Publications by authors named "Jacques Himpens"

117 Publications

Innovative Bariatric Procedures and Ethics in Bariatric Surgery: the IFSO Position Statement.

Obes Surg 2022 Aug 3. Epub 2022 Aug 3.

Center for Metabolic and Bariatric Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

With the rise in obesity and bariatric procedures worldwide, there has been a surge in new and innovative procedures that has been increasingly offered to patients. In this position statement, IFSO highlights the importance of surgical ethics in innovation and when offering new procedures. Furthermore, the task force reviewed the current literature to describe which procedures can be offered as mainstream outside research protocols versus those that are still investigational and need further data.
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http://dx.doi.org/10.1007/s11695-022-06220-8DOI Listing
August 2022

The first international Delphi consensus statement on Laparoscopic Gastrointestinal surgery.

Int J Surg 2022 Jul 13;104:106766. Epub 2022 Jul 13.

Imperial College London, UK.

Background: Laparoscopic surgery has almost replaced open surgery in many areas of Gastro-Intestinal (GI) surgery. There is currently no published expert consensus statement on the principles of laparoscopic GI surgery. This may have affected the training of new surgeons. This exercise aimed to achieve an expert consensus on important principles of laparoscopic GI surgery.

Methods: A committee of 38 international experts in laparoscopic GI surgery proposed and voted on 149 statements in two rounds following a strict modified Delphi protocol.

Results: A consensus was achieved on 133 statements after two rounds of voting. All experts agreed on tailoring the first port site to the patient, whereas 84.2% advised avoiding the umbilical area for pneumoperitoneum in patients who had a prior midline laparotomy. Moreover, 86.8% agreed on closing all 15 mm ports irrespective of the patient's body mass index. There was a 100% consensus on using cartridges of appropriate height for stapling, checking the doughnuts after using circular staplers, and keeping the vibrating blade of the ultrasonic energy device in view and away from vascular structures. An 84.2% advised avoiding drain insertion through a ≥10 mm port site as it increases the risk of port-site hernia. There was 94.7% consensus on adding laparoscopic retrieval bags to the operating count and ensuring any surgical specimen left inside for later removal is added to the operating count.

Conclusion: Thirty-eight experts achieved a consensus on 133 statements concerning various aspects of laparoscopic GI Surgery. Increased awareness of these could facilitate training and improve patient outcomes.
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http://dx.doi.org/10.1016/j.ijsu.2022.106766DOI Listing
July 2022

A Technique of Preserving Preexisting Fundoplication When Converting to Roux-en-Y Gastric Bypass.

Obes Surg 2022 Jul 5. Epub 2022 Jul 5.

Department of Visceral Surgery, Delta CHIREC Hospital, 201, Boulevard du Triomphe, 1160, Brussels, Belgium.

Background: The standard surgical treatment of gastro-esophageal reflux disease (GERD) consists of either 360° (Nissen, NFP) or 270° (Toupet, TFP) fundoplication. On some occasions, such as recurrent GERD and/or severe overweight, patients may benefit from conversion to Roux-en-Y gastric bypass (RYGB), which is however technically difficult. Most techniques of conversion involve unwrapping of the fundoplication. We developed a laparoscopic technique that includes preservation of the wrap, while constructing a standard small-pouch RYGB. We describe the surgical technique and report the short-term outcomes of our technique.

Methods: Consecutive patients underwent conversion of NFP to RYGB by our fundoplication preserving technique as described in surgical technique. Perioperative outcomes were assessed by analysis of the electronic patient records; progression of GERD symptoms and patient satisfaction were evaluated by an on-line questionnaire.

Results: Fourteen patients underwent the conversion. There were no peroperative complications and no conversions. Short-term complications were registered in 4 patients (Clavien-Dindo grade 1, n = 2; grade 2, n = 1 and grade 3a, n = 1). No long-term complications were reported. None of the participants reported significant GERD symptoms Patient satisfaction was good.

Conclusion: We developed a laparoscopic technique of NFP to RYGB conversion, with preservation of fundoplication integrity, which appears to add to the safety and efficacy of the procedure.
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http://dx.doi.org/10.1007/s11695-022-06185-8DOI Listing
July 2022

Single Anastomosis Jejuno-ileal (SAJI): a New Model of Malabsorptive Revisional Procedure for Insufficient Weight Loss or Weight Regain After Roux-en-Y Gastric Bypass.

Obes Surg 2022 Jun 28. Epub 2022 Jun 28.

Metabolic & Obesity Unit, Chirec Delta Hospital, Brussels, Belgium.

Background: In case of insufficient weight loss or weight regain or relapse of weight-related comorbidities after Roux-en-Y gastric bypass (RYGB), other procedures such as reduction of a large gastric pouch and stoma, lengthening of the Roux limb, conversion to sleeve gastrectomy and/or bilio-pancreatic diversion with duodenal switch have been advocated. Single anastomosis jejuno-ileal (SAJI) is a new revisional simple operation performed after RYGB failure which adds malabsorption to the previous gastric bypass.

Methods: SAJI includes a single jejuno-ileal anastomosis specifically joining the ileum 250-300 cm proximal to the ileo-caecal valve and the jejunum 30 cm below the gastro-jejunal anastomosis on the Roux limb of the previous RYGB. Thirty-one patients underwent SAJI for insufficient weight loss and/or weight regain after RYGB. The percent total weight loss (%TWL) after RYGB and before SAJI was 21.8 ± 7.8. All SAJI operations were performed laparoscopically. The SAJI mean operating time was 145 min.

Results: Regarding weight loss after SAJI, %TWL is 27.2 ± 7.4, 31.2 ± 6.4, 33.7 ± 5.9 and 32.9 ± 5.2 at 12, 24, 36 and 48 months, respectively. Our series recorded a low rate of peri-operative and medium-term complications with a low grade of severity (Clavien-Dindo classification grade). One patient required reoperation 36 days after SAJI for epigastrium incarcerated incisional hernia at the previous RYGB laparotomy site. Mortality was 0. Comorbidity reduction/resolution after SAJI is 83.2% for type 2 diabetes mellitus, 42.8% for arterial hypertension, 72.8% for dyslipidemia and 45.3% for OSA.

Conclusions: Treatment of failed RYGB is challenging. SAJI is a less complicated, purely low invasive malabsorptive operation that should reach satisfactory %TWL and comorbidity reduction/resolution.
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http://dx.doi.org/10.1007/s11695-022-06174-xDOI Listing
June 2022

Patient Selection in One Anastomosis/Mini Gastric Bypass-an Expert Modified Delphi Consensus.

Obes Surg 2022 08 15;32(8):2512-2524. Epub 2022 Jun 15.

Min-Sheng General Hospital, Taoyuan City, Taiwan.

Purpose: One anastomosis/mini gastric bypass (OAGB/MGB) is up to date the third most performed obesity and metabolic procedure worldwide, which recently has been endorsed by ASMBS. The main criticisms are the risk of bile reflux, esophageal cancer, and malnutrition. Although IFSO has recognized this procedure, guidance is needed regarding selection criteria. To give clinicians a daily support in performing the right patient selection in OAGB/MGB, the aim of this paper is to generate clinical guidelines based on an expert modified Delphi consensus.

Methods: A committee of 57 recognized bariatric surgeons from 24 countries created 69 statements. Modified Delphi consensus voting was performed in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was considered to indicate a consensus.

Results: Consensus was achieved for 56 statements. Remarkably, ≥ 90.0% of the experts felt that OAGB/MGB is an acceptable and suitable option "in patients with Body mass index (BMI) > 70, BMI > 60, BMI > 50 kg/m as a one-stage procedure," "as the second stage of a two-stage bariatric surgery after Sleeve Gastrectomy for BMI > 50 kg/m (instead of BPD/DS)," and "in patients with weight regain after restrictive procedures. No consensus was reached on the statement that OAGB/MGB is a suitable option in case of resistant Helicobacter pylori. This is likely as there is a concern that this procedure is associated with reflux and its related long-term complications including risk of cancer in the esophagus or stomach. Also no consensus reached on OAGB/MGB as conversional surgery in patients with GERD after restrictive procedures. Consensus for disagreement was predominantly achieved "in case of intestinal metaplasia of the stomach" (74.55%), "in patients with severe Gastro Esophageal Reflux Disease (GERD)(C,D)" (75.44%), "in patients with Barrett's metaplasia" (89.29%), and "in documented insulinoma" (89.47%).

Conclusion: Patient selection in OAGB/MGB is still a point of discussion among experts. There was consensus that OAGB/MGB is a suitable option in elderly patients, patients with low BMI (30-35 kg/m) with associated metabolic problems, and patients with BMIs more than 50 kg/m as one-stage procedure. OAGB/MGB can also be a safe procedure in vegetarian and vegan patients. Although OAGB/MGB can be a suitable procedure in patients with large hiatal hernia with concurrent hiatal hernia, it should not be offered to patients with grade C or D esophagitis or Barrett's metaplasia.
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http://dx.doi.org/10.1007/s11695-022-06124-7DOI Listing
August 2022

Adjustable Gastric Banding Conversion to One Anastomosis Gastric Bypass: Data Analysis of a Multicenter Database.

J Gastrointest Surg 2022 06 1;26(6):1147-1153. Epub 2022 Mar 1.

NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates.

Introduction: One anastomosis gastric bypass (OAGB) has been proposed as a rescue technique for laparoscopic adjustable gastric banding (LAGB) poor responders.

Aim: We sought to analyze, complications, mortality, and medium-term weight loss results after LAGB conversion to OAGB.

Methods: Data analysis of an international multicenter database.

Results: One hundred eighty-nine LAGB-to-OAGB operations were retrospectively analyzed. Eighty-seven (46.0%) were converted in one stage. Patients operated on in two stages had a higher preoperative body mass index (BMI) (37.9 vs. 41.3 kg/m, p = 0.0007) and were more likely to have encountered technical complications, such as slippage or erosions (36% vs. 78%, p < 0.0001). Postoperative complications occurred in 4.8% of the patients (4.6% and 4.9% in the one-stage and the two-stage group, respectively). Leak rate, bleeding episodes, and mortality were 2.6%, 0.5%, and 0.5%, respectively. The final BMI was 30.2 at a mean follow-up of 31.4 months. Follow-up at 1, 3, and 5 years was 100%, 88%, and 70%, respectively.

Conclusion: Conversion from LAGB to OAGB is safe and effective. The one-stage approach appears to be the preferred option in non-complicate cases, while the two-step approach is mostly done for more complicated cases.
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http://dx.doi.org/10.1007/s11605-022-05277-1DOI Listing
June 2022

"What Really Matters When Performing a Laparoscopic Roux-en Y Gastric Bypass?" Literature-Based Key Steps Towards Success and Standardization of the Procedure.

Obes Surg 2021 12 15;31(12):5441-5445. Epub 2021 Oct 15.

Visceral Surgery Unit, Delta CHIREC Hospital, Site Delta, Boulevard du Triomphe 201, 1160, Brussels, Belgium.

Lack of standardization in the Roux-en-Y gastric bypass (RY-GBP) is quite well established. We all learned the basics of the technique, but a lot of differences do exist in performing each step of the procedure. Based on scientific evidences, coming from an extensive and meticulous review of the literature of the last 20 years, we thus address the different technical steps of the procedure and their importance to try and propose a standardization of RYGBP. A lot of possibilities exist at each and every step of a RYGBP. They influence the postoperative complications, the end weight loss (EWL), weight regain, and resolution of obesity bounded comorbidities. Furthermore, lack of standardization leads to problems regarding comparison of scientific data in the related literature.
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http://dx.doi.org/10.1007/s11695-021-05750-xDOI Listing
December 2021

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

Ann Surg 2021 11;274(5):821-828

Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

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
November 2021

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries.

Obes Surg 2021 10 30;31(10):4272-4288. Epub 2021 Jul 30.

Bariatric Unit, South Tyneside and Sunderland NHS Trust, Sunderland, UK.

Background: There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.

Methods: We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.

Results: Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.

Conclusions: BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.
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http://dx.doi.org/10.1007/s11695-021-05493-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8323543PMC
October 2021

IFSO Update Position Statement on One Anastomosis Gastric Bypass (OAGB).

Obes Surg 2021 07 3;31(7):3251-3278. Epub 2021 May 3.

Harvard Medical School, Boston, MA, USA.

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued a position statement on the role of one anastomosis gastric bypass (OAGB) in the field of bariatric/metabolic surgery in 2018 De Luca et al. (Obes Surg. 28(5):1188-206, 2018). This position statement was issued by the IFSO OAGB task force and approved by the IFSO Scientific Committee and IFSO Executive Board. In 2018, the OAGB task force recognized the necessity to update the position statement in the following 2 years since additional high-quality data could emerge. The updated IFSO position statement on OAGB was issued also in response to inquiries to the IFSO by society members, universities, hospitals, physicians, insurances, patients, policy makers, and media. The IFSO position statement on OAGB has been reviewed within 2 years according to the availability of additional scientific evidence. The recommendation of the statement is derived from peer-reviewed scientific literature and available knowledge. The IFSO update position statement on OAGB will again be reviewed in 2 years provided additional high-quality studies emerge.
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http://dx.doi.org/10.1007/s11695-021-05413-xDOI Listing
July 2021

Bariatric-Metabolic Surgery Utilisation in Patients With and Without Diabetes: Data from the IFSO Global Registry 2015-2018.

Obes Surg 2021 06 27;31(6):2391-2400. Epub 2021 Feb 27.

College of Medicine and Public Health, Flinders University, Adelaide, Australia.

Background: Comparative international practice of patients undergoing bariatric-metabolic surgery for type 2 diabetes mellitus (T2DM) is unknown. We aimed to ascertain baseline age, sex, body mass index (BMI) and types of operations performed for patients with T2DM submitted to the IFSO Global Registry.

Materials And Methods: Cross-sectional analysis of patients having primary surgery in 2015-2018 for countries with ≥90% T2DM data completion and ≥ 1000 submitted records.

Results: Fifteen countries including 11 national registries met the inclusion criteria. The rate of T2DM was 24.2% (99,537 of 411,581 patients, country range 12.0-55.1%) and 77.1% of all patients were women. In every country, patients with T2DM were older than those without T2DM (overall mean age 49.2 [SD 11.4] years vs 41.8 [11.9] years, all p < 0.001). Men were more likely to have T2DM than women, odds ratio (OR) 1.68 (95% CI 1.65-1.71), p < 0.001. Men showed higher rates of T2DM for BMI <35 kg/m compared to BMI ≥35.0 kg/m, OR 2.76 (2.52-3.03), p < 0.001. This was not seen in women, OR 0.78 (0.73-0.83), p < 0.001. Sleeve gastrectomy was the commonest operation overall, but less frequent for patients with T2DM, patients with T2DM 54.9% vs without T2DM 65.8%, OR 0.63 (0.63-0.64), p < 0.001. Twelve out of 15 countries had higher proportions of gastric bypass compared to non-bypass operations for T2DM, OR 1.70 (1.67-1.72), p < 0.001.

Conclusion: Patients with T2DM had different characteristics to those without T2DM. Older men were more likely to have T2DM, with higher rates of BMI <35 kg/m and increased likelihood of food rerouting operations.
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http://dx.doi.org/10.1007/s11695-021-05280-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8113173PMC
June 2021

The IFSO Worldwide One Anastomosis Gastric Bypass Survey: Techniques and Outcomes?

Obes Surg 2021 Apr 31;31(4):1411-1421. Epub 2021 Jan 31.

Atrium Health Weight Management, Carolinas Medical Center, Charlotte, NC, USA.

Introduction: One anastomosis gastric bypass (OAGB) has become one of the most commonly performed gastric bypass procedures in some countries.

Objectives: To assess how surgeons viewed the OAGB, perceptions, indications, techniques, and outcomes, as well as the incidence of short- and long-term complications and how they were managed worldwide.

Methods: A questionnaire was sent to all IFSO members in all 5 chapters to study the pattern of practice and outcomes of OAGB.

Results: Seven hundred and forty-two surgeons responded. The most commonly performed procedures were sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and OAGB. Preoperatively, 70% of the surgeons performed endoscopy routinely. In regards to weight loss, 83% (570 surgeons) responded that OAGB produces better weight loss than SG, and 49% (342 surgeons) responded that OAGB produces better weight loss than RYGB. The most common length of the biliopancreatic limb (BPL) utilized was 200 cm. Sixty-seven percent of surgeons did not measure the total length of the small bowel. In patients with reflux disease and history of smoking, 53% and 22% of surgeons respectively still offered OAGB as a treatment option. Postoperatively, leak was documented in 963 patients, and it was the leading cause for mortality. Leak management was conservative in 35%. Conversion to RYGB was performed in 31%. In 16% the anastomosis was reinforced, 6% of the patients were reversed, and other procedures were performed in 12%. Revision of OAGB for malnutrition/steatorrhea or severe bile reflux was reported at least once by 37% and 45% of surgeons, respectively (200 cm was the most commonly encountered biliopancreatic limb BPL in those revised for malnutrition). Most common strategy for revision was conversion to RYGB (43%), reversal to normal anatomy (32%), shortening of the BPL (20%), and conversion to SG (5%). Nevertheless, 5 out of 98 mortalities (5%) were due to liver failure/malnutrition.

Conclusion: There are infrequent but potentially severe specific complications including malnutrition, liver failure, and bile reflux that may require surgical correction after OAGB.
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http://dx.doi.org/10.1007/s11695-021-05249-5DOI Listing
April 2021

Barrett's Oesophagus and Bariatric/Metabolic Surgery-IFSO 2020 Position Statement.

Obes Surg 2021 Mar 18;31(3):915-934. Epub 2021 Jan 18.

International Federation for the Surgery of Obesity and Metabolic Disorders, Rione Sirignano, 5, 80121, Naples, Italy.

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has been playing an integral role in educating both the metabolic surgical and the medical community at large about the importance of surgical and/or endoscopic interventions in treating adiposity-based chronic diseases. The occurrence of chronic conditions following bariatric/metabolic surgery (BMS), such as gastro-oesophageal reflux disease (GERD) and columnar (intestinal) epithelial metaplasia of the distal oesophagus (also known as Barrett's oesophagus (BE)), has long been discussed in the metabolic surgical and medical community. Equally, the risk of neoplastic progression of Barrett's oesophagus to oesophageal adenocarcinoma (EAC) and the resulting requirement for surgery are the source of some concern for many involved in the care of these patients, as the surgical alteration of the gastrointestinal tract may lead to impaired reconstructive options. As such, there is a requirement for guidance of the community.The IFSO commissioned a task force to elucidate three aspects of the presenting problem: First, to determine what the estimated incidence of Barrett's oesophagus is in patients presenting for BMS; second, to determine the frequency at which Barrett's oesophagus may develop following BMS (with a particular focus on the laparoscopic sleeve gastrectomy (LSG)); and third, to determine if regression of Barrett's oesophagus may occur following BMS given the close relationship of obesity and the development of BE/EAC. Based on these findings, a position statement regarding the management of this pathology in the context of BMS was developed. The following position statement is issued by the IFSO Barrett's Oesophagus task force andapproved by the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion and published peer-reviewed scientific evidence. It will be reviewed regularly.
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http://dx.doi.org/10.1007/s11695-020-05143-6DOI Listing
March 2021

The first modified Delphi consensus statement on sleeve gastrectomy.

Surg Endosc 2021 12 12;35(12):7027-7033. 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
December 2021

Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy/One Anastomosis Duodenal Switch (SADI-S/OADS) IFSO Position Statement-Update 2020.

Obes Surg 2021 Jan 6;31(1):3-25. Epub 2021 Jan 6.

International Federation for Surgery of Obesity and Metabolic Disorders, Rione Sirignano, 5, 80121, Naples, Italy.

PreambleThe International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has played an integral role in educating both the metabolic surgical and the medical communities at large about the role of innovative and new surgical and or endoscopic interventions in treating adiposity-based chronic diseases. The single anastomosis duodenal-ileal bypass with sleeve gastrectomy/one anastomosis duodenal switch (SADI-S/OADS) is a relatively new procedure that has been proposed as an alternative to the conventional duodenal switch (DS) procedure. The IFSO published a position paper on SADI-S/OADS in 2018 with which concluded that this procedure was likely to be a safe and efficacious treatment for adiposity and its related diseases. However, it noted that there was insufficient long-term data and minimal high-level evidence available. The position statement called for patients to be enrolled in long-term multidisciplinary care encouraged the registration of patients in national registries, and called for more randomized controlled trials (RCT) (Obes Surg 28:1207-16, 2018) involving the procedure. The following position statement is an update of the previous position statement. It is issued by the IFSO SADI-S/OADS task force and has been reviewed and approved by both the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence. It will be reviewed again in 2 years.
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http://dx.doi.org/10.1007/s11695-020-05134-7DOI Listing
January 2021

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

IFSO Position Statement on the Role of Esophago-Gastro-Duodenal Endoscopy Prior to and after Bariatric and Metabolic Surgery Procedures.

Obes Surg 2020 Aug;30(8):3135-3153

International Federation for the Surgery of Obesity and Metabolic Disorders, Rione Sirignano, 5, 80121, Naples, Italy.

One of the roles of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) is to provide guidance on the management of patients seeking surgery for adiposity-based chronic diseases. The role of endoscopy around the time of endoscopy is an area of clinical controversy. In 2018, IFSO commissioned a task force to determine the role of endoscopy before and after surgery for the management of adiposity and adiposity-based chronic diseases. The following position statement is issued by the IFSO Endoscopy in Bariatric/Metabolic Surgery Taskforce. It has been approved by the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence. It will be reviewed regularly.
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http://dx.doi.org/10.1007/s11695-020-04720-zDOI Listing
August 2020

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

The first consensus statement on revisional bariatric surgery using a modified Delphi approach.

Surg Endosc 2020 04 19;34(4):1648-1657. Epub 2019 Jun 19.

Bariatric Unit, Sunderland Royal Hospital, Sunderland, SR4 7TP, UK.

Background: Revisional bariatric surgery (RBS) constitutes a possible solution for patients who experience an inadequate response following bariatric surgery or significant weight regain following an initial satisfactory response. This paper reports results from the first modified Delphi consensus-building exercise on RBS.

Methods: We created a committee of 22 recognised opinion-makers with a special interest in RBS. The committee invited 70 RBS experts from 27 countries to vote on 39 statements concerning RBS. An agreement amongst ≥ 70.0% experts was regarded as a consensus.

Results: Seventy experts from twenty-seven countries took part. There was a consensus that the decision for RBS should be individualised (100.0%) and multi-disciplinary (92.8%). Experts recommended a preoperative nutritional (95.7%) and psychological evaluation (85.7%), endoscopy (97.1%), and a contrast series (94.3%). Experts agreed that Roux-Y gastric bypass (RYGB) (94.3%), One anastomosis gastric bypass (OAGB) (82.8%), and single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) (71.4%) were acceptable RBS options after gastric banding (84.3%). OAGB (84.3%), bilio-pancreatic diversion/duodenal switch (BPD/DS) (81.4%), and SADI-S (88.5%) were agreed as consensus RBS options after sleeve gastrectomy. lengthening of bilio-pancreatic limb was the only consensus RBS option after RYGB (94.3%) and OAGB (72.8%).

Conclusion: Experts achieved consensus on a number of aspects of RBS. Though expert opinion can only be regarded as low-quality evidence, the findings of this exercise should help improve the outcomes of RBS while we develop robust evidence to inform future practice.
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http://dx.doi.org/10.1007/s00464-019-06937-1DOI Listing
April 2020

Duodenal switch in revisional bariatric surgery: conclusions from an expert consensus panel.

Surg Obes Relat Dis 2019 Jun 21;15(6):894-899. Epub 2019 Mar 21.

Division of General/Bariatric Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina.

Background: Duodenal switch (BPD/DS) is gaining popularity as a secondary procedure for inadequate weight loss after an initial operation.

Objectives: We aimed to generate expert consensus points on the appropriate use of BPD/DS in the revisional bariatric surgical setting.

Setting: Data were gathered at an international conference with attendees from a variety of different institutions and settings.

Methods: Sixteen lines of questioning regarding revisional BPD/DS were presented to an expert panel of 29 bariatric surgeons. Current available literature was reviewed extensively for each topic and proposed to the panel before polling. Responses were collected and topics defined as achieving consensus (≥70% agreement) or no consensus (<70% agreement).

Results: Consensus was present in 10 of 16 lines of questioning, with several key points most prominent.

Conclusions: As a second-stage procedure, BPD/DS is most appropriate after sleeve gastrectomy (SG) for the treatment of super morbid obesity (96.7% agree) or as a subsequent operation for a reliable patient with insufficient weight loss after SG (88.5%). In a patient with weight regain and reflux and/or enlarged fundus after SG, Roux-en-Y gastric bypass is preferable and BPD/DS should be avoided (90%). BPD/DS should not be used prophylactically in patients with a history of jejunoileal bypass who are otherwise doing well (80.8%). Applicability of BPD/DS is limited by technical difficulty; 86.2% of experts would routinely recommend or consider the procedure if it were more technically feasible after failed bypass. No consensus was found on approaches to revision of BPD/DS for protein malnutrition.
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http://dx.doi.org/10.1016/j.soard.2019.03.009DOI Listing
June 2019

Bariatric Surgery Worldwide: Baseline Demographic Description and One-Year Outcomes from the Fourth IFSO Global Registry Report 2018.

Obes Surg 2019 03 12;29(3):782-795. Epub 2018 Nov 12.

Department of Bariatric Surgery, AZ Sint Blasius Medical Center, Dendermonde, Belgium.

Background: Since 2014, the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has produced an annual report of all bariatric surgery submitted to the Global Registry. We describe baseline demographics of international practice from the 4th report.

Methods: The IFSO Global Registry amalgamated data from 51 different countries, 14 of which provided data from their national registries. Data were available from 394,431 individual records, of which 190,177 were primary operations performed since 2014.

Results: Data were submitted on 72,645 Roux en Y gastric bypass operations (38.2%), 87,467 sleeve gastrectomy operations (46.0%), 14,516 one anastomosis gastric bypass procedures (7.6%) and 9534 gastric banding operations (5.0%) as the primary operation since 2014. The median patient body mass index (BMI) pre-surgery was 41.7 kg m (inter-quartile range: 38.3-46.1 kg m). Following gastric bypass, 84.1% of patients were discharged within 2 days of surgery; and 84.5% of sleeve gastrectomy patients were discharged within 3 days. Assessing operations performed between 2012 and 2016, at one year after surgery, the mean recorded percentage weight loss was 28.9% and 66.1% of those taking medication for type 2 diabetes were recorded as not using them. The proportion of patients no longer receiving treatment for diabetes was highly dependent on weight loss achieved. There was marked variation in access and practice.

Conclusions: A global description of patients undergoing bariatric surgery is emerging. Future iterations of the registry have the potential to describe the operated patients comprehensively.
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http://dx.doi.org/10.1007/s11695-018-3593-1DOI Listing
March 2019

Efficiency and risks of laparoscopic conversion of omega anastomosis gastric bypass to Roux-en-Y gastric bypass.

Surg Endosc 2019 08 23;33(8):2572-2582. Epub 2018 Oct 23.

Department of Bariatric Surgery, AZ Sint-Blasius, Dendermonde, Belgium.

Background: There is a paucity on literature data related to conversion of Omega anastomosis gastric bypass (OAGB) to Roux-en-Y gastric bypass (RYGB).

Methods: This is a retrospective study. Records of all patients who underwent this conversion were analyzed. Additionally, patients were contacted to answer a questionnaire on their current clinical condition.

Results: Twenty-eight patients underwent laparoscopic conversion between September 2007 and June 2016. Indications were peritonitis in 7 patients (leaks after OAGB in 5, perforated marginal ulcer (MU) and blow-out remnant with concomitant leak in one patient each), anastomotic bleeding in one, bile reflux in 6, recalcitrant MU in 4, afferent loop syndrome in 6, postprandial vomiting in 2 (related to anastomotic stenosis and perianastomotic diverticulum, one each), and malnutrition and hypoglycemia both in 1. Thirty-day mortality was zero, complication rate (Clavien-Dindo grade III or more) 5% ((N = 1/20), abscess) when conversion was elective and 50.0% ((N = 4/8), all persisting leaks) when conversion was urgent. All 4 leaks persisting after conversion were successfully treated by endoscopic stenting, despite stent migration in 2 patients. Follow-up was available in 92.9%, for a mean time of 64.5 ± 30.1 months. Successful symptom relief (Likert score 4 or more) was noted for bile reflux and postprandial vomiting. Additionally, malnutrition was corrected.

Conclusions: When indicated, conversion of OAGB to RYGB is a safe treatment strategy. In case conversion is performed for leak after OAGB, persisting subclinical leaks are frequent but can be efficiently addressed by endoscopic stenting.
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http://dx.doi.org/10.1007/s00464-018-6552-yDOI Listing
August 2019

Roux-en-Y gastric bypass, sleeve gastrectomy, or one anastomosis gastric bypass as rescue therapy after failed adjustable gastric banding: a multicenter comparative study.

Surg Obes Relat Dis 2018 11 11;14(11):1659-1666. Epub 2018 Aug 11.

OLVG-West, Amsterdam, the Netherlands.

Background: To date, laparoscopic adjustable gastric banding remains the third most commonly performed surgical procedure for weight loss. Some patients fail to get acceptable outcomes and undergo revisional surgery at rates ranging from 7% to 60%. Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass (OAGB), and sleeve gastrectomy (SG) are among the most common salvage options for failed laparoscopic adjustable gastric banding.

Objective: To compare the outcomes of converting failed laparoscopic adjustable gastric banding to RYGB, OAGB, or SG.

Methods: Data collected from 7 experienced bariatric centers around the world were retrospectively collected, reviewed, and analyzed. Final body mass index (BMI), change in BMI, percentage excess BMI loss, and major complications with particular attention to leaks, hemorrhage, and mortality were reported.

Results: Of 1219 patients analyzed, 74% underwent RYGB, 16% underwent OAGB, and 10% underwent SG after banding failure. The mean age was 38 years (±10 yr), and 82% of patients were women. The mean follow-up was 33 months. The follow-up rate was 100%, 87%, and 52% at 1, 3, and 5 years, respectively. At the latest follow-up, percentage excess BMI loss >50% was achieved by 75% of RYGB, 85% of OAGB, and 67% of SG patients. Postoperative complications occurred in 13% of patients after RYGB, 5% after OAGB, and 15% after SG.

Conclusion: Our data show that it is possible to achieve or maintain significant weight loss with an acceptable complication rate with all 3 surgical options.
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http://dx.doi.org/10.1016/j.soard.2018.08.005DOI Listing
November 2018

Editorial: Single Anastomosis Procedures, IFSO Position Statement.

Obes Surg 2018 05;28(5):1186-1187

UCSF, San Francisco, CA, USA.

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http://dx.doi.org/10.1007/s11695-018-3278-9DOI Listing
May 2018

Three-trocar laparoscopic duodenal switch after sleeve gastrectomy.

Surg Obes Relat Dis 2018 06 10;14(6):869-873. Epub 2018 Mar 10.

Herbert Wertheim College of Medicine, Florida International University, Miami, Florida; Hôpital du Sacre Coeur, Montreal, Quebec, Canada.

Laparoscopic duodenal switch is a recognized bariatric procedure, which can be performed in one step or as a second step after laparoscopic sleeve gastrectomy (LSG). Mainly, indications as primary surgery are super-obese or super super-obese patients, and after LSG indications are the presence of insufficient weight loss or weight regain, associated with morbid obesity co-morbidities, without gastroesophageal reflux. In this video, the authors report the technique of reduced port laparoscopic duodenal switch after LSG. The procedure is performed using a 12-mm trocar in the umbilicus, a 5-mm trocar in the right flank, and a 5-mm trocar in the left flank. One or more temporary percutaneous sutures are passed into the hepatic ligaments to increase the exposure of the first duodenum. The optical system is switched from 10 mm to 5 mm and introduced in the left 5-mm flank trocar at the step of the linear stapler insertion through the umbilical trocar. Classic construction with 150-cm alimentary limb and 100-cm common limb is performed. The duodeno-jejunostomy is fashioned in an end-to-side handsewn technique and the jejuno-ileostomy in the side-to-side semimechanical linear stapler technique. Both Petersen and mesenteric defects are closed. The umbilical access is finally meticulously closed, avoiding incisional hernia. Reduced port laparoscopic duodenal switch after LSG is a safe and feasible technique. Besides the enhanced cosmetic outcomes, this surgery is associated with a reduced use of painkillers, fewer trocar complications, and quick patient convalescence.
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http://dx.doi.org/10.1016/j.soard.2018.03.011DOI Listing
June 2018

Mini Gastric Bypass-One Anastomosis Gastric Bypass (MGB-OAGB)-IFSO Position Statement.

Obes Surg 2018 05;28(5):1188-1206

International Federation for the Surgery of Obesity and Metabolic Disorders, Rione Sirignano, 5, 80121, Naples, Italy.

Preamble: The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has played an integral role in educating both the metabolic surgical and the medical community at large about the role of innovative and new surgical and/or endoscopic interventions in treating adiposity-based chronic diseases.The mini gastric bypass is also known as the one anastomosis gastric bypass. The IFSO has agreed that the standard nomenclature should be the mini gastric bypass-one anastomosis gastric bypass (MGB-OAGB). The IFSO commissioned a task force (Appendix 1) to determine if MGB-OAGB is an effective and safe procedure and if it should be considered a surgical option for the treatment of obesity and metabolic diseases.The following position statement is issued by the IFSO MGB-OAGB task force and approved by the IFSO Scientific Committee and Executive Board. This statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence. It will be reviewed in 2 years.
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http://dx.doi.org/10.1007/s11695-018-3182-3DOI Listing
May 2018

Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy/One Anastomosis Duodenal Switch (SADI-S/OADS) IFSO Position Statement.

Obes Surg 2018 05;28(5):1207-1216

International Federation for Surgery of Obesity and Metabolic Disorders, Rione Sirignano, 5, 80121, Naples, Italy.

The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) has played an integral role in educating both the metabolic surgical and the medical community at large about the role of innovative and new surgical and or endoscopic interventions in treating adiposity-based chronic diseases. The single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) is also called the one anastomosis duodenal switch (OADS). This is a relatively new procedure that has been proposed as an alternative to the currently accepted duodenal switch (DS) procedure. The IFSO commissioned a task force (Appendix 1) to determine if SADI-S/OADS is an effective and safe procedure and if it should be considered a surgical option for the treatment of adiposity and adiposity-based chronic diseases. The following position statement is issued by the IFSO SADI-S/OADS task force and approved by the IFSO Executive Board. This statement is based on current clinical knowledge, expert opinion and published peer-reviewed scientific evidence. It will be reviewed in 2 years.
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http://dx.doi.org/10.1007/s11695-018-3201-4DOI Listing
May 2018

Modified endoscopic gastroplasty for the treatment of obesity.

Surg Endosc 2018 09 28;32(9):3936-3942. Epub 2018 Feb 28.

Cavell Obesity Center CHIREC Hospitals, Brussels, Belgium.

Background: Endoscopic sleeve gastroplasty is a safe and feasible treatment for obesity. This study is focused on our technique modification which suggests a different suturing pattern in order to distribute suture tension more evenly.

Methods: A retrospective study of 148 patients (121 women) who underwent this procedure and were monitored for 12 months was conducted. The average age was 41.53 ± 10 years. The average BMI was 35.11 ± 5.5 kg/m with the average initial weight being 98.7 ± 17 kg. A subgroup of the first 72 patients (60 women) were monitored for 18 months. A new running "Z" stitch pattern was used to provide gastric cavity reduction by means of 4 parallel suture rows. The stitch pattern was intended to provide a homogenous distribution of the disruptive force on the suture among all stitch points.

Results: %TWL was 17.53 ± 7.57 in 12 months and 18.5 ± 9% in 18 months indicating durability of the procedure. Patients with a BMI < 35 benefited most from an endoscopic gastroplasty. Leptin did not predict a response to endoscopic gastroplasty and decreased in all patients. In just one case there was a mild bleeding (0.67%) at the insertion point of the helix, which was resolved by sclerotherapy.

Conclusions: Endoscopic gastroplasty offers a real choice for obese patients. This single-center experience with a modified suturing pattern provides a successful technique for weight loss.
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http://dx.doi.org/10.1007/s00464-018-6133-0DOI Listing
September 2018

Surg Obes Relat Dis 2018 03 22;14(3):432. Epub 2017 Nov 22.

Department of Bariatric Surgery, AZ Sint Blasius Medical Center, Dendermonde, Belgium.

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http://dx.doi.org/10.1016/j.soard.2017.11.023DOI Listing
March 2018

The First Consensus Statement on One Anastomosis/Mini Gastric Bypass (OAGB/MGB) Using a Modified Delphi Approach.

Obes Surg 2018 02;28(2):303-312

Bariatric Unit, Department of General Surgery, Sunderland Royal Hospital, Sunderland, SR4 7TP, UK.

Background: An increasing number of surgeons worldwide are now performing one anastomosis/mini gastric bypass (OAGB/MGB). Lack of a published consensus amongst experts may be hindering progress and affecting outcomes. This paper reports results from the first modified Delphi consensus building exercise on this procedure.

Methods: A committee of 16 recognised opinion-makers in bariatric surgery with special interest in OAGB/MGB was constituted. The committee invited 101 OAGB/MGB experts from 39 countries to vote on 55 statements in areas of controversy or variation associated with this procedure. An agreement amongst ≥ 70.0% of the experts was considered to indicate a consensus.

Results: A consensus was achieved for 48 of the 55 proposed statements after two rounds of voting. There was no consensus for seven statements. Remarkably, 100.0% of the experts felt that OAGB/MGB was an "acceptable mainstream surgical option" and 96.0% felt that it could no longer be regarded as a new or experimental procedure. Approximately 96.0 and 91.0% of the experts felt that OAGB/MGB did not increase the risk of gastric and oesophageal cancers, respectively. Approximately 94.0% of the experts felt that the construction of the gastric pouch should start in the horizontal portion of the lesser curvature. There was a consensus of 82, 84, and 85% for routinely supplementing iron, vitamin B, and vitamin D, respectively.

Conclusion: OAGB/MGB experts achieved consensus on a number of aspects concerning this procedure but several areas of disagreements persist emphasising the need for more studies in the future.
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http://dx.doi.org/10.1007/s11695-017-3070-2DOI Listing
February 2018
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