Andreas Plamper

In addition to preoperative diagnostic gastroscopy, some bariatric surgery patients require one or more differentiated endoscopic interventions as part of postoperative complication management. The aim of this study is to analyze endoscopic interventions regarding indication, type of procedure, material used, and outcome. We prospectively collected and retrospectively analyzed data over a period of 15 years from 2006 to 2021 of all consecutive patients who underwent an interventional upper gastrointestinal endoscopy after bariatric surgery at our center. The primary study objective was the type and frequency of the treatment. Secondary study objectives included clinical outcomes and postinterventional complications. Of 3000 bariatric procedures, 145 (4.8%), among them 11.1% (n = 54) of 485 Roux-en-Y gastric bypasses, 7.1% (n = 20) of 282 redo operations, 5.7% (n = 20) of 351 revisional operations, 3.3% (n = 13) of 398 sleeve gastrectomies, and 1.9% (n = 26) of 1394 one-anastomosis gastric bypasses, received an interventional endoscopy for postoperative complication management. 79.3% (n = 115) were female, mean age was 42.4 (± 10.7) years, mean BMI was 43.5 (± 9.8) kg/m². Complication after interventional endoscopy happened in 1.6%, revisional surgery was necessary in 0.5% (n = 3). Causes for endoscopic intervention were stenosis (52.4%), leakage/fistula (35.9%), intraluminal bleeding (13.1%), dumping syndrome (9.0%), and gallstones (1.4%). The performed interventions were balloon dilation (48.3%), stent therapy (33.1%), metallic clipping (12.4%), injection therapy (0.09%), bougienage (0.07%), vacuum therapy (0.06%), and pigtail therapy (0.04%). Endoscopic intervention is an effective and safe way of treating adverse events after bariatric surgery. Stenosis and leakage were the most frequent complications, with endoscopic balloon dilatation and stent therapy as the most frequent and successful treatment options. RYGB was the procedure with the most endoscopic interventional involvement. To better learn about outcomes of specific endoscopic techniques further studies preferably with larger multicenter samples are required.

Since long-term results after laparoscopic sleeve gastrectomy (LSG) are rather scarce, this study aims to add LSG results with a minimum of 5 years of follow-up. Prospectively collected data from primary LSG in a tertiary bariatric center from 08/2007 to 12/2018 with follow-up ≥ 5 years were analyzed retrospectively. Primary endpoints included total body weight loss (%TBWL) and excess weight loss (%EWL), insufficient weight loss (IWL), weight regain (WR), remission of associated diseases, development of new-onset gastroesophageal reflux disease (GERD), and nutritional deficiencies. Furthermore, the study focused on incidence, time point, and causes of conversion and revision operations. A total of 207 LSG (132 female, mean age 43 (± 10.7) years) entered this study. 33.3% (52 of 156 without conversion) were lost to follow-up for ≥ 5-year data. Perioperative mortality was 0.5% (n = 1). %TBWL was 27.1% (± 12.4) and %EWL 52.5% (± 24.3). IWL or WR was found in 48.8%, new-onset GERD occurred in 27.5% of cases, leading to conversion in 26.6% and revisions in 2%. Nutritional deficiencies were observed in 23.7%, while resolution of associated diseases was sufficient. This patient group with a mean BMI > 50 kg/m² at baseline showed fair results regarding weight loss issues and remission of associated diseases at ≥ 5 years postoperatively. Yet, a rate of 48.8% of either IWL and/or WR and 27.5% of new-onset GERD required conversion and revision operations in 28.6%. To better learn about long-term results of LSG, further studies preferably with larger multicenter samples and comparisons with alternative primary procedures, preferably in a prospectively randomized approach, possibly with focus on high BMI patients, are required.

Background/Objectives: Metabolic dysfunction-associated steatotic liver disease (MASLD) is closely associated with obesity and insulin resistance (IR). Identifying characteristics that predict a higher risk of fibrosis using noninvasive methods is particularly important. Methods: We performed a secondary analysis of data from an RCT of 48 patients after one anastomosis gastric bypass (OAGB) surgery, supplemented with specifically formulated probiotics and micronutrients or control treatment for 12 weeks. Patients were categorized using alanine aminotransferase (ALAT; >35 U/L for women, >50 U/L for men), higher NAFLD fibrosis score (NFS) > −1.455), and IR (HOMA-IR > 2.0). This trial was registered at Clinicaltrials.gov (ID: NCT03585413). Results: Abnormal ALAT was associated with high triglycerides, blood pressure (BP), glucose, and fatty liver index (FLI). NFS > −1.455 was linked to higher age, body mass, waist circumference, and FLI, and lower albumin and platelet count. HOMA-IR > 2.0 was associated with higher BP and triglycerides, lower HDL-cholesterol, higher serum transaminases, and higher probabilities of steatosis and fibrosis. Twelve weeks postoperatively, patients with NFS > −1.455 showed greater reductions in body mass, systolic BP, serum insulin, and HbA1c, whereas those with NFS ≤ −1.455 showed improvements in FLI and lipid metabolism but had high glucose concentrations. Patients with HOMA-IR ≤ 2.0 also had high glucose concentrations. Conclusions: The evaluation of common biomarker scores for fibrosis and IR may help clinicians to recognize severe NAFLD and improve the outcomes of OAGB surgery.

Background: Bariatric surgery in super-super-obese (SSO) patients remains a continuous challenge due to intraabdominal fat masses, higher liver volume and existing comorbidities. A convenient procedure in SSO patients is one anastomosis gastric bypass (OAGB). The aim of this study was to compare the outcome of SSO patients undergoing OAGB in comparison to laparoscopic sleeve gastrectomy (LSG). Methods: We retrospectively reviewed data from SSO patients who underwent OAGB and LSG in our institution between 2008 and 2020. Primary endpoints included percentage total body weight loss and percentage BMI loss at 12, 24, and 36 months after the operation. Secondary endpoints were perioperative complications, procedure length, length of hospital stay and outcome of comorbidities. Results: 243 patients were included in this study. 93 patients underwent LSG and 150 underwent OAGB. At any of the time points evaluated, weight loss in patients after OAGB was greater than in LSG patients, while procedure length was significantly shorter for OAGB than LSG (81.4 vs. 92.1 min, p-value < 0.001). Additionally, mean length of hospital stay was shorter in the OAGB group (3.4 vs. 4.5 days, p-value < 0.001). There were more severe complications (Clavien-Dindo ≥ 3a) in the LSG group (11.8% vs 2.7%, p-value = 0.005). Conclusion: In this retrospective analysis, OAGB was superior to LSG in terms of weight loss in SSO patients. Procedure length and hospital stay were shorter after OAGB in comparison to LSG and there were fewer severe complications. OAGB can therefore be regarded a safe and effective treatment modality for SSO patients.

Background. Bariatric surgery is a widely used treatment for morbid obesity. Prediction of postoperative weight loss currently relies on prediction models, which mostly overestimate patients’ weight loss. Data about the influence of Non-alcoholic fatty liver disease (NAFLD) on early postoperative weight loss are scarce. Methods. This prospective, single-center cohort study included 143 patients receiving laparoscopic gastric bypass surgery (One Anastomosis-Mini Gastric Bypass (OAGB-MGB) or Roux-en-Y Gastric Bypass (RYGB)). Liver biopsies were acquired at surgery. NAFLD activity score (NAS) assigned patients to “No NAFLD”, “NAFL” or “NASH”. Follow up data were collected at 3, 6 and 12 months. Results. In total, 49.7% of patients had NASH, while 41.3% had NAFL. Compared with the No NAFLD group, NAFL and NASH showed higher body-mass-index (BMI) at follow-up (6 months: 31.0 kg/m² vs. 36.8 kg/m² and 36.1 kg/m², 12 months: 27.0 kg/m² vs. 34.4 and 32.8 kg/m²) and lower percentage of total body weight loss (%TBWL): (6 months: 27.1% vs. 23.3% and 24.4%; 12 months: 38.5% vs. 30.1 and 32.6%). Linear regression of NAS points significantly predicts percentage of excessive weight loss (%EWL) after 6 months (Cologne-weight-loss-prediction-score). Conclusions. Histopathological presence of NAFLD might lead to inferior postoperative weight reduction after gastric bypass surgery. The mechanisms underlying this observation should be further studied.

Sleeve gastrectomy (SG) is an effective procedure to treat morbid obesity. SG induces remission of type 2 diabetes and metabolic syndrome and improves non-alcoholic fatty liver disease (NAFLD). However, it is imperative to clarify the extent to which these beneficial effects may be attributed to SG among other concomitant changes including postoperative diet. The current study addresses this question in a rodent model of obesity by subjecting it to SG, normal diet, or a combination of the two. Male Wistar-rats were fed with either high fat diet (HF, n = 32) or received chow diet (CD, n = 8). After 15 weeks, the HF-fed rats underwent either SG or sham operation, following which they were randomised to either continue HF or switched to CD for another 6 weeks. Body weight, fasting blood glucose level, blood pressure, and adipokine expression (leptin, adiponectin, MCP-1) in the adipose tissue along with triglycerides level in the blood serum were assessed to evaluate metabolic function. Hepatic function was assessed by histological evaluation of liver fibrosis (Hydroxyproline, Sirius Red) and reverse transcription polymerase chain reaction (RT-PCR) of the inflammation marker monocyte chemoattractant protein-1 (MCP-1). Postoperative dietary change improved adipose tissue inflammation and arterial blood pressure regardless of the surgical intervention, while SG improved hyperglycaemia, blood triglyceride levels and, regardless of the postoperative diet, hepatic inflammation and fibrosis. However, combined administration of SG with post-operative normal diet was the most effective with regard to reducing the body weight. HF for 15 weeks induced obesity with metabolic syndrome and NAFLD in rats. SG and dietary intervention improved metabolic state and NAFLD; however, their combination was significantly more effective.

Bariatric surgery is continuously growing with more than half a million procedures performed yearly worldwide.[1] Its safety regarding morbidity and mortality and its effectiveness regarding long-term weight loss have been demonstrated repeatedly. Among the most common procedures, the bypass procedures such as Roux-en-Y gastric bypass (RYGB) or mini-gastric bypass (MGB) seem to be superior to sleeve gastrectomy (SG) concerning remission of metabolic comorbidities, especially type 2 diabetes mellitus (T2DM).[2] [3] [4] According to the current literature, the average surgeon (including the bariatric surgeon) will—from a statistical point of view—encounter a haemophiliac patient only once during his surgical career.[5] In experienced institutions, no differences could be found in the outcome of haemophiliac patients undergoing various surgical procedures compared with patients without impaired hemostasis.[6] [7] Nevertheless, bariatric surgery is challenging in patients with haemophilia, and to the best of our knowledge, except one case of SG in haemophilia B, no cases of gastric bypass in haemophiliac patients have been reported in the literature so far.[8] Herein, we report on a 40-year-old male patient suffering from both severe haemophilia A (factor VIII activity below 1%, normal range: 70–150%) and obesity since childhood. When he came to our centre at the age of 14 years, prophylaxis was started. He suffered from inactive hepatitis B and C, but there was no HIV infection. At the age of 25 years, he already weighed 100 kg (BMI: 35.0 kg/m²), and there was a further increase of 16 kg within 6 years to a peak weight of 116 kg (BMI: 40.6 kg/m²); at the time of initial presentation to the bariatric centre, the BMI was 38.2 kg/m² (109 kg, 1.70 m). His annual bleeding rate was three bleedings per year. He repeatedly suffered from multiple haemarthrosis of both knee, elbow, and ankle joints, resulting in an endoprosthesis of the right knee joint in 2015. Other obesity-related comorbidities were T2DM (baseline HbA1c: 10.5%), hypertension, and reflux disease. After various unsuccessful conservative weight loss treatments, including a multidisciplinary program over 6 months, he was approved for bariatric surgery by his health care insurance and scheduled for laparoscopic MGB in November 2016. MGB was favoured over SG for expected better outcome on T2DM, and over RYGB because the single anastomosis would be easily accessible in case of a bleeding event. A five-trocar laparoscopic approach was applied, starting with the creation of a long and narrow gastric pouch (calibrated by a 10-mm bougie) approximately 3 cm below the angulus up to the angle of His. The remnant stomach and a 180-cm-long biliopancreatic limb were bypassed by performing an antecolic end-to-side gastroenterostomy ([Fig. 1]). The staple lines were completely reinforced with titanium clips for additional haemostasis. The 60-minute-long procedure was completed by a toluidine blue test to prove tightness of the anastomosis and placement of a drain for 1 day. The operative technique has been described by our group in detail earlier.[9] On the evening before the operation, 26 IU/kg bw (body weight) rFVIII was applied intravenously. Therapy with 1 g tranexamic acid every 8 hours was started and continued until day 4. On the operation day, the total FVIII consumption was 105 IU/kg bw (divided into three doses). On the first postoperative day, the total FVIII dose was reduced to 85 IU/kg bw (divided into two doses), and on the second postoperative day, the total FVIII consumption was 59 IU/kg bw (divided into two doses). Twelve-hour trough levels of FVIII activity ranged from 85 to 100%. From day 7 on, replacement therapy was continued initially with 42 IU/kg bw (divided into two doses). Thereafter, to guarantee wound healing, the dose was tapered over 4 weeks. The peri- and postoperative course was uneventful. No bleeding complications occurred. The patient was discharged after 5 days and received 5,000 IU (international units) dalteparin daily for thromboprophylaxis. At 3-month follow-up, he already lost 18.6 kg (total body weight loss [TBWL]: 17.1%, excess weight loss [EWL]: 49.5%). Hypertension medication was completely stopped, while diabetic medication could be reduced to metformin only (HbA1c: 7%). His physical activity improved remarkably, as he was able to perform physical training thrice a week. At 6-month follow-up, weight loss increased to 26.9 kg (TBWL: 24.7%, EWL: 71.5%). HbA1c dropped to 5.9%, and so metformin medication was stopped. Proton pump inhibitors (PPI) medication could be abandoned, as reflux symptoms had stopped completely. At 9-month follow-up, weight loss was 27.4 kg, TBWL was 25.1%, and EWL was 72.9%. One year after the operation, weight loss stabilized at 29 kg, resulting in 26.6% TBWL and 77.1% EWL ([Fig. 2]). The BMI at 1-year follow-up thus decreased to 28 kg/m², while the comorbidities of T2DM and hypertension continued to be in complete remission. Laboratory exams demonstrated normal levels for micronutrients including folic acid, B vitamins, zinc, parathormone, albumin, iron, and ferritin (without iron substitution). Prior to surgery, prophylaxis was performed with three injections of a rFVIII concentrate with prolonged half-life per week: 2 × 2,000 IU (19 IU/kg bw) and 1 × 3,000 IU (28 IU/kg bw). FVIII trough levels after injection of 2,000 IU were 18% after 24 hours and 4.2% after 48 hours. Seventy-two-hour FVIII trough level after injection of 3,000 IU was 3.3%. Nine months after surgery, prophylaxis was continued with 2 × 2,000 IU (25 IU/kg bw) and 1 × 3,000 IU (37 IU/kg bw). FVIII trough levels after injection of 2,000 IU were 35% after 24 hours and 11.8% after 48 hours, and 72-hour FVIII trough level after injection of 3,000 IU was 4.7%. With a postoperative weight loss of 25%, we saw an increase of FVIII trough levels of 100% after 24 and 48 hours, and of 40% after 72 hours. Before switching to a FVIII concentrate with extended half-life, the patient has been on a prophylactic regimen with daily injections of 2,000 IU of rFVIII concentrate (17 IU/kg bw) due to arthropathy. Treatment with rFVIII concentrate with extended half-life led to a reduction of injection frequency (three vs. seven injections) and to a reduction of FVIII consumption (7,000 vs. 14,000 IU/week) with comparable FVIII activities. After bariatric surgery, the patient experienced a reduction in the annual joint bleeding rate from 2 bleedings in the year before surgery to 0.5 bleedings per year leading to a pharmacoeconomic benefit. A further reduction of FVIII dosage was not considered because of underlying arthropathy and increased physical activity in consequence to weight loss after surgery. To the best of our knowledge, we are able to report about the first gastric bypass procedure in an obese, haemophilia A patient and have shown that laparoscopic MGB can be successfully performed with very good results regarding weight loss and control of comorbidities. A close collaboration between specialized centres for bariatric surgery as well as for haemophilia was essential for an uneventful intra- and postoperative outcome without elevated risk despite the severe haemophilia. Further studies are necessary to evaluate the influence of body composition and pharmacokinetics for dosing. Informed consent was collected from the patient for this study. A.P. and K.P.R. operated on the patient, performed the surgical follow-up and wrote the article. G.G. and S.H. were responsible for the factor VIII administration/monitoring and wrote the section on FVIII administration. P.L. and J.D. wrote parts of the article and revised it. J.O. made final revisions and contributed the rFVIII.