Procedure and Patient Selection in Bariatric and Metabolic Surgery

Introduction: Sleeve Gastrectomy (SG), Roux-en-Y Gastric Bypass (RYGB), and One Anastomosis Gastric Bypass (OAGB) are the commonest bariatric procedures performed worldwide. The purpose of this review was to analyse comparative data on these three procedures to aid patient and procedure selection for patients seeking Bariatric and Metabolic Surgery (BMS). Evidence Acquisition: We examined published English language scientific literature available on PubMed for data comparing SG, RYGB, and OAGB for various groups of patients. Evidence Synthesis: There are a number of variables that can influence patient and procedure selection for individuals seeking BMS. High-quality data comparing each of these procedures for every patient subgroup, for each possible outcome measure is lacking. It is, therefore, not currently possible to make strict recommendations regarding patient and procedure selection. At the same time, the multidisciplinary teams should understand that risks of surgery may simply be too high for some patients – such as those suffering from end-stage organ disease and those suffering from mega obesity (BMI ≥ 70 kg/m2). Surgery should only be offered to such high-risk groups in dedicated centres with appropriate expertise. For other patients, surgeons should carefully consider the pros and cons of each procedure, their own experience, and patient preferences before deciding the most appropriate BMS procedure for them. Conclusion: This review examines various factors influencing patient and procedure selection in bariatric surgery. Authors feel it is currently not possible to make strict recommendations and surgeons should carefully discuss the pros and cons of bariatric surgery and that of various options available in their practice with the patients before making a final recommendation

Induction of labour in pregnancies with fetal demise: a randomised control trial

Background: The present study aims at comparing efficacy and safety of two different regimens of induction of labour (IOL) in pregnancies with fetal demise. Settings and Design: A randomised controlled trial was conducted on 100 eligible pregnant women diagnosed with intrauterine fetal demise who were admitted in the labour ward of a tertiary care hospital. Methods: All participants were randomly divided into two groups in group A and group B. In Group A, IOL was done with transcervical foley’s catheter and vaginal misoprostol while in group B, mifepristone with vaginal misoprostol were used for IOL. During intrapartum period the mode of delivery, induction-delivery interval, total dose of induction agent used and amount of total blood loss were noted. Any side effect if present was also noted. Results: Comparing both the groups, Induction delivery interval was less in group A as compared to group B. Conclusions: Use of mifepristone with misoprostol as well as Foley’s with misoprostol were found to be equally safe and effective methods

A drug utilization study in glaucoma patients in ophthalmology out patient department in a tertiary care hospital

Background: According to World Health Organization (WHO) studies Glaucoma is a chronic progressive symptomatic disease that damages retinal cells and is one of the leading cause of preventable blindness worldwide. Availability of newer topical agents has modernized the management of glaucoma.Methods: A prospective observational study was carried out from August 2016 to December 2016 at ophthalmology Out Patient Department of L.G General Hospital, Ahmedabad by authours after the approval of the Institutional Ethics Committee.Results: Out of total 101 patients, 71 were males and 30 were females. Average age of patient is 54 years. Common variant of Glaucoma was Primary Open Angle Glaucoma in 57.4% of patients. Average number of drugs per prescription was 2 (45%). Most commonly used Fixed Dose Combination was Brimonidine +Timolol Drops which was used in 87 (86.1%) patients. Most commonly used adjuvant drug was Tab. Acetazolamide (60% of patients).Conclusions: Common variant of Glaucoma was Primary Open Angle Glaucoma in 57.4% of patients. Most commonly used Fixed Dose Combination was Brimonidine+Timolol Drops which was used in 87 (86.1%) patients and commonly used Single drug therapy is Tab. Acetazolamide in (60% of patients)

Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus

Bariatric surgery; Consensus; Metabolic surgeryCirugía bariátrica; Consenso; Cirugía metabólicaCirurgia bariàtrica; Consens; Cirurgia metabòlicaMetabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future

Bariatric and metabolic surgery in patients with low body mass index: an online survey of 543 bariatric and metabolic surgeons

Bariatric surgery; Metabolic surgery; SurveyCirugía bariátrica; Cirugía metabólica; EncuestaCirurgia bariàtrica; Cirurgia metabòlica; EnquestaBackground Metabolic and bariatric surgery (MBS) in patients with low body mass index patients is a topic of debate. This study aimed to address all aspects of controversies in these patients by using a worldwide survey. Methods An online 35-item questionnaire survey based on existing controversies surrounding MBS in class 1 obesity was created by 17 bariatric surgeons from 10 different countries. Responses were collected and analysed by authors. Results A total of 543 bariatric surgeons from 65 countries participated in this survey. 52.29% of participants agreed with the statement that MBS should be offered to class-1 obese patients without any obesity related comorbidities. Most of the respondents (68.43%) believed that MBS surgery should not be offered to patients under the age of 18 with class I obesity. 81.01% of respondents agreed with the statement that surgical interventions should be considered after failure of non-surgical treatments. Conclusion This survey demonstrated worldwide variations in metabolic/bariatric surgery in patients with class 1 obesity. Precise analysis of these results is useful for identifying different aspects for future research and consensus building

Areas of Non-Consensus Around One Anastomosis/Mini Gastric Bypass (OAGB/MGB): A Narrative Review

One anastomosis/mini gastric bypass (OAGB/MGB) is now an established bariatric and metabolic surgical procedure with good outcomes. Despite two recent consensus statements around OAGB/MGB, there are some issues which are not accepted as consensus and need more long-term data and research

Portomesenteric vein thrombosis in patients undergoing sleeve gastrectomy: An updated meta-analysis of 101,865 patients

Background: Portomesenteric vein thrombosis (PMVT) is a rare but potentially fatal complication of sleeve gastrectomy (SG). The rising prevalence of SG has led to a surge in the occurrence of PMVT, while the associated risk factors have not been fully elucidated.Objectives: This study aims to determine the incidence and risk factors of PMVT in patients undergoing SG.Methods: A comprehensive literature search was performed in PubMed (MEDLINE) and EMBASE databases. Proportion and regression meta-analyses were conducted.Results: A total of 75 studies and 101,865 patients undergoing SG and 355 patients with PMVT were identified. At a mean follow-up of 14.4 (SD: 16.3) months the incidence of PMVT was found to be 0.48% (95%CI: 0.39-0.60%). The majority of the population presented with abdominal pain (91.8%) at an average of 22.4 days postoperatively and PMV was mainly diagnosed with CT scan (96.0%). Hematologic abnormalities predisposing to thrombophilia were identified in 34.9% of the population. Age (p=0.02) and center volume (p &lt;0.0001) were significantly associated with PMVT, while gender, BMI, hematologic abnormality, prior history of deep vein thrombosis or pulmonary embolism, type of prophylactic anticoagulation, and duration of prophylactic anticoagulation were not associated with the incidence of PMVT in meta-regression analyses. Treatment included therapeutic anticoagulation in 93.4% and the mortality rate was 4/355 (1.1%).Conclusion: PMVT is a rare complication of sleeve gastrectomy with an incidence rate &lt;1% that is associated with center volume and age but is not affected by the duration or type of thromboprophylaxis administered postoperatively.<br/

Weight Management Interventions for Adults With Idiopathic Intracranial Hypertension:A Systematic Review and Practice Recommendations

Background and Objectives Idiopathic intracranial hypertension (IIH) is associated with obesity, however there is a lack of clinical consensus on how to manage weight in IIH. The aim of this systematic review is to evaluate weight loss interventions in people with IIH to determine which intervention is superior in terms of weight loss, reduction in intracranial pressure, benefit to visual and headache outcomes, quality of life, and mental health.Methods A systematic review was carried out in accordance with PRISMA guidelines and registered with PROSPERO (CRD42023339569). MEDLINE and CINAHL were searched for relevant literature published from inception until 15th December 2022. Screening and quality appraisal was conducted by two independent reviewers. Recommendations were graded using Scottish Intercollegiate Guidelines Network (SIGN) methodology.Results A total of 17 studies were included. Bariatric surgery resulted in 27.2-27.8kg weight loss at 24 months (Level 1- to 1++). Lifestyle weight management interventions resulted in between 1.4 to 15.7kg weight loss (Level 2+ to 1++). Bariatric surgery resulted in the greatest mean reduction in ICP (-11.9cm H2O) at 24 months (Level 1++), followed by multi-component lifestyle intervention + acetazolamide (-11.2cm H2O) at 6 months (Level 1+), and then a very low energy diet intervention (-8.0cm H2O) at 3 months (Level 2++). The least ICP reduction was shown at 24 months after completing a 12-month multi-component lifestyle intervention (-3.5 cm H2O) (Level 1++). Reduction in body weight was shown to be highly correlated with reduction in ICP (Level 2++ to 1++).Discussion Bariatric surgery should be considered for women with IIH and a BMI ≥35kg/m2 since this had the most robust evidence for sustained weight management (Grade A). A multi-component lifestyle intervention (diet + physical activity + behaviour) had the most robust evidence for modest weight loss with a BMI &lt;35kg/m2 (Grade B). Longer term outcomes for weight management interventions in people with IIH are required, to determine if there is a superior weight loss intervention for IIH

Weight Management Interventions for Adults with Idiopathic Intracranial Hypertension:A Systematic Review and Practice Recommendations

Background and Objectives: Idiopathic intracranial hypertension (IIH) is associated with obesity; however, there is a lack of clinical consensus on how to manage weight in IIH. The aim of this systematic review was to evaluate weight loss interventions in people with IIH to determine which intervention is superior in terms of weight loss, reduction in intracranial pressure (ICP), benefit to visual and headache outcomes, quality of life, and mental health.Methods: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered with PROSPERO (CRD42023339569). MEDLINE and CINAHL were searched for relevant literature published from inception until December 15, 2022. Screening and quality appraisal was conducted by 2 independent reviewers. Recommendations were graded using Scottish Intercollegiate Guidelines Network methodology.Results: A total of 17 studies were included. Bariatric surgery resulted in 27.2-27.8 kg weight loss at 24 months (Level 1-to 1++). Lifestyle weight management interventions resulted in between 1.4 and 15.7 kg weight loss (Level 2+ to 1++). Bariatric surgery resulted in the greatest mean reduction in ICP (-11.9 cm H2O) at 24 months (Level 1++), followed by multicomponent lifestyle intervention + acetazolamide (-11.2 cm H2O) at 6 months (Level 1+) and then a very low-energy diet intervention (-8.0 cm H2O) at 3 months (Level 2++). The least ICP reduction was shown at 24 months after completing a 12-month multicomponent lifestyle intervention (-3.5 cm H2O) (Level 1++). Reduction in body weight was shown to be highly correlated with reduction in ICP (Level 2++ to 1++).Discussion: Bariatric surgery should be considered for women with IIH and a body mass index (BMI) ≥35 kg/m2 since this had the most robust evidence for sustained weight management (grade A). A multicomponent lifestyle intervention (diet + physical activity + behavior) had the most robust evidence for modest weight loss with a BMI &lt;35 kg/m2 (grade B). Longer-Term outcomes for weight management interventions in people with IIH are required to determine whether there is a superior weight loss intervention for IIH.</p