluate the impact of HrQoL on patients with obesity after BPD-DS. Graphical Abstract

Purpose Hypoalbuminemia and anemia are commonly observed indications for one anastomosis gastric bypass (OAGB) reversal and remain significant concerns following the procedure. Sufficient common channel limb length (CCLL) is crucial to minimize nutritional complications. However, limited literature exists regarding the impact of CCLL on OAGB outcomes. This study aimed to assess the effect of CCLL on weight loss and nutritional status in patients who underwent OAGB. Methods A prospective cohort study was conducted from August 2021 to July 2022, involving 64 patients with a body mass index of 40–50 kg/m 2 . The standardized length of the biliopancreatic limb (BPLL) for all patients in this study was set at 175 cm. Additionally, the measurement of the common channel limb length (CCLL) was performed consistently by the same surgeon for all included patients. Results The mean age and BMI of the patients were 39.91 ± 10.03 years and 43.13 ± 2.43 kg/m 2 , respectively, at the time of surgery. There was a statistically significant negative correlation between CCLL and percent total weight loss (%TWL) at the 12-month mark after OAGB ( P  = 0.02). Hypoalbuminemia was observed in one patient (1.6%), while anemia was present in 17 patients (26.6%) at the one-year follow-up. Statistical analysis revealed no significant difference in the incidence of anemia and hypoalbuminemia between patients with CCLL < 4 m and those with CCLL ≥ 4 m. Conclusion A CCLL of 4 m does not appear to completely prevent nutritional complications following OAGB. However, maintaining a CCLL of at least 4 m may be associated with a reduced risk of postoperative nutritional deficiencies.

Metabolic and bariatric surgery has been well described in the existing literature to be an effective and safe modality for weight loss in patients with obesity. Recently, hypoabsorptive procedures such as one-anastomosis gastric bypass (OAGB), biliopancreatic diversion with duodenal switch (BPD-DS), and single-anastomosis duodenoileostomy with sleeve (SADI-S) have gained traction, particularly among patients with severe obesity. These procedures combine restrictive and hypoabsorptive mechanisms, resulting in significant and sustainable weight loss, especially in those with severe obesity and associated comorbidities. However, the risk of malnutrition and nutritional deficiency following these procedures has been a deterrent for surgeons in their adoption. This review evaluates the existing literature on the safety, efficacy, and long-term outcomes of OAGB, BPD-DS, and SADI-S. While these hypoabsorptive procedures represent highly effective options for treating obesity, the associated nutritional complications necessitate the need for long-term follow-up and supplementation and highlight the need for careful patient selection.

Background and Objectives: Type 2 diabetes (T2D), closely associated with obesity, contributes to increased morbidity and mortality due to complications such as cardiometabolic disease. This review aims to evaluate the effectiveness of metabolic and bariatric surgeries (MBS) and endoscopic bariatric therapies (EBTs) in achieving diabetes remission and to examine key predictors influencing remission outcomes. Materials and Methods: This review synthesizes data from studies on MBS and EBT outcomes, focusing on predictors for diabetes remission such as preoperative insulin use, diabetes duration, HbA1c, and C-peptide levels. Additionally, predictive scoring systems, including the Individualized Metabolic Surgery (IMS), DiaRem, Advanced-DiaRem, ABCD, and Robert et al. scores, were analyzed for their utility in forecasting remission likelihood. Results: Key predictors of T2D remission include shorter diabetes duration, lower HbA1c, and higher C-peptide levels, while prolonged insulin use, and higher insulin doses are associated with lower remission rates. Scoring models like IMS and DiaRem demonstrate that lower scores correlate with a higher likelihood of remission, especially for procedures such as Roux-En-Y gastric bypass (RYGB). RYGB generally shows higher remission rates compared to sleeve gastrectomy (SG), particularly among patients with mild disease severity, while EBTs like ESG and IGBs contribute 5–20% total weight loss (TWL) and moderate glycemic control improvements. Conclusions: Both MBS and EBTs are effective for T2D management, with predictive scoring models aiding in individualized patient selection to optimize remission outcomes. Further research to validate these predictive tools across diverse populations could enhance treatment planning for both surgical and endoscopic interventions.

Background and Objectives: Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed metabolic and bariatric surgeries worldwide. Marginal ulcers (MU) are a common complication following RYGB, yet their pathophysiology and the contributing risk factors to their development are not fully understood. Materials and Methods: This retrospective cohort study examined patients who underwent RYGB between January 2008 and December 2023, with 1 to 5 years of follow-up. Data collected included patient- and procedure-related risk factors, as well as postoperative MU events. Statistical analysis methods included the independent samples t-tests, multivariate regression, and Cox regression analyses. Results: Our final cohort included 2106 patients and was predominantly female (80.5%), with a mean age of 47.8 ± 12.1 years and body mass index (BMI) of 45.5 ± 7.5 kg/m2. MU occurred in 241 (11.4%) patients, with a mean time to occurrence of 4.5 ± 0.02 years. History of smoking (HR = 1.87, p < 0.001) and gastroesophageal reflux disease (HR = 2.36, p < 0.001) significantly increased hazard for MU, while proton pump inhibitor use (HR = 0.18, p < 0.001) was associated with reduced hazard. Aspirin exposure, regardless of dose and chronicity, did not impact MU. Conclusions: Our findings highlight the importance of preoperative assessment and counseling in patients planning to undergo RYGB. Patient-related factors should guide postoperative monitoring and prophylaxis of MU, as this remains a debated topic amongst experts.

Very low-calorie diets (VLCDs) have been commonly implemented prior to metabolic and bariatric surgery (MBS) with the goal of shrinking left liver lobe size and reducing intra-abdominal mesenteric fat. Through this manuscript, we aimed to review the available literature discussing the types of VLCDs, their mode of implementation, preoperative duration, and the intraoperative and postoperative measures. A total of 103 articles was used in the generation of this review, including 3402 MBS candidates across the studies. VLCD was shown to induce significant preoperative weight loss, reduction in body fat mass, glycemic improvement, and decrease in proinflammatory makers. Liver volume reduction of 5%-23% and abdominal wall circumference reduction of 2.0-8.5 cm were noted following short regimens of VLCD, leading to improvement in perceived intraoperative difficulty. Postoperatively, metabolic improvements and reduction in perioperative complication rates were observed in some studies. In conclusion, VLCD demonstrated potential preoperative, intraoperative, and postoperative improvements in patients undergoing MBS.