The safety profile of one-anastomosis gastric bypass compared to Roux-en-Y gastric bypass: a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program analysis.

One anastomosis gastric bypass (OAGB) is an American Society for Metabolic and Bariatric Surgery (ASMBS)-endorsed bariatric surgery. As utilization of OAGB increases, it is important that the safety profile of OAGB be rigorously assessed. We studied the 30-day safety of OAGB compared to a similar gastro-jejunal anastomotic procedure, Roux-en-Y gastric bypass (RYGB). Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) participating bariatric centers in the United States. A matched case-control study was conducted of patients who underwent primary gastric bypass surgery 2021-2022, identified in the MBSAQIP database. Each patient who underwent OAGB was matched to 4 controls who underwent RYGB on age (±10), sex, race, body mass index (BMI) (±5 kg/m2), preoperative functional status, American Society of Anesthesiologists (ASA) classification, and 13 comorbidities. Univariate and multivariate regression analyses were performed. A total of 1569 patients who underwent OAGB were matched to 6276 controls. Matched baseline characteristics were similar between groups. Operative time, length of stay (LOS), and overall complication rate were lower in the OAGB cohort (P < .001) with higher 30-day BMI loss percentage (P = .048). Specifically, OAGB was associated with a significantly lower bowel obstruction rate, as compared to RYGB (.1% versus 1.0%, P < .001). On logistic regression adjusting for all variables used in matching, OAGB was associated with a 27% decrease in overall complication rate (odds ratio [OR] .73, 95% confidence interval [CI] .62-.87, P < .001). Although OAGB is minimally utilized, the 30-day safety profile appears favorable. As compared to RYGB, OAGB was associated with shorter operative time and LOS, and a lower complication rate, partially due to minimization of small bowel obstructions with a loop anatomy. Further evidence in the comparative long-term safety profile is still needed.

Arshad SA ，Clapp B ，Samreen S ，Noria SF ，Edwards M ，Kindel TL ... -  《-》

Evaluating Safety and Durability of Adolescent Metabolic and Bariatric Surgery.

Metabolic bariatric surgery (MBS) has demonstrated safety in its usage in the adolescent population and can aid in curbing the rising obesity epidemic. However, long-term data surrounding durability of MBS in this population is limited. This study aims to examine both short and long-term outcomes of MBS in adolescents, as well as identify patient characteristics and demographics that may impact operative safety and durability. The New York Statewide Planning and Research Cooperative System was utilized to identify patients 12-19 y old who underwent a bariatric procedure from 2007 to 2018. Patients were followed for the need for revisional or conversion (RC) procedures. Safety was defined by 30-d readmission, length of stay (LOS), and in-hospital complications. Durability was characterized by the incidence of RC after the initial procedure. Variables that were significantly associated with each outcome on univariable analysis were selected for in multivariable regression models. 2241 adolescents underwent MBS in the study time frame; 58.46% of them underwent sleeve gastrectomy (SG). The median LOS was 1.66 ± 1.04 d. The overall in-hospital complication rate was 3.44%; 30-d readmission rate was 3.17%. Roux-en-Y Gastric Bypass (RYGB) patients were more likely to have a 30-d readmission than SG (OR = 1.75 95% CI 1.03-2.96). Factors associated with in hospital complications were preexisting hypertension (OR = 2.008 95% CI 1.141-3.535) and hypothyroidism (OR = 2.459 95% CI 1.132-5.341). Overall, the RC rate was 6.65%. RC rate following laparoscopic adjustable gastric banding (LAGB), RYGB, and SG was 27.33%, 2.08%, and 1.22%, respectively. The incidence of RC was significantly different between patients undergoing different types of bariatric surgery (P-value<0.0001), and it was significantly higher after LAGB comparing to RYGB (HR = 16.16, 95% CI: 7.56-34.51) as well as comparing to SG (HR = 9.22, 95% CI: 5.07-16.78). Insurance status, race or ethnicity, and socioeconomic disadvantage were not significantly associated with 30-d readmissions, in-hospital complications, LOS, or RC. Adolescent patients experience a low rate of postoperative adverse events following MBS. These procedures remain durable over time for this patient cohort. These positive results are regardless of race, ethnicity, and insurance status. This study identifies that female patients and LAGB patients are at highest risk for need for eventual RC, suggesting the need for closer postoperative follow-up for these specific patient cohorts.

Torres A ，Khomutova A ，Sethi I ，Zhang X ，Yang J ，Lee E ，Spaniolas K ... -  《-》

Concurrent minimally invasive bariatric surgery and ventral hernia repair with mesh; Is it safe? Propensity score matching analysis using the 2015-2022 MBSAQIP database.

Obesity is a risk factor for the development of ventral hernias. Approximately eight percent of patients undergoing bariatric surgery have a concomitant ventral hernia. However, the optimal timing of hernia repair in these patients is debated. Concerns regarding mesh insertion in a potentially contaminated field are often cited by opponents of a combined approach. Our study compares 30-day outcomes of bariatric surgery with concurrent ventral hernia repair with mesh versus bariatric surgery alone. Using the 2015-2022 MBSAQIP database, patients aged 18-65 years who underwent minimally invasive sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) with or without concurrent ventral hernia repair with mesh (VHR-M) were identified. 30-day postoperative outcomes were compared between patients who underwent SG or RYGB with VHR-M versus SG or RYGB alone. 1:1 propensity score matching was performed using 26 preoperative characteristics to adjust confounders. Among 1,236,644 patients who underwent SG (n = 871,326) or RYGB (n = 365,318), 3,121 underwent SG + VHR-M and 2,321 RYGB + VHR-M. The concurrent approach had longer operative times, in SG + VHR-M (86.06 ± 42.78 vs. 73.80 ± 38.45 min, p < 0.001), and in RYGB + VHR-M (141.91 ± 58.68 vs. 128.47 ± 62.37 min, p < 0.001). The RYGB + VHR-M cohort had higher rates of reoperations (3.2% vs. 2.1%, p = 0.024). Overall, 30-day outcomes, and bariatric-specific complications such as mortality, unplanned ICU admissions, surgical site complications, cardiac, pulmonary, renal complications, anastomotic leaks, postoperative bleeding, and intestinal obstruction were similar between SG + VHR-M or RYGB + VHR-M groups versus SG or RYGB alone. Bariatric surgery performed concurrently with VHR-M is safe and feasible and does not excessively prolong operative times. However, patients undergoing RYGB with VHR-M do have a higher rate of reoperations, therefore a staged VHR is recommended. On the other hand, concurrent SG and VHR-M may benefit after an appropriate individualized risk stratification assessment.

Brown J ，Cornejo J ，Zevallos A ，Sarmiento J ，Powell J ，Shojaeian F ，Mokhtari-Esbuie F ，Adrales G ，Li C ，Sebastian R ... -  《-》

Comparison of One-Year Outcomes in Sleeve Gastrectomy vs. One Anastomosis Gastric Bypass in a Single Bariatric Unit.

Introduction Sleeve gastrectomy (SG) is the most popular bariatric procedure worldwide in terms of numbers performed. However, there has been a rise in the popularity of the one anastomosis (mini) gastric bypass (OAGB). There have been various studies comparing the outcomes of SG vs OAGB and this study aims to add our experience and compare one-year outcome data between SG and OAGB in a single UK bariatric centre. Methods A retrospective search of our database between June 2021 and August 2023 was performed to identify those patients undergoing either laparoscopic SG or OAGB. Initial and one-year follow-up data was collected including percentage total weight loss (%TWL), percentage excess body weight loss (%EBWL), incidence of post-operative reflux, remission of co-morbidities (diabetes), glycated haemoglobin (HbA1c) changes, operating time and post-operative complications.  Results A total of 64 OAGB and 53 SG patients were identified in this time frame. Nineteen OAGB and 26 SG patients had one-year outcome data available and so were included in the final analysis. Pre-op BMI was significantly lower in the OAGB group (OAGB = 47.1, SG = 52.7, p<0.05). Initial age, rates of pre-operative gastro-oesophageal reflux symptoms and pre-operative diabetes were comparable. Regarding one-year outcomes, %EBWL was comparable, as was the length of stay, reduction in HbA1c and resolution of diabetes. Operating time was significantly shorter in the SG group (OAGB = 140 mins, SG = 111 mins, p<0.05). While the number of patients with post-operative complications was the same in both groups, two patients in the OAGB group suffered from ulcer disease with one requiring a return to theatre for this. No patients in the SG group suffered from ulcer disease. One OAGB patient required conversion to Roux-en-Y gastric bypass (RYGB) for reflux, while three SG patients required conversion to RYGB for resistant reflux. Conclusion Both OAGB and SG patients in our centre have comparable outcomes with regard to excess body weight loss and resolution of diabetes. SG was quicker to perform. OAGB may be associated with higher rates of ulceration while SG may be associated with higher rates of treatment-resistant reflux requiring conversion surgery. The literature has revealed greater weight loss and increased rates of diabetes resolution with OAGB. This along with our findings will be considered when counselling our patients on the bariatric procedures available to them.

Das K ，Nadeem F ，Kabir SA 《Cureus》

Comparison of Two Modern Survival Prediction Tools, SORG-MLA and METSSS, in Patients With Symptomatic Long-bone Metastases Who Underwent Local Treatment With Surgery Followed by Radiotherapy and With Radiotherapy Alone.

Survival estimation for patients with symptomatic skeletal metastases ideally should be made before a type of local treatment has already been determined. Currently available survival prediction tools, however, were generated using data from patients treated either operatively or with local radiation alone, raising concerns about whether they would generalize well to all patients presenting for assessment. The Skeletal Oncology Research Group machine-learning algorithm (SORG-MLA), trained with institution-based data of surgically treated patients, and the Metastases location, Elderly, Tumor primary, Sex, Sickness/comorbidity, and Site of radiotherapy model (METSSS), trained with registry-based data of patients treated with radiotherapy alone, are two of the most recently developed survival prediction models, but they have not been tested on patients whose local treatment strategy is not yet decided. (1) Which of these two survival prediction models performed better in a mixed cohort made up both of patients who received local treatment with surgery followed by radiotherapy and who had radiation alone for symptomatic bone metastases? (2) Which model performed better among patients whose local treatment consisted of only palliative radiotherapy? (3) Are laboratory values used by SORG-MLA, which are not included in METSSS, independently associated with survival after controlling for predictions made by METSSS? Between 2010 and 2018, we provided local treatment for 2113 adult patients with skeletal metastases in the extremities at an urban tertiary referral academic medical center using one of two strategies: (1) surgery followed by postoperative radiotherapy or (2) palliative radiotherapy alone. Every patient's survivorship status was ascertained either by their medical records or the national death registry from the Taiwanese National Health Insurance Administration. After applying a priori designated exclusion criteria, 91% (1920) were analyzed here. Among them, 48% (920) of the patients were female, and the median (IQR) age was 62 years (53 to 70 years). Lung was the most common primary tumor site (41% [782]), and 59% (1128) of patients had other skeletal metastases in addition to the treated lesion(s). In general, the indications for surgery were the presence of a complete pathologic fracture or an impending pathologic fracture, defined as having a Mirels score of ≥ 9, in patients with an American Society of Anesthesiologists (ASA) classification of less than or equal to IV and who were considered fit for surgery. The indications for radiotherapy were relief of pain, local tumor control, prevention of skeletal-related events, and any combination of the above. In all, 84% (1610) of the patients received palliative radiotherapy alone as local treatment for the target lesion(s), and 16% (310) underwent surgery followed by postoperative radiotherapy. Neither METSSS nor SORG-MLA was used at the point of care to aid clinical decision-making during the treatment period. Survival was retrospectively estimated by these two models to test their potential for providing survival probabilities. We first compared SORG to METSSS in the entire population. Then, we repeated the comparison in patients who received local treatment with palliative radiation alone. We assessed model performance by area under the receiver operating characteristic curve (AUROC), calibration analysis, Brier score, and decision curve analysis (DCA). The AUROC measures discrimination, which is the ability to distinguish patients with the event of interest (such as death at a particular time point) from those without. AUROC typically ranges from 0.5 to 1.0, with 0.5 indicating random guessing and 1.0 a perfect prediction, and in general, an AUROC of ≥ 0.7 indicates adequate discrimination for clinical use. Calibration refers to the agreement between the predicted outcomes (in this case, survival probabilities) and the actual outcomes, with a perfect calibration curve having an intercept of 0 and a slope of 1. A positive intercept indicates that the actual survival is generally underestimated by the prediction model, and a negative intercept suggests the opposite (overestimation). When comparing models, an intercept closer to 0 typically indicates better calibration. Calibration can also be summarized as log(O:E), the logarithm scale of the ratio of observed (O) to expected (E) survivors. A log(O:E) > 0 signals an underestimation (the observed survival is greater than the predicted survival); and a log(O:E) < 0 indicates the opposite (the observed survival is lower than the predicted survival). A model with a log(O:E) closer to 0 is generally considered better calibrated. The Brier score is the mean squared difference between the model predictions and the observed outcomes, and it ranges from 0 (best prediction) to 1 (worst prediction). The Brier score captures both discrimination and calibration, and it is considered a measure of overall model performance. In Brier score analysis, the "null model" assigns a predicted probability equal to the prevalence of the outcome and represents a model that adds no new information. A prediction model should achieve a Brier score at least lower than the null-model Brier score to be considered as useful. The DCA was developed as a method to determine whether using a model to inform treatment decisions would do more good than harm. It plots the net benefit of making decisions based on the model's predictions across all possible risk thresholds (or cost-to-benefit ratios) in relation to the two default strategies of treating all or no patients. The care provider can decide on an acceptable risk threshold for the proposed treatment in an individual and assess the corresponding net benefit to determine whether consulting with the model is superior to adopting the default strategies. Finally, we examined whether laboratory data, which were not included in the METSSS model, would have been independently associated with survival after controlling for the METSSS model's predictions by using the multivariable logistic and Cox proportional hazards regression analyses. Between the two models, only SORG-MLA achieved adequate discrimination (an AUROC of > 0.7) in the entire cohort (of patients treated operatively or with radiation alone) and in the subgroup of patients treated with palliative radiotherapy alone. SORG-MLA outperformed METSSS by a wide margin on discrimination, calibration, and Brier score analyses in not only the entire cohort but also the subgroup of patients whose local treatment consisted of radiotherapy alone. In both the entire cohort and the subgroup, DCA demonstrated that SORG-MLA provided more net benefit compared with the two default strategies (of treating all or no patients) and compared with METSSS when risk thresholds ranged from 0.2 to 0.9 at both 90 days and 1 year, indicating that using SORG-MLA as a decision-making aid was beneficial when a patient's individualized risk threshold for opting for treatment was 0.2 to 0.9. Higher albumin, lower alkaline phosphatase, lower calcium, higher hemoglobin, lower international normalized ratio, higher lymphocytes, lower neutrophils, lower neutrophil-to-lymphocyte ratio, lower platelet-to-lymphocyte ratio, higher sodium, and lower white blood cells were independently associated with better 1-year and overall survival after adjusting for the predictions made by METSSS. Based on these discoveries, clinicians might choose to consult SORG-MLA instead of METSSS for survival estimation in patients with long-bone metastases presenting for evaluation of local treatment. Basing a treatment decision on the predictions of SORG-MLA could be beneficial when a patient's individualized risk threshold for opting to undergo a particular treatment strategy ranged from 0.2 to 0.9. Future studies might investigate relevant laboratory items when constructing or refining a survival estimation model because these data demonstrated prognostic value independent of the predictions of the METSSS model, and future studies might also seek to keep these models up to date using data from diverse, contemporary patients undergoing both modern operative and nonoperative treatments. Level III, diagnostic study.

Lee CC ，Chen CW ，Yen HK ，Lin YP ，Lai CY ，Wang JL ，Groot OQ ，Janssen SJ ，Schwab JH ，Hsu FM ，Lin WH ... -  《-》