Weight Recidivism After Bariatric Surgery

Weight Recidivism After Bariatric Surgery

S2 2017 Top Ten Abstracts / Surgery for Obesity and Related Diseases 13 (2017) S1–S6 A102 ALARMING TRENDS REGARDING LAPAROSCOPIC SLEEVE GASTRECTOMY...

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2017 Top Ten Abstracts / Surgery for Obesity and Related Diseases 13 (2017) S1–S6

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ALARMING TRENDS REGARDING LAPAROSCOPIC SLEEVE GASTRECTOMY Benjamin Clapp1; Colin Martyn2; Matthew Wynn2; Chase Foster2; Caesar Ricci2; Alan Tyroch2; Montana O'Dell2; 1Benjamin Clapp MD PA, El Paso TX; 2Texas Tech PF School of Medicine, El Paso TX Background: The laparoscopic sleeve gastrectomy is now the most common bariatric operation in the United States. It has become a standard in the armamentarium of the bariatric surgeon, and is the only operation offered by some surgeons. However, there is a lack of long term data on outcomes of the sleeve, namely the rate of revision and durability of the weight loss. Newly published data from around the world is starting to show alarming trends in these two areas. This paper will examine the published and presented data with at least a 7 year follow up. Methods: We performed a meta-analysis of publications with at least 7 years of follow up with the key words: sleeve gastrectomy, laparoscopic, weight regain, reflux, revisions, conversion, long term follow up, and 7 through 11 year follow up. We queried the PubMed, Medline, and ClinicalKey search engines, which included abstracts also. I2 statistic was used to determine the heterogeneity across the studies. In presence of heterogeneity, the Random effect models using the Der-Simonian and Laird method were used to estimate the pooled estimates. Meta regression was also used to assess the effect of BMI and follow up years on the incidence of failure. Results: Nine cohort studies with at least 7 years of follow up were included in this meta-analysis. A total of 2375 (completers 652) patients were included in the analysis. The overall incidence of failure rate (o50EWL) was estimated as 24.2% (I2¼75.9%; 95%CI: 16.5%, 31.9%) with the range of 12% to 35%. In the revision patients, the pooled estimate of failure rate was estimated as 33% (I2¼92.6%; 95% CI: 19%, 46%) for EWL (n¼7) while 7.7% (I2¼27.5%; 95%CI: 4.7%, 10.6%) was estimated for GERD (n¼5). Rate of failure was 24.7% in no-revision group while 24% in the revision group. The longer (48) follow up duration showed a trend towards positive association (regression coefficient¼1.82, p¼0.11) with failure rate compared to o¼8 years of follow up, however no effect of BMI was noticed (regression coefficient¼0.005, p¼0.63). Conclusions: Based on available data up to the beginning of 2017, bariatric surgeons should be wary regarding the long-term outcomes of the sleeve gastrectomy, especially regarding revisions and weight

regain. It is incumbent on the surgeon to make sure that bariatric patients are truly informed regarding the results of the sleeve gastrectomy. A103

WEIGHT RECIDIVISM AFTER BARIATRIC SURGERY Michael Morell1; Shanu Kothari2; Andrew Borgert3; Matthew Baker2; Brandon Grover2; 1Gundersen Medical Foundation, Encinitas CA; 2Gundersen Health System, La Crosse WI; 3Gundersen Medical Foundation, La Crosse WI Background: A proportion of patients have been observed to regain some weight after bariatric surgery; however, the amount of weight regain and concept of weight recidivism have not been well defined. A measure of 50% excess weight loss (EWL) has been commonly used to define successful weight loss. The objective of this study was to demonstrate the variability in outcomes based on different definitions of successful weight loss following bariatric surgery. We also sought to identify potential risk factors for weight recidivism after laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). Methods: A retrospective review of all patients who underwent LRYGB or LSG from September 2001 through December 2016 was completed. Patients with o1 year of follow-up data were excluded. Several definitions of weight recidivism were considered: 1) BMI increase to ≥35 kg/m2 after experiencing a BMI ≤35kg/m2, 2) BMI increase of ≥5 kg/m over nadir BMI, 3) Any 10kg increase from nadir weight, 4) Weight regain of 425% EWL over nadir, and 5) EWL o50% after experiencing ≥50% EWL. Results: Overall, 1766 patients underwent bariatric surgery; 1490 underwent LRYGB and 276 underwent LSG. Preoperative mean age and BMI were 44.9±10.4 years and 47.6±6.4 kg/m2, respectively; 81% were female. The lowest BMI and maximum EWL was reached between 1-2 years follow-up at 30.2±5.4 kg/m2, and 80±21%, respectively. Overall, 1,395 of 1,496 patients (93%) with complete data experienced ≥50% EWL by 1-2 years postoperative. Over 50% of patients with complete data maintained their weight based on several of the proposed definitions of weight recidivism through 5 years follow-up (Table). While patients with versus without type 2 diabetes were less likely to experience ≥50% EWL at 1-2 years postoperative (89% vs. 95%; Po0.001), no differences were observed for those with dyslipidemia, hypertension, or advanced age. The mean preoperative BMI was 51.8±7.1 vs. 47.3±6.2 kg/m2 for those that did vs. did not experience ≥50% EWL at 1-2 years postoperative (Po0.001). Conclusions: A very high percentage (93%) of patients achieve ≥50% EWL after surgery. Over a long-term follow-up period, a large proportion of patients maintained their weight based on various definitions of weight recidivism. Preoperative BMI and presence of diabetes are associated with reduced EWL in the early postoperative period. Obesity is a chronic disease and weight recidivism varies widely (25-50% at 5 years postoperative) based

2017 Top Ten Abstracts / Surgery for Obesity and Related Diseases 13 (2017) S1–S6

on various definitions. A standard definition is still needed and further research in this area is warranted. A104

LIVE SURGERY COURSES. RETROSPECTIVE SAFETY ANALYSIS AFTER 11 EDITIONS Amador Garcia Ruiz1; Beatriz Campillo Alonso1; Maria Sorribas Grifell2; Almino Cardoso Ramos3; Manoel Galvao Neto3; Mario Nora4; Andrés Sánchez Pernaute5; Antonio Torres5; JORDI PUJOL GEBELLI2; 1HOSPITAL UNIVERSITARIO DE BELLVITGE, L'Hospitalet de Llobregat Barcelona; 2HOSPITAL UNIVERSITARIO DE BELLVITGE, Barcelona España; 3Gastro Obeso Center. Sao Paulo. Brazil, Sao Paulo Sao Paulo; 4CHEDV. Porto. Portugal; 5Hospital Clinico San Carlos. Madrid, Madrid Madrid Introduction: Live surgery is one of the most intersting topics of every meeting or course in the field of surgery. The facilities that laparoscopy gives for broadcasting make it an excellent tool in continuous medical education. Surgeons who take part in those live surgeries may be experienced but there are several conditions that may influence the results and the safety of the procedure. On a yearly basis since 2006 our Institution hosts an International Bariatric Course. Every year, first line international surgeons took part and performed most of the surgeries. Objectives: To analyze the safety and the results of a series of patients operated for the last 10 years in a live surgery course organized at our Institution. Methods: We restrospectively analyzed all the patients operated at those courses since 2006 to 2016. We evaluated postoperative morbidity and mortality and long term results. Results: 107 patients were operated. 74 were women (68.5%) with a mean age was 44.75 years old (range 22 to 64). 38 cases (35.2%) were revisional surgery and 5 of those were patients operated in previous editions. The most performed procedures were Roux-n-Y Gastric Bypass (38.9%), Sleeve Gastrectomy (16.7%) and Duodenal Switch (14%). 10 cases were endoscopic procedures, 2 of them were revisions after a failed primary surgery. Overall morbidity was 14 cases (13%) and 6 of them required reoperation at early postoperative time (5.6%). Most of the complications were Clavien 2-3. The most common complication was bleeding (72.4%). There was no anastomotic leak, there was just one duodenal stump leak. During follow up 6 patients had any kind of surgical complication and 5 were indicated for revisional surgery. There was no mortality. Discussion: Even the population type and the indications for primary and revisional surgery were equivalent to our daily practice, we found a higher morbidity and reoperation rate. Also, the conversion rate in long term follow-up was higher. Despite the educational benefits of these courses we might take into consideration the higher risk to our patients for future editions. A105

INVESTIGATION OF THE ROLE OF THE GUT MICROBIOTA IN SUSTAINED WEIGHT LOSS FOLLOWING ROUX-EN-Y GASTRIC BYPASS SURGERY Farnaz Fouladi1; Amanda Brooks1; Carrie Nelson1; Ian Carroll2; Kristine Steffen1; 1North Dakota State University, Fargo ND; 2 University of North Carolina, Chapel hill NC

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Background: The aim of this study was to investigate the role of the gut microbiota in weight regain after RYGB surgery using a humanized mouse model. Method: The gut microbiota from patients who had undergone RYGB 3-5 years prior and had lost and maintained more than 50% of their excess weight (successful weight loss, SWL, n¼3) or lost and/or maintained less than 50% of their excess weight (poor weight loss, PWL, n¼3) were characterized using high-throughput sequencing of the 16S rRNA genes. To investigate the etiological role of the gut microbiota in suboptimal post-surgical weight outcomes, a humanized mouse model was employed. In this model, 15 C57BL/6 mice received a broad spectrum of antibiotics for 17 days. Following antibiotic treatment, fecal samples from human patients were transplanted into the antibiotic-treated mice through oral gavage. Weight gain and food intake were measured at weekly intervals following colonization. Plasma glucagon-likepeptide-1 (GLP-1) was measured by an enzyme-linked immunosorbent assay one week following colonization. Results: PWL patients had a mean BMI of 38.13 kg/m2 and SWL patients had a mean BMI of 29.97 kg/m2 at the time of enrollment with average percent excess weight loss of 40.3% and 60.0%, respectively. The gut microbiota was compositionally different between PWL and SWL patients. Following fecal transplantation, mice colonized with the gut microbiota from PWL patients gained significantly greater weight compared to mice colonized with SWL at week 1 (2.93% vs. -2.31% of the baseline weight; po0.05), week 2 (9.54% vs. 2.09%; po0.05), week 3 (14.47% vs. 4.62%; po0.05), and week 4 (18.47% vs. 7.05%; po0.05). Average weekly food intake was not significantly different between mice colonized with PWL and SWL microbiota (31.60±11.33 g vs. 29.48±7.64 g). Plasma levels of GLP-1 one week after colonization tended to be higher in mice colonized with GWL microbiota compared with mice colonized with PWL microbiota, but this finding did not reach significance (55.84±13.42 pM vs. 40.98 ±6.63 pM). Conclusions: The preliminary data support the hypothesis that the difference in the gut microbiota between patients with PWL and SWL may contribute to weight gain after surgery. Results from this animal study suggest that the gut microbiota could affect weight profile through mechanisms independent of food intake. Additional work is underway to enlarge the sample sizes of human volunteers and mice to confirm the preliminary results and to further investigate the influence of the post-surgical gut microbiota on GLP-1 and bile acids.

THURSDAY NOVEMBER 2nd, 2017

TOP TEN PAPERS PART 2

8:00am–10:15am

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PATIENT PERSPECTIVES ON EMERGENCY DEPARTMENT SELF-REFERRAL Haley Stevens1; Amanda Stricklen1; Rachel Ross1; Arthur Carlin2; Rafael Alvarez1; Amir Ghaferi1; 1University of Michigan, Ann Arbor MI; 2Henry Ford Health System, Detroit MI Introduction: Reducing avoidable emergency department (ED) visits is an increasingly important target of quality improvement