Publications by authors named "Gerhard Prager"

144 Publications

Defining Global Benchmarks in Elective Secondary Bariatric Surgery Comprising Conversional, Revisional and Reversal Procedures.

Ann Surg 2021 Jul 29. Epub 2021 Jul 29.

Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland Department of General Surgery, AZ Sint Jan Brugge-Oostende, Bruges, Belgium Department of Surgery, Rijnstate Hospital/Vitalys Clinics, Arnhem, The Netherlands Department of General Surgery, University Hospital Leuven, Leuven, Belgium Minimally Invasive and Bariatric Surgery, Fresno Heart and Surgical Hospital, Fresno, CA, USA The Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, FL, USA Bariatric and Metabolic Center, Department of Surgery, Clinica Las Condes, Las Condes, Santiago, Chile Department of Visceral Surgery, Clarunis: St.Clara Hosptital, Basel, Switzerland Department of Visceral Surgery, University Hospital Lausanne, Lausanne, Switzerland Digestive Surgery and Liver Transplantation Unit, University Hospital Nice, University Côte d'Azur, Nice, France Department of Surgery, Medical University of Vienna, Vienna, Austria Department ofGastroenterological Surgery, University of Helsinki, Helsinki University Hospital, Helsinki, Finland Department of Surgery, Hospital Clínico San Carlos, Complutense University of Madrid, Madrid, Spain Bariatric and Metabolic Surgery Center, Dipreca Hospital, Las Condes, Santiago, Chile Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton, UK Department of Surgery, St Blasius Hospital, Dendermonde, Belgium Department of Surgery, Delta CHIREC Hospital, Brussels, Belgium Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan The European School of Laparoscopic Surgery, St Pierre University Hospital, Brussels, Belgium Department of Surgery, University of Turku, Turku, Finland Department of Surgery, Riviera-Chablais Hospital, Rennaz, Switzerland Department of Clinical Research, University of Basel, Basel, Switzerland Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland Department of Hepatobiliary and Pancreas Surgery and Liver Transplantation, Royal Free Hospital, London, UK.

Objective: To define "best possible" outcomes for secondary bariatric surgery (BS).

Background: Management of poor response and of long-term complications after BS is complex and under-investigated. Indications and types of reoperations vary widely and postoperative complication rates are higher compared to primary BS.

Methods: Out of 44,884 BS performed in 18 high-volume centers from 4 continents between 06/2013-05/2019, 5,349 (12%) secondary BS cases were identified. Twenty-one outcome benchmarks were established in low-risk patients, defined as the 75th percentile of the median outcome values of centers. Benchmark cases had no previous laparotomy, diabetes, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, thromboembolic events, BMI> 50 kg/m2 or age> 65 years.

Results: The benchmark cohort included 3143 cases, mainly females (85%), aged 43.8 ± 10 years, 8.4 ± 5.3 years after primary BS, with a BMI 35.2 ± 7 kg/m2. Main indications were insufficient weight loss (43%) and gastro-esophageal reflux disease/dysphagia (25%). 90-days postoperatively, 14.6% of benchmark patients presented ≥1 complication, mortality was 0.06% (n = 2). Significantly higher morbidity was observed in non-benchmark cases (OR 1.37) and after conversional/reversal or revisional procedures with gastrointestinal suture/stapling (OR 1.84). Benchmark cutoffs for conversional BS were ≤4.5% re-intervention, ≤8.3% re-operation 90-days postoperatively. At 2-years (IQR 1-3) 15.6% of benchmark patients required a reoperation.

Conclusion: Secondary BS is safe, although postoperative morbidity exceeds the established benchmarks for primary BS. The excess morbidity is due to an increased risk of gastrointestinal leakage and higher need for intensive care. The considerable rate of tertiary BS warrants expertise and future research to optimize the management of non-success after BS.
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http://dx.doi.org/10.1097/SLA.0000000000005117DOI Listing
July 2021

Characterization of endogenous bile acid composition in individuals with cold-activated brown adipose tissue.

Mol Cell Endocrinol 2021 10 28;536:111403. Epub 2021 Jul 28.

Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Vienna, Austria. Electronic address:

Introduction: Bile acid signaling has been suggested to promote BAT activity in various experimental models. However, little is known if and how physiologic bile acid metabolism is linked to BAT function in humans. Here we investigated the association between BAT activity and circulating bile acid concentrations in lean and obese individuals.

Methods: BAT F-fluorodeoxyglucose uptake was measured after a standardized cooling protocol by positron emission tomography/computed tomography. Cold-induced thermogenesis was assessed by indirect calorimetry. Fasting bile acid concentrations were determined by high performance liquid chromatography-high-resolution mass spectrometry.

Results: In a cohort of 24 BAT-negative and 20 BAT-positive individuals matched by age, sex, and body mass index, circulating bile acid levels were similar between groups except for higher ursodeoxycholic acid and a trend towards a lower 12α-OH/non-12α-OH bile acid ratio in lean participants with active BAT compared to those without. Moreover, the 12α-OH/non-12α-OH ratio, a marker of CYP8B1 activity, correlated negatively with BAT volume and activity.

Conclusion: Fasting concentrations of major bile acids are not associated with cold-induced BAT activity in humans. However, the inverse association between BAT activity and 12α-OH/non-12α-OH ratio may suggest CYP8B1 as a potential new target in BAT function and warrants additional investigation.
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http://dx.doi.org/10.1016/j.mce.2021.111403DOI Listing
October 2021

Sex differences in brown adipose tissue activity and cold-induced thermogenesis.

Mol Cell Endocrinol 2021 08 11;534:111365. Epub 2021 Jun 11.

Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Vienna, Austria. Electronic address:

Introduction: Brown adipose tissue (BAT) is suggested to exhibit a sexual dimorphism and thus contributes to the observed sex differences in cardiometabolic risk observed between women and men. Clinical data supporting this hypothesis are however scarce. The aim of this study was to investigate the relationship between BAT activity and sex using positron emission tomography (PET) - the current gold-standard for BAT quantification.

Methods: In this study, we included 95 subjects with a wide BMI range (20-55 kg/m) aged from 18 to 50 years. Avoiding shivering, participants were cooled with a water-perfused vest to achieve adequate BAT activation. BAT activity was determined by F-fluorodeoxyglucose PET/computed tomography (F-FDG PET/CT). Cold-induced thermogenesis (CIT) was quantified by indirect calorimetry.

Results: BAT was present in 44.6% of pre-menopausal women and in 35.9% of men (p = 0.394). CIT was significantly higher in women (p = 0.024). Estradiol levels were positively associated with CIT independent of age, sex, body fat and other sex hormones (b = 0.360, p = 0.016). In women, CIT decreased during the menstrual cycle, with lower levels in the luteal phase similar to median concentrations in men.

Conclusion: The prevalence of cold-activated BAT is slightly but non-significantly higher in pre-menopausal women than men. CIT is increased in females and independently associated with estradiol, suggesting that sex hormones may play a role in different thermogenic responses between men and women.
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http://dx.doi.org/10.1016/j.mce.2021.111365DOI Listing
August 2021

Combined effects of PNPLA3, TM6SF2 and HSD17B13 variants on severity of biopsy-proven non-alcoholic fatty liver disease.

Hepatol Int 2021 Aug 2;15(4):922-933. Epub 2021 Jun 2.

Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.

Objective: Several single-nucleotide polymorphisms have been identified to be disadvantageous or protective in regard to disease severity in patients with non-alcoholic fatty liver disease (NAFLD). However, it is unclear, whether including genetic risk factor(s) either alone or combined into risk stratification algorithms for NAFLD actually provides incremental benefit over clinical risk factors.

Design: Patients with biopsy-proven NAFLD were genotyped for the PNPLA3-rs738409(minor allele:G), TM6SF2-rs58542926(minor allele:T) and HSD17B13- rs72613567 (minor allele:TA) variants. The NAFLD activity score (NAS) and fibrosis stage (F0-F4) were used to grade and stage all liver biopsy samples. Patients from seven centers throughout Central Europe were considered for the study.

Results: 703 patients were included: NAS ≥ 5:173(24.6%); Fibrosis: F3-4:81(11.5%). PNPLA3 G/G genotype was associated with a NAS ≥ 5(aOR 2.23, p = 0.007) and advanced fibrosis (aOR-3.48, p < 0.001).TM6SF2 T/- was associated with advanced fibrosis (aOR 1.99, p = 0.023). HSD17B13 TA/- was associated with a lower probability of NAS ≥ 5(TA/T: aOR 0.65, p = 0.041, TA/TA: aOR 0.40, p = 0.033). Regarding the predictive capability for NAS ≥ 5, well-known risk factors (age, sex, BMI, diabetes, and ALT; baseline model) had an AUC of 0.758, Addition of PNPLA3(AUC 0.766), HSB17B13(AUC 0.766), and their combination(AUC 0.775), but not of TM6SF2(AUC 0.762), resulted in a higher diagnostic accuracy of the model. Addition of genetic markers for the prediction of advanced fibrosis (baseline model: age, sex, BMI, diabetes: AUC 0.777) resulted in a higher AUC if PNPLA3(AUC 0.789), and TM6SF2(AUC 0.786) but not if HSD17B13(0.777) were added.

Conclusion: In biopsy-proven NAFLD, PNPLA3 G/-, TM6SF2 T/- and HSD17B13 TA/- carriage are associated with severity of NAFLD. Incorporating these genetic risk factors into risk stratification models might improve their predictive accuracy for severity of NAFLD and/or advanced fibrosis on liver biopsy.
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http://dx.doi.org/10.1007/s12072-021-10200-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8382644PMC
August 2021

Reply to: Comparing performance of apneic oxygenation methods in morbidly obese patients.

Surg Obes Relat Dis 2021 08 8;17(8):1522-1523. Epub 2021 May 8.

Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Division of General Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria.

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http://dx.doi.org/10.1016/j.soard.2021.05.008DOI Listing
August 2021

Individualized treatment options for patients with non-cirrhotic and cirrhotic liver disease.

World J Gastroenterol 2021 May;27(19):2281-2298

Cambridge Institute of Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, University of Cambridge, Cambridge CB2 0AW, United Kingdom.

The obesity pandemic has led to a significant increase in patients with metabolic dysfunction-associated fatty liver disease (MAFLD). While dyslipidemia, type 2 diabetes mellitus and cardiovascular diseases guide treatment in patients without signs of liver fibrosis, liver related morbidity and mortality becomes relevant for MAFLD's progressive form, non-alcoholic steatohepatitis (NASH), and upon development of liver fibrosis. Statins should be prescribed in patients without significant fibrosis despite concomitant liver diseases but are underutilized in the real-world setting. Bariatric surgery, especially Y-Roux bypass, has been proven to be superior to conservative and/or medical treatment for weight loss and resolution of obesity-associated diseases, but comes at a low but existent risk of surgical complications, reoperations and very rarely, paradoxical progression of NASH. Once end-stage liver disease develops, obese patients benefit from liver transplantation (LT), but may be at increased risk of perioperative infectious complications. After LT, metabolic comorbidities are commonly observed, irrespective of the underlying liver disease, but MAFLD/NASH patients are at even higher risk of disease recurrence. Few studies with low patient numbers evaluated if, and when, bariatric surgery may be an option to avoid disease recurrence but more high-quality studies are needed to establish clear recommendations. In this review, we summarize the most recent literature on treatment options for MAFLD and NASH and highlight important considerations to tailor therapy to individual patient's needs in light of their risk profile.
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http://dx.doi.org/10.3748/wjg.v27.i19.2281DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8130039PMC
May 2021

Fifteen Years After Sleeve Gastrectomy: Weight Loss, Remission of Associated Medical Problems, Quality of Life, and Conversions to Roux-en-Y Gastric Bypass-Long-Term Follow-Up in a Multicenter Study.

Obes Surg 2021 08 22;31(8):3453-3461. Epub 2021 May 22.

Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.

Purpose: Since 2014, sleeve gastrectomy (SG) has been the most frequently performed bariatric-metabolic operation worldwide (2018: 386,096). There are only a few studies reporting a long-term follow-up (up to 11 years) available today. The aim of this study was to evaluate the long-term outcome of SG with a follow-up of at least 15 years regarding weight loss, remission of associated medical problems (AMP), conversions, and quality of life (QOL).

Setting: Multicenter cross-sectional study; university hospital.

Methods: This study includes all patients who had SG before 2005 at the participating bariatric centers. History of weight, AMP, conversions, and QOL were evaluated by interview at our bariatric center.

Results: Fifty-three patients met the inclusion criteria of a minimal follow-up of 15 years. Weight and body mass index at the time of the SG were 136.8kg and 48.7kg/m. Twenty-six patients (49.1%) were converted to Roux-en-Y gastric bypass (RYGB) for weight regain and gastroesophageal reflux within the follow-up period. Total weight loss after 15 years was 31.5% in the non-converted group and 32.9% in the converted group. Remission rates of AMP and QOL were stable over the follow-up period.

Conclusion: Fifteen years after SG, a stable postoperative weight was observed at the cost of a high conversion rate. Patients converted to RYGB were able to achieve further weight loss and preserve good remission rates of AMP. SG in patients without the need of a conversion to another bariatric-metabolic procedure may be considered effective. Careful preoperative patient selection is mandatory when performing SG.
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http://dx.doi.org/10.1007/s11695-021-05475-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8270807PMC
August 2021

Iron Deficiency - Not Only a Premenopausal Topic After Bariatric Surgery?

Obes Surg 2021 07 5;31(7):3242-3250. Epub 2021 Apr 5.

Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.

Purpose: In our centre, specialized high dose multivitamin supplementation designed to meet the needs of patients after gastric bypass surgery is routinely recommended in the early postoperative period. The aim of the present study was to analyse whether iron supplementation prescribed in clinical practice is sufficient in both sexes and whether multivitamin supplementation standardized for women might potentially lead to iron overload in men.

Materials/methods: This was a retrospective study covering the period up to 36 months after bariatric surgery. Three groups were compared (men, premenopausal and postmenopausal women). The iron status was evaluated employing serum ferritin concentrations.

Results: A total of 283 patients who had at least one follow-up visit between January 2015 and April 2018 at a specialized academic outpatient centre were included (71 men, 130 premenopausal women, 82 postmenopausal women). Thirty-six months after surgery, 33.3%, 68.4% and 54.5% of the men, pre- and postmenopausal women, respectively, were iron deficient. The preoperative prevalence of excess ferritin levels was 13.7% in premenopausal, 3.0% in postmenopausal women, 5.7% in men and declined in the following months.

Conclusion: Iron deficiency is very common after gastric bypass surgery, and even high dosages of multivitamin and mineral supplements might not be sufficient to prevent the development of iron deficiency. Men, pre- and postmenopausal women differ in their prevalence of iron deficiency which demands adapted iron dosage regimens based on the sex and the age. Iron overload is rare in all observed groups and highest in premenopausal women.
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http://dx.doi.org/10.1007/s11695-021-05380-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8175328PMC
July 2021

Bariatric Surgery-How Much Malabsorption Do We Need?-A Review of Various Limb Lengths in Different Gastric Bypass Procedures.

J Clin Med 2021 Feb 10;10(4). Epub 2021 Feb 10.

Division of General Surgery, Department of Surgery, Vienna Medical University, 1090 Vienna, Austria.

The number of obese individuals worldwide continues to increase every year, thus, the number of bariatric/metabolic operations performed is on a constant rise as well. Beside exclusively restrictive procedures, most of the bariatric operations have a more or less malabsorptive component. Several different bypass procedures exist alongside each other today and each type of bypass is performed using a distinct technique. Furthermore, the length of the bypassed intestine may differ as well. One might add that the operations are performed differently in different parts of the world and have been changing and evolving over time. This review evaluates the most frequently performed bariatric bypass procedures (and their variations) worldwide: Roux-en-Y Gastric Bypass, One-Anastomosis Gastric Bypass, Single-Anastomosis Duodeno-Ileal Bypass + Sleeve Gastrectomy, Biliopancreatic Diversion + Duodenal Switch and operations due to weight regain. The evaluation of the procedures and different limb lengths focusses on weight loss, remission of comorbidities and the risk of malnutrition and deficiencies. This narrative review does not aim at synthesizing quantitative data. Rather, it provides a summary of carefully selected, high-quality studies to serve as examples and to draw tentative conclusions on the effects of the bypass procedures mentioned above. In conclusion, it is important to carefully choose the procedure and small bowel length excluded from the food passage suited best to each individual patient. A balance has to be achieved between sufficient weight loss and remission of comorbidities, as well as a low risk of deficiencies and malnutrition. In any case, at least 300 cm of small bowel should always remain in the food stream to prevent the development of deficiencies and malnutrition.
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http://dx.doi.org/10.3390/jcm10040674DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7916324PMC
February 2021

The first modified Delphi consensus statement on sleeve gastrectomy.

Surg Endosc 2021 Jan 12. Epub 2021 Jan 12.

Dutch Obesity Clinic (NOK), The Hague, Netherlands.

Introduction: Sleeve gastrectomy (SG) is the commonest bariatric procedure worldwide. Yet there is significant variation in practice concerning its various aspects. This paper report results from the first modified Delphi consensus-building exercise on SG.

Methods: We established a committee of 54 globally recognized opinion makers in this field. The committee agreed to vote on several statements concerning SG. An agreement or disagreement amongst ≥ 70.0% experts was construed as a consensus.

Results: The committee achieved a consensus of agreement (n = 71) or disagreement (n = 7) for 78 out of 97 proposed statements after two rounds of voting. The committee agreed with 96.3% consensus that the characterization of SG as a purely restrictive procedure was inaccurate and there was 88.7% consensus that SG was not a suitable standalone, primary, surgical weight loss option for patients with Barrett's esophagus (BE) without dysplasia. There was an overwhelming consensus of 92.5% that the sleeve should be fashioned over an orogastric tube of 36-40 Fr and a 90.7% consensus that surgeons should stay at least 1 cm away from the angle of His. Remarkably, the committee agreed with 81.1% consensus that SG patients should undergo a screening endoscopy every 5 years after surgery to screen for BE.

Conclusion: A multinational team of experts achieved consensus on several aspects of SG. The findings of this exercise should help improve the outcomes of SG, the commonest bariatric procedure worldwide, and guide future research on this topic.
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http://dx.doi.org/10.1007/s00464-020-08216-wDOI Listing
January 2021

Duration of safe apnea in patients with morbid obesity during passive oxygenation using high-flow nasal insufflation versus regular flow nasal insufflation, a randomized trial.

Surg Obes Relat Dis 2021 Feb 23;17(2):347-355. Epub 2020 Sep 23.

Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Division of General Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria.

Background: Obese patients are at risk for rapid oxygen desaturation during anesthesia induction. Apneic oxygenation with regular flow oxygen insufflation has successfully been used to prolong the duration of safe apnea without desaturation (DAWD) in morbidly obese patients. Using high-flown nasal insufflation of oxygen (HFNI) for apneic oxygenation might further increase the DAWD.

Objectives: To compare the duration of safe apnea using high-flown nasal insufflation of oxygen or standard flow oxygen insufflation for apneic oxygenation in a simulated difficult intubation scenario in patients with morbid obesity.

Setting: Operating room, University Hospital, Austria.

Methods: In a prospective, randomized, clinical trial, patients received standardized preoxygenation and anesthesia induction. Apneic oxygenation was performed using standard nasal prongs (10 L/min) or HFNI (120 L/min) during laryngoscopy. A Cormack-Lehane 3° view was maintained until the oxygen saturation on pulse oximetry (SpO) dropped ≤95% or for a maximum of 15 minutes. The primary outcome of this study was to compare the duration of safe apnea using HFNI or standard flow oxygen insufflation for apneic oxygenation. In addition, arterial blood gas results, and airway pressures were investigated.

Results: In 40 patients with morbid obesity (body mass index [BMI] >40 kg/m) and the American Society of Anesthesiologists physical classification ≤3 who underwent bariatric surgery, the median duration of safe apnea was 601 (268-900) seconds in the standard group and 537 (399-808) seconds in the HFNI group (P = .698). No differences in arterial blood gas results were observed between the groups. The median airway pressure was 0 (0-0) cm HO in the standard group and 1 (0-2) cm HO in the HFNI group (P = .005).

Conclusion: Compared with standard nasal apneic oxygenation, HFNI did not increase the duration of safe apnea in patients with morbid obesity. A significant but clinically negligible higher airway pressure was observed when using HFNI.
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http://dx.doi.org/10.1016/j.soard.2020.09.027DOI Listing
February 2021

Surgical Technique for One-Anastomosis Gastric Bypass.

Surg Technol Int 2020 Nov;37:57-61

.Laparoscopic One-Anastomosis Gastric Bypass (OAGB) is a bariatric procedure that combines the principles of restriction and malabsorption, which are achieved by creating a long and narrow gastric pouch and bypassing part of the small bowel (duodenum and part of the jejunum). It is currently the third most common bariatric procedure worldwide; more than19,000 operations (4.8%) are performed per year. OAGB is synonymous with "Mini Gastric Bypass" and "Omega Loop Gastric Bypass". There are numerous technical variants for performing OAGB and organizing pre- and postoperative care. This article is based on the approach to bariatric surgery at the Department of General Surgery at Vienna Medical University. We focus on patient preparation before a bariatric/metabolic procedure with mandatory and optional examinations to decrease the patient's risk and find the procedure best suited for each individual patient. Next, the surgical technique itself is described, including positioning of the patient, positioning of the trocars and related tips, tricks, and technical highlights, as well as the specifics of the postoperative course. OAGB is an effective procedure for weight loss and remission of comorbidities with a low risk of malnutrition for patients with good compliance. For OAGB to be successful, important technical steps such as a long and narrow pouch, exact length of the biliopancreatic limb and hiatoplasty, if necessary, should be taken. In terms of post-operative care, regular check-ups are vital to ensure a positive outcome in long-term follow-up and the early detection of adverse developments.
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November 2020

Course of depressive symptomatology and its association with serum uric acid in one-anastomosis gastric bypass patients.

Sci Rep 2020 10 27;10(1):18405. Epub 2020 Oct 27.

Department of Social and Preventive Medicine, Centre for Public Health, Medical University of Vienna, Vienna, Austria.

The changes in depressive symptomatology during the first year following one-anastomosis gastric bypass (OAGB) were evaluated and its association with uric acid (sUA). Fifty patients were included in this analysis. Beck Depression Inventory (BDI) for measuring depressive symptomatology, blood samples, and anthropometric measurements were assessed before (T0), at 6 (T6), and 12 months (T12) after surgery. There was a significant reduction in BDI total score at T6 (- 5.6 (95% CI - 2.1, - 9.1) points; p = 0.001) and at T12 (- 4.3 (95% CI - 0.9, - 7.9) points; p = 0.011). BMI loss was unrelated to depressive symptomatology. Patients with moderate to severe depressive symptomatology presented lower sUA levels than patients with none or minimal to mild (p = 0.028). ROC analysis revealed that sUA levels below 5.0 at T6 and 4.5 mg/dl at T12 had a prognostic accuracy for depression severity. Furthermore, delta sUA was significantly associated with delta BMI (β = 0.473; p = 0.012) and delta waist circumference (β = 0.531; p = 0.003). These findings support an improvement in depressive symptomatology in the first year postoperatively, however, without relation to BMI loss. Patients with moderate to severe depressive symptomatology presented with lower sUA levels over time. Therefore, sUA could be useful to predict moderate to severe depressive symptomatology in patients undergoing OAGB in clinical practice.
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http://dx.doi.org/10.1038/s41598-020-75407-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591541PMC
October 2020

Effect of one-anastomosis gastric bypass on cardiovascular risk factors in patients with vitamin D deficiency and morbid obesity: A secondary analysis.

Nutr Metab Cardiovasc Dis 2020 11 20;30(12):2379-2388. Epub 2020 Aug 20.

Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Austria; Department of Medicine 1, Karl Landsteiner Institute for Obesity and Metabolic Disorders, Rudolfstiftung Hospital, Vienna, Austria.

Background And Aims: Bariatric patients often suffer from vitamin D (VD) deficiency, and both, morbid obesity and VD deficiency, are related to an adverse effect on cardiovascular disease (CVD) risk. Therefore, we assessed the change of known CVD risk factors and its associations during the first 12 months following one-anastomosis gastric bypass (OAGB).

Methods And Results: In this secondary analysis, CVD risk factors, medical history and anthropometric data were assessed in fifty VD deficient (25-hydroxy-vitamin D (25(OH)D) <75 nmol/l) patients, recruited for a randomized controlled trial of VD supplementation. Based on previous results regarding bone-mass loss and the association between VD and CVD risk, the study population was divided into patients with 25(OH)D ≥50 nmol/l (adequate VD group; AVD) and into those <50 nmol/l (inadequate VD group; IVD) at 6 and 12 months (T6/12) postoperatively. In the whole cohort, substantial remission rates for hypertension (38%), diabetes (30%), and dyslipidaemia (41%) and a significant reduction in CVD risk factors were observed at T12. Changes of insulin resistance markers were associated with changes of total body fat mass (TBF%), 25(OH)D, and ferritin. Moreover, significant differences in insulin resistance markers between AVD and IVD became evident at T12.

Conclusion: These findings show that OAGB leads to a significant reduction in CVD risk factors and amelioration of insulin resistance markers, which might be connected to reduced TBF%, change in 25(OH)D and ferritin levels, as an indicator for subclinical inflammation, and an adequate VD status. REGISTERED AT CLINICALTRIALS.GOV: (Identifier: NCT02092376) and EudraCT (Identifier: 2013-003546-16).
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http://dx.doi.org/10.1016/j.numecd.2020.08.011DOI Listing
November 2020

Pouch volume and pouch migration after Roux-en-Y gastric bypass: a comparison of gastroscopy and 3 D-CT volumetry: is there a "migration crisis"?

Surg Obes Relat Dis 2020 Dec 1;16(12):1902-1908. Epub 2020 Aug 1.

Division of General Surgery, Department of Surgery, Vienna Medical University, Vienna, Austria. Electronic address:

Background: Roux-en-Y gastric bypass (RYGB) is the second most frequently performed bariatric procedure worldwide. While pouch migration is a common phenomenon after sleeve gastrectomy, it has hardly been documented after RYGB so far.

Objectives: The aim of this study was to correlate the diagnostic performance of gastroscopy of the gastroesophageal junction with 3-dimensional computed tomography (CT) during postoperative care of patients revised due to weight regain after RYGB, with particular attention to intrathoracic pouch migration (ITM) and pouch volume.

Setting: University Hospital Setting, Austria.

Methods: Thirty RYGB patients that were revised owing to weight regain (median age 37.5 yr) before December 2017 were included in this prospective study. CT findings were correlated with gastroscopy regarding pouch size and ITM. Pouch distention was achieved with both oral contrast and effervescent granules. All patients had CT and gastroscopy on the same day. In addition, patients were evaluated for reflux disease based on clinical history.

Results: ITM was found in 20 of 30 (66.7%) patients in CT, whereas gastroscopy did not correctly identify any herniation. In 16 of 28 (57.1%) patients pouch measurements at gastroscopy and CT showed a difference <40%. In 2 patients, pouch distention was not sufficient for CT volumetry. The intraclass correlation coefficient proved to be .594. Symptomatic reflux was present in 10 of 30 (33.3%) patients, 5 of whom had ITM.

Conclusion: ITM is an underreported finding after revised RYGB and missed in gastroscopy. In terms of pouch volume, 3-dimensional-CT volumetry demonstrated only moderate agreement with gastroscopy.
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http://dx.doi.org/10.1016/j.soard.2020.07.024DOI Listing
December 2020

Silent Gastroesophageal Reflux Disease in Patients with Morbid Obesity Prior to Primary Metabolic Surgery.

Obes Surg 2020 12 10;30(12):4885-4891. Epub 2020 Sep 10.

Department of Surgery, Upper GI Research & Service, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.

Purpose: Long-term follow-up after sleeve gastrectomy (SG) revealed a high incidence of gastroesophageal reflux disease (GERD) frequently caused by preoperative silent pathologic reflux. We aimed to evaluate prevalence and phenotypes of GERD in asymptomatic patients with morbid obesity prior to metabolic surgery according to modern objective testing.

Material And Methods: Prospective collection of data including consecutive patients with morbid obesity (body mass index (BMI) ≥ 35 kg/m) prior to metabolic surgery was applied for this study between 2014 and 2019. Patients underwent clinical examinations, endoscopy, pH metry, and high-resolution manometry and were analyzed according to the Lyon consensus.

Results: Of 1379 patients undergoing metabolic surgery, 177 (12.8%, females = 105) asymptomatic individuals with a median age of 42.6 (33.8; 51.6) years and a median BMI of 44.6 (41.3; 50.8) kg/m completed objective testing and were included during the study period. GERD was diagnosed in 55 (31.1%), whereas criteria of borderline GERD were met in another 78 (44.1%). GERD was mediated by a structural defective lower esophageal sphincter (p = 0.004) and highlighted by acidic (p = 0.004) and non-acidic (p = 0.022) reflux episodes. Esophageal motility disorders were diagnosed in 35.6% (n = 63) of individuals with a novel hypercontractile disorder found in 7.9% (n = 14) of patients.

Conclusion: GERD affects a majority of asymptomatic patients with morbid obesity prior to primary bariatric surgery. Future longitudinal trials will have to reveal the clinical significance of esophageal motility disorders in patients with morbid obesity.
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http://dx.doi.org/10.1007/s11695-020-04959-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719109PMC
December 2020

The First Modified Delphi Consensus Statement for Resuming Bariatric and Metabolic Surgery in the COVID-19 Times.

Obes Surg 2021 01 1;31(1):451-456. Epub 2020 Aug 1.

CHI Memorial Hospital, Chattanooga, TN, USA.

The purpose of this study was to achieve consensus amongst a global panel of expert bariatric surgeons on various aspects of resuming Bariatric and Metabolic Surgery (BMS) during the Coronavirus Disease-2019 (COVID-19) pandemic. A modified Delphi consensus-building protocol was used to build consensus amongst 44 globally recognised bariatric surgeons. The experts were asked to either agree or disagree with 111 statements they collectively proposed over two separate rounds. An agreement amongst ≥ 70.0% of experts was construed as consensus as per the predetermined methodology. We present here 38 of our key recommendations. This first global consensus statement on the resumption of BMS can provide a framework for multidisciplinary BMS teams planning to resume local services as well as guide future research in this area.
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http://dx.doi.org/10.1007/s11695-020-04883-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7395568PMC
January 2021

Stapling Through a Bougie During Sleeve Gastrectomy in a Superobese Patient-a Video Vignette.

Obes Surg 2020 10 2;30(10):4167-4168. Epub 2020 Jul 2.

Division of General Surgery, Department of Surgery, Vienna Medical University, Waehringer Guertel 18-20, 1090, Vienna, Austria.

Purpose: Bariatric-metabolic surgery in superobese patients (BMI > 50 kg/m) is very challenging indeed with little room for error. In many cases, a two-step procedure is required, since more complex primary bariatric procedures can be technically demanding and bearing a relevant risk for the patient. At our institution, laparoscopic sleeve gastrectomy (SG) is the preferred primary procedure, followed by a conversion to either SADI-S or Roux-en-Y gastric bypass (RYGB) after initial weight loss is achieved [1, 2]. This video aims at demonstrating the conversion from primary SG to RYGB due to an adverse event in a 45-year-old superobese female patient (weight, 170 kg; BMI, 73 kg/m).

Methods: An intraoperative laparoscopic video has been anonymized and edited to demonstrate the course of the operation on the patient mentioned above.

Results: The start of the procedure was uneventful. After a successful mobilization of the greater curvature, the stomach was resected with an electronic stapling device guided by a firm 36-french bougie (Rüsch, Germany) towards the angle of His. Due to a limited view, a stapler was placed over the bougie, which resulted in the stomach being subtotally transected, the staples attaching the bougie to the sleeve about 5 cm from the gastroesophageal junction. Salvage surgery after removing the remnants of the bougie was a conversion to RYGB.

Conclusion: When performing a bariatric-metabolic surgery in superobese patients, an extended skill level is required to provide a solution, should anything go wrong. Therefore, we suggest bariatric-metabolic surgery in superobese patients to be performed solely and specifically at high-volume centres.
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http://dx.doi.org/10.1007/s11695-020-04790-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7467964PMC
October 2020

Swallow Magnetic Resonance Imaging Compared to 3D-Computed Tomography for Pouch Assessment and Hiatal Hernias After Roux-en-Y Gastric Bypass.

Obes Surg 2020 11;30(11):4192-4197

Department of Biomedical Imaging and Image-guided Therapy, Vienna Medical University, Vienna, Austria.

Introduction/purpose: Weight regain and weight loss failure after bariatric surgery are important issues that may require a weight regain procedure. Three-dimensional-computed tomography (3D-CT) is a well-established method allowing exact measurements of pouch volume. The aims of this study were to prove the applicability of swallow MRI as a non-ionizing procedure and compare it to 3D-CT in patients after weight regain procedures following RYGB.

Materials And Methods: Twelve post-RYGB patients who had a follow-up operation for weight regain before 12/2017 were included in this prospective study. Swallow MRI and 3D-CT were performed in each patient to evaluate the size of the anastomosis, pouch volume, and intrathoracic pouch migration (ITM).

Results: Mean pouch volume in swallow MRI and 3D-CT were 40.4 ± 21.0 ml and 43.5 ± 30.2 ml, respectively (p = 0.83), and pouch diameter at the maximal distention was 35.3 ± 5.9 ml (MRI) and 31.0 ± 10.0 ml (CT) (p = 0.16). The rate of ITM was 75% in both examinations (p = 1.0).

Conclusion: Swallow MRI is a valid method for the assessment of pouch volume in different phases of the swallowing process and is comparable to 3D-CT. The diagnosis of ITM using swallow MRI was equal to 3D-CT.
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http://dx.doi.org/10.1007/s11695-020-04758-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7525276PMC
November 2020

Pre-operative Obesity-Associated Hyperandrogenemia in Women and Hypogonadism in Men Have No Impact on Weight Loss Following Bariatric Surgery.

Obes Surg 2020 10 13;30(10):3947-3954. Epub 2020 Jun 13.

Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.

Background: In severe obesity, hypogonadism in men and androgen excess in women are frequently observed. Sex hormones play an important role in body composition and glucose and lipid metabolism. However, whether pre-operative gonadal dysfunction impacts weight loss after bariatric surgery is not fully known.

Methods: A total of 49 men and 104 women were included in a retrospective analysis. Anthropometric characteristics, glucose and lipid metabolism, and androgen concentrations were assessed pre-operatively and 17.9 ± 11 or 19.3 ± 12 months post-operatively in men and women. Men with (HYPO) and without (controls: CON pre-operative hypogonadism, as well as women with (HYPER) and without (controls: CON pre-operative hyperandrogenemia, were compared.

Results: In men, pre-operative hypogonadism was present in 55% and linked to a higher body mass index (BMI): HYPO 50 ± 6 kg/m vs. CON 44 ± 5 kg/m, p = 0.001. Bariatric surgery results in comparable changes in BMI in HYPO and CON - 16 ± 6 kg/m vs. - 14 ± 5 kg/m, p = 0.30. Weight loss reversed hypogonadism in 93%. In women, androgen excess was present in 22%, independent of pre-operative BMI: CON 44 ± 7 kg/m vs. HYPER 45 ± 7 kg/m, p = 0.57. Changes in BMI were comparable in HYPER and CON after bariatric surgery - 15 ± 6 kg/m vs. - 15 ± 5 kg/m, p = 0.88. Hyperandrogenemia was reversed in 61%.

Conclusions: Besides being frequently observed, hypogonadism in men and androgen excess in women have no impact on post-surgical improvements in body weight and glucose and lipid metabolism. Weight loss resulted in reversal of hypogonadism in almost all men and of hyperandrogenemia in the majority of women.
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http://dx.doi.org/10.1007/s11695-020-04761-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7467956PMC
October 2020

Psychopharmacological Medication Has No Influence on Vitamin Status After Bariatric Surgery in Long-term Follow-up.

Obes Surg 2020 10;30(10):3753-3760

Department of Internal Medicine III, Division of Endocrinology and Metabolism, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.

Context: A substantial number of patients undergoing bariatric surgery are prescribed psychopharmacological medication. However, the impact of concomitant psychopharmacological medication on the frequency of relevant vitamin deficiencies in postoperative follow-up is not known.

Methods: Five hundred twenty-four patients with obesity who underwent bariatric surgery (January 2004 to September 2018) with follow-up of at least 12 months, were included in retrospective analysis. Postoperative follow-up visits between January 2015 and September 2019 were analyzed. Anthropometric and laboratory data were analyzed at the first documented follow-up visit after on average 39.5 ± 37.3 months and at every following visit during the observation period. Patients with prescribed psychopharmacological drugs (PD) were compared with patients without (control group, CON).

Results: Psychopharmacological medication was documented in 25% (132) of patients. In 59 patients documented prescription of more than one psychiatric drug was found, whereas psychopharmacological monotherapy was found in 73 patients. Frequencies of vitamin deficiencies were comparable between PD and CON (vitamin A: p = 0.852; vitamin D: p = 0.622; vitamin E: p = 0.901; folic acid: p = 0.941). Prevalence of vitamin B deficiency was rare (6% CON, 1% PD) but was significantly higher in CON (p = 0.023). A comparison of CON and POLY also showed no significant differences between the groups concerning prevalence of vitamin deficiencies.

Conclusions: Intake of psychopharmacological medication is highly prevalent in patients after bariatric surgery. Patients with psychopharmacological medication, who participate in structured follow-up care after bariatric surgery, are not at higher risk for vitamin deficiencies compared with controls.
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http://dx.doi.org/10.1007/s11695-020-04698-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7467953PMC
October 2020

Sleeve Gastrectomy: Surgical Technique, Outcomes, and Complications.

Surg Technol Int 2020 May;36:63-69

Division of General Surgery, Department of Surgery, Vienna Medical University, Vienna, Austria.

The number of bariatric surgical procedures performed worldwide increases every year and has recently exceeded 685,000. Over 50% of these are laparoscopic sleeve gastrectomy (SG), and Roux-en-Y gastric bypass accounts for an additional 30%. Bariatric/metabolic surgery seeks to achieve not only weight loss and the remission of comorbidities, such as diabetes mellitus type II, arterial hypertension, sleep apnea, risk of cancer, non-alcoholic liver steatosis, etc., but also improvements in the patient's quality of life. SG is mainly a restrictive procedure consisting of the resection and removal of a major part of the stomach, which has an additional impact on hormones such as Ghrelin and Glucagon-like Peptide 1. The first part of this article focuses on patient preparation before a bariatric procedure with mandatory and additional examinations to decrease the patient's risk. Next, the surgical technique itself, including positioning of the patient, positioning of the trocars and related tips and tricks, and the postoperative course are described. The second part discusses the outcomes of SG, including weight loss, remission of comorbidities and quality of life. Further possible acute complications of SG such as leaks, bleeding or stenoses as well as long-term complications (reflux, weight regain and malnutrition) and respective treatments are also described. In conclusion, SG is an effective procedure for weight loss with a low risk for the patient to develop malnutrition. In terms of post-operative care, regular check-ups are vital to ensure a positive outcome as well as for the early detection of possible issues. Reflux and weight regain are common issues with SG in a long-term follow-up; thus, patients should be selected carefully for this procedure.
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May 2020

Clinical practice guidelines of the European Association for Endoscopic Surgery (EAES) on bariatric surgery: update 2020 endorsed by IFSO-EC, EASO and ESPCOP.

Surg Endosc 2020 06 23;34(6):2332-2358. Epub 2020 Apr 23.

Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.

Background: Surgery for obesity and metabolic diseases has been evolved in the light of new scientific evidence, long-term outcomes and accumulated experience. EAES has sponsored an update of previous guidelines on bariatric surgery.

Methods: A multidisciplinary group of bariatric surgeons, obesity physicians, nutritional experts, psychologists, anesthetists and a patient representative comprised the guideline development panel. Development and reporting conformed to GRADE guidelines and AGREE II standards.

Results: Systematic review of databases, record selection, data extraction and synthesis, evidence appraisal and evidence-to-decision frameworks were developed for 42 key questions in the domains Indication; Preoperative work-up; Perioperative management; Non-bypass, bypass and one-anastomosis procedures; Revisional surgery; Postoperative care; and Investigational procedures. A total of 36 recommendations and position statements were formed through a modified Delphi procedure.

Conclusion: This document summarizes the latest evidence on bariatric surgery through state-of-the art guideline development, aiming to facilitate evidence-based clinical decisions.
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http://dx.doi.org/10.1007/s00464-020-07555-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7214495PMC
June 2020

Reply to the Letter to the Editor Concerning Anti-reflux Mucosectomy (ARMS) in Sleeve Gastrectomy Patients with GERD and Barrett's Esophagus.

Obes Surg 2020 06;30(6):2417-2418

Division of General Surgery, Department of Surgery, Vienna Medical University, Währinger Guertel 18-20, 1090, Vienna, Austria.

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http://dx.doi.org/10.1007/s11695-020-04499-zDOI Listing
June 2020

Impact of limb length on nutritional status in one-anastomosis gastric bypass: 3-year results.

Surg Obes Relat Dis 2020 Apr 19;16(4):476-484. Epub 2019 Dec 19.

Division of General Surgery, Department of Surgery, Vienna Medical University, Vienna, Austria. Electronic address:

Background: Bariatric metabolic surgery is a well-established treatment option associated with significant weight loss and an improvement of metabolic co-morbidities. However, the changes in gastrointestinal anatomy frequently result in nutritional deficiencies.

Objective: To evaluate the impact of biliopancreatic limb length in one-anastomosis gastric bypass (OAGB) on micronutrient and protein deficiencies.

Setting: University hospital, Austria.

Methods: All patients that were (1) undergoing OAGB between 2012 and 2014, and (2) had at least 3 postoperative follow-up visits were retrospectively analyzed. Systemic levels of parathyroid hormone, vitamins (A, D, E, and B12), folic acid, magnesium, calcium, iron, albumin, and ferritin were correlated to biliopancreatic limb length as follows: short limb (150 cm), intermediate limb (200 cm), and long limb (250 cm).

Results: A total of 155 patients fulfilled inclusion criteria (female/male: n = 111/44). OAGB led to a mean percent excess weight loss of 79.9 (±24.2) and a reduction of mean body mass index from 45.4 kg/m (±6.1 kg/m) at baseline to 30.2 kg/m (±9.9 kg/m). Preoperative deficiencies were seen in 25-hydroxy-vitamin D (93.8%), folic acid (27.6%), ferritin (4.1%), vitamin A (5.5%), and vitamin B12 (2.3%). In patients with long limb, systemic folic acid levels were significantly lower after 24 months postoperatively compared with short and intermediate limb (P < .05). No difference was observed for vitamin D, A, E, B12, and iron and no patient suffered from severe protein malnutrition.

Conclusion: Nutritional deficiencies were common after OAGB without severe deficiencies in biliopancreatic limb lengths ranging from 150 to 250 cm. A trend can be observed with more pronounced deficiencies with intermediate and long limb lengths without significant differences for most micronutrients.
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http://dx.doi.org/10.1016/j.soard.2019.12.012DOI Listing
April 2020

Plasma homocysteine after laparoscopic Roux-en-Y gastric bypass increases in the early postoperative phase but decreases in the long-term follow-up. A retrospective analysis.

Surg Obes Relat Dis 2020 Mar 9;16(3):372-380. Epub 2019 Dec 9.

Department of Surgery, Medical University of Vienna, Vienna, Austria. Electronic address:

Background: Homocysteine is an important independent risk factor for predicting cardiovascular disease (CVD). However, changes in the homocysteine levels after bariatric surgery remain controversial.

Objectives: Modeling differences in homocysteine after bariatric surgery.

Setting: University Hospital, Austria.

Methods: Seven hundred eight consecutive bariatric surgery patients (78% female, 22% male, mean body mass index 41 kg/m preoperatively) underwent laparoscopic long-limb Roux-en-Y gastric bypass in a 6-year period and were retrospectively evaluated for changes in their preoperative homocysteine levels, at 3, 6, 9, 12, 18, 24, 36, 48, 60, and 72 months postoperatively. Furthermore, a postal and telephone screening for postoperative CVD with a follow-up of 71% was conducted.

Results: Hyperhomocysteinemia was present in 11.8% preoperatively (normal range: <15 μmol/L). The median plasma homocysteine level was 10.4 preoperatively, 12.1 at 3, 11.2 at 6, 10.0 at 9, 9.8 at 12, 8.9 at 18, 8.7 at 24, 8.6 at 36, 9.1 at 48, 9.8 at 60, and 10.0 μmol/L at 72 months postoperatively. After subdividing the study population in morbidly obese (n = 509, body mass index 40-50 kg/m) and super-obese (n = 199, body mass index >50 kg/m) patients, the short-term increase into homocysteine levels remained. Overall, newly onset CVD risk was 4.2%. After subdividing the CVD risk into risk for myocardial infarction, stroke, and risk for deep vein thrombosis/pulmonary embolism the distribution was as follows: .2% myocardial infarction, .59% stroke, and 2.97% deep vein thrombosis/pulmonary embolism (median 36 [interquartile range 36-48] mo postoperatively).

Conclusion: Laparoscopic Roux-en-Y gastric bypass leads to increased homocysteine levels in the early postoperative period. However, there was no relationship between increased homocysteine levels and CVD event onset.
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http://dx.doi.org/10.1016/j.soard.2019.11.021DOI Listing
March 2020

Roux-en-Y Gastric Bypass as a Treatment for Barrett's Esophagus after Sleeve Gastrectomy.

Obes Surg 2020 04;30(4):1273-1279

Division of General Surgery, Department of Surgery, Vienna Medical University, Waehringer Guertel 18-20, 1090, Vienna, Austria.

Background: Laparoscopic sleeve gastrectomy (SG) is the most frequently performed bariatric procedure today. While an increasing number of long-term studies report the occurrence of Barrett's esophagus (BE) after SG, its treatment has not been studied, yet.

Objectives: The aim of this study was to evaluate Roux-en-Y gastric bypass (RYGB) as treatment for BE and reflux after SG.

Setting: University hospital setting, Austria METHODS: This multi-center study includes all patients (n = 10) that were converted to RYGB due to BE after SG in Austria. The mean interval between SG and RYGB was 42.7 months. The follow-up after RYGB in this study was 33.4 months. Gastroscopy, 24 h pH-metry, and manometry were performed and patients were asked to complete the BAROS and GIQLI questionnaires.

Results: Weight and BMI at the time of SG was 120.8 kg and 45.1 kg/m. Eight patients (80.0%) went into remission of BE after the conversion to RYGB. Two patients had RYGB combined with hiatoplasty. The mean acid exposure time in 24 h decreased from 36.8 to 3.8% and the mean DeMeester score from 110.0 to 16.3. Patients scored 5.1 on average in the BAROS after conversion from SG to RYGB which denotes a very good outcome.

Conclusions: RYGB is an effective therapy for patients with BE and reflux after SG. Its outcomes in the current study were BE remission in the majority of cases as well as a decrease in reflux activity. Further studies with larger cohorts are necessary to confirm these findings.
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http://dx.doi.org/10.1007/s11695-019-04292-7DOI Listing
April 2020

Evaluation and comparison of six noninvasive tests for prediction of significant or advanced fibrosis in nonalcoholic fatty liver disease.

United European Gastroenterol J 2019 10 12;7(8):1113-1123. Epub 2019 Jul 12.

Department of Internal Medicine, Medical University of Graz, Graz, Austria.

Background: In nonalcoholic fatty liver disease (NAFLD), advanced fibrosis has been identified as an important prognostic factor with increased liver-related mortality and treatment need. Due to the high prevalence of NAFLD, noninvasive risk stratification is needed to select patients for liver biopsy and treatment.

Objective: To compare the diagnostic accuracy of several widely available noninvasive tests for assessment of fibrosis among patients with NAFLD with or without nonalcoholic steatohepatitis (NASH).

Methods: We enrolled consecutive patients with NAFLD admitted to two Austrian referral centers who underwent liver biopsy. Liver stiffness measurement (LSM) was obtained by vibration-controlled transient elastography (VCTE, FibroScan) and blood samples were collected for determination of enhanced liver fibrosis (ELF) test, FibroMeter, FibroMeter, NAFLD fibrosis score (NFS), and fibrosis-4 index (FIB-4).

Results: Our study cohort contained 186 patients with histologically confirmed NAFLD. On liver histology, NASH was present in 92 patients (50%), significant fibrosis (F ≥ 2) in 71 patients (38%), advanced fibrosis (F ≥ 3) in 49 patients (26%), and F ≥ 3 plus NASH in 35 patients (19%). For diagnosis of F ≥ 2, F ≥ 3, and F ≥ 3 plus NASH, respectively, receiver operating characteristic (ROC) analysis revealed superior diagnostic accuracy of ELF score (area under ROC curve (AUROC) 0.85, 0.90, 0.90), FibroMeter (AUROC 0.86, 0.88, 0.89), FibroMeter (AUROC 0.84, 0.88, 0.88), and LSM per protocol (AUROC 0.87, 0.95, 0.91) versus FIB-4 (AUROC 0.80, 0.82, 0.81) or NFS (AUROC 0.78, 0.80, 0.79).

Conclusion: Proprietary fibrosis panels and VCTE show superior diagnostic accuracy for noninvasive diagnosis of fibrosis stage in NAFLD as compared to FIB-4 and NFS.
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http://dx.doi.org/10.1177/2050640619865133DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6794685PMC
October 2019

Defining Global Benchmarks in Bariatric Surgery: A Retrospective Multicenter Analysis of Minimally Invasive Roux-en-Y Gastric Bypass and Sleeve Gastrectomy.

Ann Surg 2019 11;270(5):859-867

Minimally Invasive and Bariatric Surgery, Fresno Heart and Surgical Hospital, Fresno, CA.

Objective: To define "best possible" outcomes for bariatric surgery (BS)(Roux-en-Y gastric bypass [RYGB] and sleeve gastrectomy [SG]).

Background: Reference values for optimal surgical outcomes in well-defined low-risk bariatric patients have not been established so far. Consequently, outcome comparison across centers and over time is impeded by heterogeneity in case-mix.

Methods: Out of 39,424 elective BS performed in 19 high-volume academic centers from 3 continents between June 2012 and May 2017, we identified 4120 RYGB and 1457 SG low-risk cases defined by absence of previous abdominal surgery, concomitant procedures, diabetes mellitus, sleep apnea, cardiopathy, renal insufficiency, inflammatory bowel disease, immunosuppression, anticoagulation, BMI>50 kg/m and age>65 years. We chose clinically relevant endpoints covering the intra- and postoperative course. Complications were graded by severity using the comprehensive complication index. Benchmark values were defined as the 75th percentile of the participating centers' median values for respective quality indicators.

Results: Patients were mainly females (78%), aged 38±11 years, with a baseline BMI 40.8 ± 5.8 kg/m. Over 90 days, 7.2% of RYGB and 6.2% of SG patients presented at least 1 complication and no patients died (mortality in nonbenchmark cases: 0.06%). The most frequent reasons for readmission after 90-days following both procedures were symptomatic cholelithiasis and abdominal pain of unknown origin. Benchmark values for both RYGB and SG at 90-days postoperatively were 5.5% Clavien-Dindo grade ≥IIIa complication rate, 5.5% readmission rate, and comprehensive complication index ≤33.73 in the subgroup of patients presenting at least 1 grade ≥II complication.

Conclusion: Benchmark cutoffs targeting perioperative outcomes in BS offer a new tool in surgical quality-metrics and may be implemented in quality-improvement cycle.ClinicalTrials.gov Identifier NCT03440138.
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http://dx.doi.org/10.1097/SLA.0000000000003512DOI Listing
November 2019
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