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The Management of Biliary Disease in Patients with Severe Obesity Undergoing Metabolic and Bariatric Surgery-An International Expert Survey

Kermansaravi, Mohammad; Shikora, Scott; Dillemans, Bruno; Kurian, Marina; LaMasters, Teresa; Vilallonga, Ramon; Prager, Gerhard; Chiappetta, Sonja; ,
OBJECTIVE:This study aimed to survey international experts in metabolic and bariatric surgery (MBS) to improve and consolidate the management of biliary disease in patients with severe obesity undergoing MBS. BACKGROUND:Obesity and rapid weight loss after MBS are risk factors for the development of gallstones. Complications, such as cholecystitis, acute cholangitis, and biliary pancreatitis, are potentially life-threatening, and no guidelines for the proper management of gallstone disease exist. METHODS:An international scientific team designed an online confidential questionnaire with 26 multiple-choice questions. The survey was answered by 86 invited experts (from 38 different countries), who participated from August 1, 2023, to September 9, 2023. RESULTS:Two-thirds of experts (67.4%) perform concomitant cholecystectomy in symptomatic gallstones during MBS. Half of experts (50%) would wait 6-12 weeks between both surgeries with an interval approach. Approximately 57% of the experts prescribe ursodeoxycholic acid (UDCA) prophylactically after MBS, and most recommend a 6-month course. More than the half of the experts (59.3%/53.5%) preferred laparoscopic assisted transgastric ERCP as the approach for treating CBD stones in patients who previously had RYGB/OAGB. CONCLUSION/CONCLUSIONS:Concomitant cholecystectomy is preferred by the experts, although evidence in the literature reports an increased complication rate. Prophylactic UDCA should be recommended to every MBS patient, even though the current survey demonstrated that not all experts are recommending it. The preferred approach for treating common bile duct stones is a laparoscopic assisted transgastric ERCP after gastric bypass. The conflicting responses will need more scientific work and clarity in the future.
PMID: 38400945
ISSN: 1708-0428
CID: 5634662

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

Kermansaravi, Mohammad; Chiappetta, Sonja; Parmar, Chetan; Shikora, Scott A; Prager, Gerhard; LaMasters, Teresa; Ponce, Jaime; Kow, Lilian; Nimeri, Abdelrahman; Kothari, Shanu N; Aarts, Edo; Abbas, Syed Imran; Aly, Ahmad; Aminian, Ali; Bashir, Ahmad; Behrens, Estuardo; Billy, Helmuth; Carbajo, Miguel A; Clapp, Benjamin; Chevallier, Jean-Marc; Cohen, Ricardo V; Dargent, Jerome; Dillemans, Bruno; Faria, Silvia L; Neto, Manoel Galvao; Garneau, Pierre Y; Gawdat, Khaled; Haddad, Ashraf; ElFawal, Mohamad Hayssam; Higa, Kelvin; Himpens, Jaques; Husain, Farah; Hutter, Matthew M; Kasama, Kazunori; Kassir, Radwan; Khan, Amir; Khoursheed, Mousa; Kroh, Matthew; Kurian, Marina S; Lee, Wei-Jei; Loi, Ken; Mahawar, Kamal; McBride, Corrigan L; Almomani, Hazem; Melissas, John; Miller, Karl; Misra, Monali; Musella, Mario; Northup, C Joe; O'Kane, Mary; Papasavas, Pavlos K; Palermo, Mariano; Peterson, Richard M; Peterli, Ralph; Poggi, Luis; Pratt, Janey S A; Alqahtani, Aayad; Ramos, Almino C; Rheinwalt, Karl; Ribeiro, Rui; Rogers, Ann M; Safadi, Bassem; Salminen, Paulina; Santoro, Sergio; Sann, Nathaniel; Scott, John D; Shabbir, Asim; Sogg, Stephanie; Stenberg, Erik; Suter, Michel; Torres, Antonio; Ugale, Surendra; Vilallonga, Ramon; Wang, Cunchuan; Weiner, Rudolf; Zundel, Natan; Angrisani, Luigi; De Luca, Maurizio
Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.
PMCID:10858961
PMID: 38341469
ISSN: 2045-2322
CID: 5635252

Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60 kg/m2): a Modified Delphi Study

Ponce de Leon-Ballesteros, Guillermo; Pouwels, Sjaak; Romero-Velez, Gustavo; Aminian, Ali; Angrisani, Luigi; Bhandari, Mohit; Brown, Wendy; Copaescu, Catalin; De Luca, Maurizio; Fobi, Mathias; Ghanem, Omar M.; Hasenberg, Till; Herrera, Miguel F.; Herrera-Kok, Johnn H.; Himpens, Jacques; Kow, Lilian; Kroh, Matthew; Kurian, Marina; Musella, Mario; Narwaria, Mahendra; Noel, Patrick; Pantoja, Juan P.; Ponce, Jaime; Prager, Gerhard; Ramos, Almino; Ribeiro, Rui; Ruiz-Ucar, Elena; Salminen, Paulina; Shikora, Scott; Small, Peter; Stier, Christine; Taha, Safwan; Taskin, Eren Halit; Torres, Antonio; Vaz, Carlos; Vilallonga, Ramon; Verboonen, Sergio; Zerrweck, Carlos; Zundel, Natan; Parmar, Chetan
Background: Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60 kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology. Methods: A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70% of experts"™ votes was achieved. Results: A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations. Conclusion: This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population. Graphical Abstract: [Figure not available: see fulltext.]
SCOPUS:85182420013
ISSN: 0960-8923
CID: 5629712

Measuring Outcomes in the Treatment of Obesity

Jenkins, Megan; Kurian, Marina; Moore, Rachel
PMID: 38055228
ISSN: 2168-6262
CID: 5595752

Surgeon experience with insurance barriers to offering gastric bypass as an evidence-based operation for pathologic GERD

Ibele, Anna R; Nau, Peter N; Galvani, Carlos; Roth, J Scott; Goldberg, Ross F; Kurian, Marina S; Khaitan, Leena; Gould, Jon; Pandya, Yagnik K; ,
INTRODUCTION:Obesity is an increasingly prevalent public health problem often associated with poorly controlled gastroesophageal reflux disease. Fundoplication has been shown to have limited long-term efficacy in patients with morbid obesity and does not address additional weight-related co-morbidities. Roux-en-Y gastric bypass (RYGB) is the gold standard operation for durable resolution of GERD in patients with obesity, and is also used as a salvage operation for GERD after prior foregut surgery. Surgeons report access to RYGB as surgical treatment for GERD is often limited by RYGB-specific benefit exclusions embedded within insurance policies, but the magnitude and scope of this problem is unknown. METHODS:A 9-item survey evaluating surgeon practice and experience with insurance coverage for RYGB for GERD was developed and piloted by a SAGES Foregut Taskforce working group. This survey was then administered to surgeon members of the SAGES Foregut Taskforce and to surgeons participating in the SAGES Bariatrics and/or Foregut Facebook groups. RESULTS:respectively as cutoff for the RYGB. 89% viewed RYGB as the procedure of choice for GERD after bariatric surgery. 69% reported using RYGB to address recurrent reflux secondary to failed fundoplication. 74% of responders experienced trouble with insurance coverage at least half the time RYGB was offered for GERD, and 8% reported they were never able to get approval for RYGB for GERD indications in their patient populations. CONCLUSION:For many patients, GERD and obesity are related diseases that are best addressed with RYGB. However, insurance coverage for RYGB for GERD is often limited by policies which run contrary to evidence-based medicine. Advocacy is critical to improve access to appropriate surgical care for GERD in patients with obesity.
PMID: 37491660
ISSN: 1432-2218
CID: 5604952

IFSO Consensus on Definitions and Clinical Practice Guidelines for Obesity Management"”an International Delphi Study

Salminen, Paulina; Kow, Lilian; Aminian, Ali; Kaplan, Lee M.; Nimeri, Abdelrahman; Prager, Gerhard; Behrens, Estuardo; White, Kevin P.; Shikora, Scott; Dayyeh, Barham K.Abu; Alfaris, Nasreen; Al Qahtani, Aayeed; Andersen, Barbara; Angrisani, Luigi; Bashir, Ahmad; Batterham, Rachel L.; Behrens, Estuardo; Bhandari, Mohit; Bond, Dale; Chevallier, Jean Marc; Cohen, Ricardo V.; Dicker, Dror; Fox, Claudia K.; Garneau, Pierre; Gawdat, Khaled; Haddad, Ashraf; Himpens, Jacqués; Inge, Thomas; Kurian, Marina; Faria, Silvia Leite; Macedo, Guilherme; Miras, Alexander Dimitri; Moize, Violeta; Pattou, Francois; Poggi, Luis; Ponce, Jaime; Ramos, Almino; Rubino, Francesco; Sanchez-Pernaute, Andrés; Sarwer, David; Sharma, Arya M.; Stier, Christine; Thompson, Christopher; Vidal, Josep; Petry, Tarissa Beatrice Zanata
Introduction: This survey of international experts in obesity management was conducted to achieve consensus on standardized definitions and to identify areas of consensus and non-consensus in metabolic bariatric surgery (MBS) to assist in an algorithm of clinical practice guidelines for the management of obesity. Methods: A three-round Delphi survey with 136 statements was conducted by 43 experts in obesity management comprising 26 bariatric surgeons, 4 endoscopists, 8 endocrinologists, 2 nutritionists, 2 counsellors, an internist, and a pediatrician spanning six continents over a 2-day meeting in Hamburg, Germany. To reduce bias, voting was unanimous, and the statements were neither favorable nor unfavorable to the issue voted or evenly balanced between favorable and unfavorable. Consensus was defined as ≥ 70% inter-voter agreement. Results: Consensus was reached on all 15 essential definitional and reporting statements, including initial suboptimal clinical response, baseline weight, recurrent weight gain, conversion, and revision surgery. Consensus was reached on 95/121 statements on the type of surgical procedures favoring Roux-en-Y gastric bypass, sleeve gastrectomy, and endoscopic sleeve gastroplasty. Moderate consensus was reached for sleeve gastrectomy single-anastomosis duodenoileostomy and none on the role of intra-gastric balloons. Consensus was reached for MBS in patients > 65 and < 18 years old, with a BMI > 50 kg/m2, and with various obesity-related complications such as type 2 diabetes, liver, and kidney disease. Conclusions: In this survey of 43 multi-disciplinary experts, consensus was reached on standardized definitions and reporting standards applicable to the whole medical community. An algorithm for treating patients with obesity was explored utilizing a thoughtful multimodal approach. Graphical Abstract: [Figure not available: see fulltext.]
SCOPUS:85177690816
ISSN: 0960-8923
CID: 5623142

2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) Indications for Metabolic and Bariatric Surgery

Eisenberg, Dan; Shikora, Scott A; Aarts, Edo; Aminian, Ali; Angrisani, Luigi; Cohen, Ricardo V; de Luca, Maurizio; Faria, Silvia L; Goodpaster, Kasey P S; Haddad, Ashraf; Himpens, Jacques M; Kow, Lilian; Kurian, Marina; Loi, Ken; Mahawar, Kamal; Nimeri, Abdelrahman; O'Kane, Mary; Papasavas, Pavlos K; Ponce, Jaime; Pratt, Janey S A; Rogers, Ann M; Steele, Kimberley E; Suter, Michel; Kothari, Shanu N
MAJOR UPDATES TO 1991 NATIONAL INSTITUTES OF HEALTH GUIDELINES FOR BARIATRIC SURGERY: Metabolic and bariatric surgery (MBS) is recommended for individuals with a body mass index (BMI) >35 kg/m2, regardless of presence, absence, or severity of co-morbidities.MBS should be considered for individuals with metabolic disease and BMI of 30-34.9 kg/m2.BMI thresholds should be adjusted in the Asian population such that a BMI >25 kg/m2 suggests clinical obesity, and individuals with BMI >27.5 kg/m2 should be offered MBS.Long-term results of MBS consistently demonstrate safety and efficacy.Appropriately selected children and adolescents should be considered for MBS.(Surg Obes Relat Dis 2022; https://doi.org/10.1016/j.soard.2022.08.013 ) © 2022 American Society for Metabolic and Bariatric Surgery. All rights reserved.
PMID: 36336720
ISSN: 1708-0428
CID: 5356952

Publisher Correction: 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) Indications for Metabolic and Bariatric Surgery

Eisenberg, Dan; Shikora, Scott A; Aarts, Edo; Aminian, Ali; Angrisani, Luigi; Cohen, Ricardo V; de Luca, Maurizio; Faria, Silvia L; Goodpaster, Kasey P S; Haddad, Ashraf; Himpens, Jacques M; Kow, Lilian; Kurian, Marina; Loi, Ken; Mahawar, Kamal; Nimeri, Abdelrahman; O'Kane, Mary; Papasavas, Pavlos K; Ponce, Jaime; Pratt, Janey S A; Rogers, Ann M; Steele, Kimberley E; Suter, Michel; Kothari, Shanu N
PMID: 36445365
ISSN: 1708-0428
CID: 5383532

2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery

Eisenberg, Dan; Shikora, Scott A; Aarts, Edo; Aminian, Ali; Angrisani, Luigi; Cohen, Ricardo V; De Luca, Maurizio; Faria, Silvia L; Goodpaster, Kasey P S; Haddad, Ashraf; Himpens, Jacques M; Kow, Lilian; Kurian, Marina; Loi, Ken; Mahawar, Kamal; Nimeri, Abdelrahman; O'Kane, Mary; Papasavas, Pavlos K; Ponce, Jaime; Pratt, Janey S A; Rogers, Ann M; Steele, Kimberley E; Suter, Michel; Kothari, Shanu N
Major updates to 1991 National Institutes of Health guidelines for bariatric surgery.
PMID: 36280539
ISSN: 1878-7533
CID: 5359312

American Society for Metabolic and Bariatric Surgery 2020 estimate of metabolic and bariatric procedures performed in the United States

Clapp, Benjamin; Ponce, Jaime; DeMaria, Eric; Ghanem, Omar; Hutter, Matthew; Kothari, Shanu; LaMasters, Teresa; Kurian, Marina; English, Wayne
BACKGROUND:Metabolic and bariatric surgery (MBS), despite being the only effective durable treatment for obesity, remains underused as approximately 1% of all patients who qualify undergo surgery. The American Society for Metabolic and Bariatric Surgery created a Numbers Taskforce to specify annual rate of utilization for obesity treatment interventions and to determine if patients in need are receiving appropriate treatment. OBJECTIVE:The objective of this study was to provide the best estimated number of metabolic and bariatric procedures performed in the United States in 2020. SETTING/METHODS:United States. METHODS:We reviewed data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), National Surgical Quality Improvement Program, Bariatric Outcomes Longitudinal Database, and Nationwide Inpatient Sample. In addition, data from industry and state databases were used to estimate activity at nonaccredited centers. Data from 2020 were compared mainly with data from the previous 2 years. RESULTS:Compared with 2019, the total number of MBS performed in 2020 decreased from approximately 256,000 to 199,000. Sleeve gastrectomy continues to be the most common procedure. The gastric bypass procedure trend remained relatively stable, and the gastric band procedure trend continued to decline. The percentage of revision procedures and biliopancreatic diversion with duodenal switch procedures increased slightly. Single-anastomosis duodeno-ileostomy was listed for the first time in 2020. Intragastric balloons placement declined from the previous year. CONCLUSION/CONCLUSIONS:There was a 22.5% decrease in MBS volume from 2019 to 2020, which coincided with the COVID-19 pandemic. Sleeve gastrectomy continues to be the dominant procedure, and for the first time, single-anastomosis duodeno-ileostomy is reported in the MBSAQIP database.
PMID: 35970741
ISSN: 1878-7533
CID: 5299842