Obésité : Article pp.66-69 du Vol.10 n°1 (2015)

Obésité (2015) 10:66-69 DOI 10.1007/s11690-015-0472-y

REVUE DE PRESSE / PRESS REVIEW

The Utility of Routine Postoperative Upper Gastrointestinal Swallow Studies Following Laparoscopic Sleeve Gastrectomy [1]

Mizrahi I, Tabak A, Grinbaum R, et al (2014) Obes Surg 24:1415–9

Laparoscopic sleeve gastrectomy (LSG) has grown in popularity in recent years for the treatment of morbid obe­

sity. Controversy exists regarding the usefulness of upper gastrointestinal (UGI) swallow studies on the first post­

operative day in detecting possible complications. The aim of our study was to determine the efficacy and cost benefit of routine UGI studies on the first postoperative day follow­

ing LSG. We retrospectively reviewed the hospital’s records to identify patients who underwent LSG between January 2012 and June 2013. All patients had iodine­based contrast swallow study on the first postoperative day. Reports from all imaging studies and medical files were retrospectively reviewed, and complications were recorded. The Institu­

tional Review Board waived the requirement for informed consent. During the study period, 722 patients underwent LSG. Mean BMI was 43 kg/m [2] (range 25–70). Of the 722 UGI studies, 721 were normal. The 1 abnormal study showed complete obstruction due to an incarcerated hiatal hernia. Five patients presented with a leak (0.7%). UGI swallow studies failed to detect any of the leaks resulting in a sensitivity of 0%. All leaks were apparent on com­

puted tomography (CT) scans on postoperative days 2, 5, 7, 23, and 90. The total cost of the UGI swallow studies was

$180,500. Performing routine UGI studies on the first post­

operative day following LSG is clearly not cost beneficial.

UGI contrast studies are not efficient to screen for suture line leaks. We recommend obtaining a CT scan when there is clinical suspicion for a complication.

Commentaires : La sensibilité du transit œsogastro­

duodénal (TOGD) postopératoire systématique annoncée dans cet article est frappante : 0 %, cependant, il confirme la tendance observée par tous. La faible rentabilité du TOGD

après by­pass avait déjà été soulignée dans la méta­analyse de Quartararo et al. [2] portant sur 19 389 patients. Les auteurs avaient observé que le TOGD était un mauvais exa­

men diagnostic de la fistule anastomotique postopératoire (sensibilité : 1,1 %) qu’il soit réalisé de manière systéma­

tique ou uniquement en présence de signes cliniques, avec un risque de faux­positif de 22 %. La présence de signes cliniques non spécifiques précoces (tachycardie, désatura­

tion, douleur abdominale, fébricule) est associée à une forte valeur prédictive positive. La sensibilité du TDM opacifié varie entre 50 et 70 % indépendamment de l’intervention réalisée et permet la détection de signes directs et indirects de fistule ; cependant, son utilisation systématique est limi­

tée par son accessibilité, son coût élevé, le poids maximal supporté par la table souvent atteint chez les obèses opérés, et doit être réservée aux patients symptomatiques.

Effect of Reversible Intermittent Intra‑abdominal Vagal Nerve Blockade on Morbid Obesity:

the ReCharge Randomized Clinical Trial [3]

Ikramudin S, Blackstone RP, Brancatisano A, et al (2014) JAMA 312:915–22

Importance: Although conventional bariatric surgery results in weight loss, it does so with potential short­term and long­term morbidity.

Objective: To evaluate the effectiveness and safety of intermittent, reversible vagal nerve blockade therapy for obesity treatment.

Design, setting, and participants: A randomized, dou­

ble­blind, sham­controlled clinical trial involving 239 par­

ticipants who had a body mass index of 40 to 45 or 35 to 40 and 1 or more obesity­related condition was conducted at 10 sites in the United States and Australia between May and December 2011. The 12­month blinded portion of the 5­year study was completed in January 2013.

Interventions: One hundred sixty­two patients received an active vagal nerve block device and 77 received a sham device.

All participants received weight management education.

Main outcomes and measures: The coprimary efficacy objectives were to determine whether the vagal nerve block was superior in mean percentage excess weight loss to sham by a 10­point margin with at least 55% of patients in the vagal

L. Genser (*)

e-mail : laurent.genser@gmail.com C. Barrat (*)

e-mail : christophe.barrat@jvr.aphp.fr

L. Genser ∙ C. Barrat

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Obésité (2015) 10:66-69 67

block group achieving a 20% loss and 45% achieving a 25%

loss. The primary safety objective was to determine whether the rate of serious adverse events related to device, procedure, or therapy in the vagal block group was less than 15%.

Results: In the intent­to­treat analysis, the vagal nerve block group had a mean 24.4% excess weight loss (9.2%

of their initial body weight loss) vs 15.9% excess weight loss (6.0% initial body weight loss) in the sham group. The mean difference in the percentage of the excess weight loss between groups was 8.5 percentage points (95% CI, 3.1–

13.9), which did not meet the 10­point target (P = 0.71), although weight loss was statistically greater in the vagal nerve block group (P = 0.002 for treatment difference in a post hoc analysis). At 12 months, 52% of patients in the vagal nerve block group achieved 20% or more excess weight loss and 38% achieved 25% or more excess weight loss vs 32%

in the sham group who achieved 20% or more loss and 23%

who achieved 25% or more loss. The device, procedure, or therapy­related serious adverse event rate in the vagal nerve block group was 3.7% (95% CI, 1.4%–7.9%), significantly lower than the 15% goal. The adverse events more frequent in the vagal nerve block group were heartburn or dyspepsia and abdominal pain attributed to therapy; all were reported as mild or moderate in severity.

Conclusion and relevance: Among patients with morbid obesity, the use of vagal nerve block therapy compared with a sham control device did not meet either of the prespecified coprimary efficacy objectives, although weight loss in the vagal block group was statistically greater than in the sham device group. The treatment was well tolerated, having met the primary safety objective.

Commentaires : Les premiers travaux portant sur les pos­

sibles effets amincissant du blocage vagal ont été rapportés, il y a 20 ans [4], comme thérapeutique minimale invasive.

Cependant, malgré plusieurs études contrôlées randomi­

sées portant sur des effectifs importants, les bénéfices à un an semblent très variables et pour l’instant limités avec une perte d’excès de poids maximale d’environ 15–20 % [3,5].

Par ailleurs, une surincidence de symptômes gastro­intes­

tinaux chez les patients traités a été observée rendant ce traitement peu attractif.

The Effectiveness and Risks of Bariatric Surgery:

an Updated Systematic Review and Meta‑Analysis, 2003–2012 [6]

Chang SH, Stoll CR, Song J, et al (2014) JAMA Surg 149:275–87

Importance: The prevalence of obesity and outcomes of bariatric surgery are well established. However, analyses

of the surgery impact have not been updated and compre­

hensively investigated since 2003.

Objective: To examine the effectiveness and risks of bariatric surgery using up­to­date, comprehensive data and appropriate meta­analytic techniques.

Data sources: Literature searches of Medline, Embase, Scopus, Current Contents, Cochrane Library, and Clinical­

trials.gov between 2003 and 2012 were performed.

Study selection: Exclusion criteria included publication of abstracts only, case reports, letters, comments, or reviews;

animal studies; languages other than English; duplicate studies; no surgical intervention; and no population of inter­

est. Inclusion criteria were a report of surgical procedure performed and at least 1 outcome of interest resulting from the studied surgery was reported: comorbidities, mortality, complications, reoperations, or weight loss. Of the 25,060 initially identified articles, 24,023 studies met the exclusion criteria, and 259 met the inclusion criteria.

Data extraction and synthesis: A review protocol was fol­

lowed throughout. Three reviewers independently reviewed studies, abstracted data, and resolved disagreements by con­

sensus. Studies were evaluated for quality.

Main outcomes and measures: Mortality, complications, reoperations, weight loss, and remission of obesity­related diseases.

Results: A total of 164 studies were included (37 ran­

domized clinical trials and 127 observational studies).

Analyses included 161,756 patients with a mean age of 44.56 years and body mass index of 45.62. We con­

ducted random­effects and fixed­effect meta­analyses and meta­regression. In randomized clinical trials, the mortal­

ity rate within 30 days was 0.08% (95% CI, 0.01–0.24%);

the mortality rate after 30 days was 0.31% (95% CI, 0.01–

0.75%). Body mass index loss at 5 years postsurgery was 12 to 17. The complication rate was 17% (95% CI, 11–23%), and the reoperation rate was 7% (95% CI, 3–12%). Gas­

tric bypass was more effective in weight loss but associated with more complications. Adjustable gastric banding had lower mortality and complication rates; yet, the reoperation rate was higher and weight loss was less substantial than gastric bypass. Sleeve gastrectomy appeared to be more effective in weight loss than adjustable gastric banding and comparable with gastric bypass.

Conclusions and relevance: Bariatric surgery provides substantial and sustained effects on weight loss and ame­

liorates obesity­attributable comorbidities in the majority of bariatric patients, although risks of complication, reop­

eration, and death exist. Death rates were lower than those reported in previous meta­analyses.

Commentaires : Il s’agit d’une méta­analyse très impor­

tante, car elle porte sur les études publiées après 2003 et donc est plus proche de nos pratiques actuelles. La dernière

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68 Obésité (2015) 10:66-69

méta­analyse traitant de cette thématique datait de 2004 [7]

et portait sur des articles antérieurs à 2003. Les résultats des trois techniques les plus couramment réalisés en France y sont présentés (anneau gastrique ajustable — gastric bypass­sleeve). Cette méta­analyse confirme la tendance observée, à savoir que le by­pass semble être la technique la plus efficace en termes de perte d’excès de poids et d’amélioration des comorbidités avec une perte d’excès de poids au­delà de trois ans supérieure à celle observée après anneau ou sleeve (76 vs 58 et 59 %). Les résultats de la sleeve sont peu évalués au­delà de trois ans ; cependant, dans l’expérience de Boza et al., la perte de poids semble maintenue avec 62,9 % de %EWL moyennes à cinq ans (161 sleeves gastrectomies, 70 % de suivi) [8]. Cependant, la morbidité postopératoire globale du by­pass (12–21 %), qu’elle soit précoce (< 30 jours) ou tardive, est supérieure à celle de la sleeve (9–13 %) ou de l’anneau gastrique ajustable (7–13 %). Par rapport à la période 1990–2003 couverte par la méta­analyse précédente, la morbidité et la mortalité globales sont en baisse, cela peut être attribué à la meilleure gestion des risques per et postopératoires mais également à l’adoption de procédures moins morbides, ce travail ne prenant pas en compte les résultats des dériva­

tions biliopancréatiques. En revanche, les réinterventions sont plus fréquentes après anneau (7–12 %) qu’après by­pass (2,5–5,3 %) ou sleeve (3–9 %) ; cependant, le motif de réopération n’était pas mentionné (reprise pour compli­

cation ou pour échec de perte pondérale) limitant la valeur à accorder à ce résultat. La mortalité postopératoire pré­

coce du by­pass est comparable à celle de la sleeve (0,38 vs 0,29 %) mais supérieure à celle de l’anneau (0,07 %).

Au total, à moyen terme (trois ans), en termes d’efficacité et de morbi­mortalité, la sleeve semble se placer entre l’an­

neau et le by­pass. Une version « plus détaillée » de ce tra­

vail peut être trouvée dans la méta­analyse de la Cochrane publiée récemment [9].

Predictors of Short‑Term Diabetes Remission after Laparoscopic Roux‑en‑Y Gastric Bypass [10]

Iacobellis G, Xu C, Campo RE, et al (2015) Obes Surg [Epub ahead of print]

Purpose: A remission of type 2 diabetes mellitus (T2DM) is one of the major goals of the contemporary bari­

atric surgery. The goal of our study is to identify predictors of short­term postoperative diabetes remission in order to facilitate preoperative patient selection.

Materials and methods: Two hundred forty­five obese (body mass index [BMI] ≥ 35 kg/m²) T2DM subjects who underwent laparoscopic Roux­en­Y gastric bypass (RYGB)

were followed up to 1 year after bariatric surgery. Diabetes remission was defined as hemoglobin A1c (HbA1c) ≤ 6%

and fasting blood glucose (FBG) < 100 mg/dl in absence of all diabetic medications.

Results: Twenty­six percent of the patients seen in f/u achieved complete remission at 1 year. Average Hba1c decreased from 8 to 6.7% and 6.4% after 6 and 12 months, respectively. Regression analysis showed that age (P = 0.01), number of diabetes complications (P = 0.03), family history of diabetes (P = 0.04), preoperative use of insulin (P = 0.04), and peri­ and postoperative weight loss (P = 0.05, for both) were the best preoperative predictors of diabetes remission at 6 and 12 months (R 2 = 0.3).

Conclusion: Younger patients, with fewer diabetic com­

plications, no family history of diabetes, not using insulin, and with greater peri­ and postoperative weight loss were the best candidates to achieve a rapid diabetes remission after RYGB.

Commentaires : Quels sont les facteurs prédictifs de rémission complète du diabète de type 2, à six mois et un an après by­pass, quels sont les meilleurs candidats à la rémission ? Les auteurs ont fait le choix (courageux) de prendre les critères stricts de rémission complète du dia­

bète de type 2 définis par l’American Diabetes Association [11] (ADA) (HbA1c < 6 %, glycémie à jeun < 5,6 mmol/l ; absence de traitement antidiabétique) sans se limiter à l’HbA1c et aux traitements [12,13]. L’hétérogénéité des cri­

tères de rémission utilisés limite souvent les conclusions à tirer de ces articles comme l’avait montré l’équipe de la Cleveland Clinic dans un travail portant sur la rémission à long terme du DT2 après chirurgie bariatrique [14]. En analyse multivariée, les meilleurs candidats à la rémission complète à 6 et 12 mois parmi les obèses sévères opérés d’un gastric bypass sont les patients plus jeunes, sans insu­

line, ne présentant pas les complications liées au DT2, sans antécédents familiaux de diabète et ayant obtenu une perte de poids périopératoire importante suggérant que la rémis­

sion est au moins pour partie dépendante de la perte de poids. D’autres publications avaient rapporté l’importance de la durée d’évolution du diabète sur la rémission, non retrouvée dans cette étude (p = 0,09).

Weight Loss Before Bariatric Surgery and Postoperative Complications Data From the Scandinavian Obesity Registry (SOReg) [15]

Anderin C, Gustafsson UO, Heijbel N, Thorell A (2015) Ann Surg [Epub ahead of print]

Background: A preoperative weight­reducing regimen is usually adhered to in most centers performing bariatric

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Obésité (2015) 10:66-69 69

surgery for obesity. The potential to reduce postoperative complications by such a routine is yet to be defined.

Methods: Data on 22,327 patients undergoing primary gastric bypass from January 1, 2008, to June 30, 2012, were analyzed.

Results: In all patients, median preoperative total weight change was –4.8%. Corresponding values in the 25th, 50th, and 75th percentile were 0.5, –4.7, and –9.5%, respectively.

Complications were noted in 9.1% of the patients. When comparing patients in the 75th with those in the 25th per­

centile of preoperative weight loss, the risk of complica­

tions was reduced by 13%. For specific complications, the corresponding risks were reduced for anastomotic leak­

age by 24%, for deep infection/abscess by 37%, and for minor wound complications by 54%. Similarly, however, less pronounced risk reductions were found when compar­

ing patients in the 50th with those in the 25th percentile of preoperative weight loss. For patients in the highest range of body mass index (BMI), the risk reduction associated with preoperative weight loss was statistically significant for all analyzed complications, whereas corresponding risk reductions were only occasionally encountered and less pro­

nounced in patients with lower BMI.

Conclusions: Weight loss before bariatric surgery is asso­

ciated with marked reduction of risk of postoperative com­

plications. Moreover, the degree of risk reduction seems to be related to amount of weight lost and patients in the higher range of BMI are likely to benefit most from preoperative weight reduction.

Commentaires : Très beau travail réalisé à partir du registre suédois, à propos de 22 327 patients opérés d’un gastric bypass, sans antécédent de chirurgie bariatrique (afin de ne pas introduire le biais des secondes manches chirurgicales). La morbidité globale est comparable à celle observée dans les autres séries (9 %). Les auteurs ont analysé la corrélation entre perte de poids préopératoire et incidence des complications postopératoires en regar­

dant l’impact quartile par quartile et ont observé qu’une perte pondérale avant by­pass de 4,5 % était associée à une diminution significative de l’incidence des complications septiques post opératoires (fistule, collections intra­abdo­

minales–abcès de paroi). Ces bénéfices étaient encore plus marqués chez les patients du dernier quartile (–9,5 % de perte pondérale préopératoire) ; cependant, il aurait été intéressant de voir si ces bénéfices s’observaient égale­

ment après gastrectomie longitudinale. Nous savions déjà que la perte de poids préopératoire était un facteur prédic­

tif de succès de la chirurgie aussi bien en termes d’inten­

sité et de maintien à moyen et long termes de la perte de poids que d’amélioration des comorbidités [16,17]. Cette étude renforce l’importance de la prise en charge globale

multidisciplinaire préopératoire afin que les patients obèses sévères puissent bénéficier pleinement de la chirurgie.

Références

1. Mizrahi I, Tabak A, Grinbaum R, et al (2014) The utility of routine postoperative upper gastrointestinal swallow studies following laparoscopic sleeve gastrectomy. Obes Surg 24:1415–9

2. Quartararo G, Facchiano E, Scaringi S, et al (2014) Upper gas­

trointestinal series after Roux­en­Y gastric bypass for morbid obe­

sity: effectiveness in leakage detection: a systematic review of the literature. Obes Surg 24:1096–101

3. Ikramuddin S, Blackstone RP, Brancatisano A, et al (2014) Effect of reversible intermittent intra­abdominal vagal nerve blockade on morbid obesity: the ReCharge randomized clinical trial. JAMA 312:915–22

4. Cigaina VV, Pinato G, Rigo VV, et al (1996) Gastric Peristalsis Control by Mono Situ Electrical Stimulation: a Preliminary Study.

Obes Surg 3:247–9

5. Sarr MG, Billington CJ, Brancatisano R, et al (2012) The EMOWER study: randomized, prospective, double­blind, mul­

ticenter trial of vagal blockade to induce weight loss in morbid obesity. Obes Surg 22:1771–82

6. Chang SH, Stoll CRT, Song J, et al (2014) The effectiveness and risks of bariatric surgery: an updated systematic review and meta­analysis, 2003–2012. JAMA Surg 149:275–87

7. Buchwald H, Avidor Y, Braunwald E, et al (2004) Bariatric sur­

gery: a systematic review and meta­analysis. JAMA 292:1724–37 8. Boza C, Daroch D, Barros D, et al (2014) Long­term outcomes of

laparoscopic sleeve gastrectomy as a primary bariatric procedure.

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9. Colquitt JL, Pickett K, Loveman E, Frampton GK (2014) Sur­

gery for weight loss in adults. Cochrane Database Syst Rev 8:CD003641

10. Iacobellis G, Xu C, Campo RE, et al (2015) Predictors of short­term diabetes remission after laparoscopic Roux­en­Y gas­

tric bypass. Obes Surg [Epub ahead of print]

11. Buse JB, Caprio S, Cefalu WT, et al (2009) How do we define cure of diabetes? Diabetes Care 32:2133–5

12. Schauer PR, Kashyap SR, Wolski K, et al (2012) Bariatric surgery versus intensive medical therapy in obese patients with diabetes.

N Engl J Med 366:1567–76

13. Schauer PR, Bhatt DL, Kirwan JP, et al (2014) Bariatric surgery versus intensive medical therapy for diabetes — 3­year outcomes.

N Engl J Med 370:2002–13

14. Brethauer SA, Aminian A, Romero­Talamás H, et al (2013) Can diabetes be surgically cured? Long­term metabolic effects of bariatric surgery in obese patients with type 2 diabetes mellitus.

Ann Surg 258:628–36; discussion 636–7

15. Anderin C, Gustafsson UO, Heijbel N, Thorell A (2015) Weight loss before bariatric surgery and postoperative complications:

data from the Scandinavian Obesity Registry (SOReg). Ann Surg [Epub ahead of print]

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Obes Surg 6:524–6

17. Ballantyne GH (2003) Measuring outcomes following baria­

tric surgery: weight loss parameters, improvement in co­morbid conditions, change in quality of life and patient satisfaction. Obes Surg 13:954–64

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