Browsing by Author "Parmar, C"
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- Best practice approach for redo-surgeries after sleeve gastrectomy, an expert's modified Delphi consensusPublication . Kermansaravi, M; Parmar, C; Chiappetta, S; Shikora, S; Aminian, A; Abbas, SI; Angrisani, L; Bashir, A; Behrens, E; Bhandari, M; Clapp, B; Cohen, R; Dargent, Jerome; Dilemans, Bruno; De Luca, Maurizio; Haddad, Ashraf; Gawdat, Khaled; Elfawal, Mohamed Hayssam; Himpens, Jaques; Huang, Chih-Kun; Husain, Farah; Kasama, Kazunori; Kassir, Radwan; Khan, Amir; Kow, Lilian; Kroh, Matthew; Lakdawala, Muffazal; Lopez Corvala, JA; Miller, Karl; Musella, M; Nimeri, A; Noel, P; Palermo, M; Poggi, L; Poghosyan, T; Prager, G; Prasad, A; Alqahtani, A; Rheinwalt, K; Ribeiro, R; Shabbir, A; Torres, A; Villalonga, R; Wang, C; Mahawar, K; Zundel, NBackground: Sleeve gastrectomy (SG) is the most common metabolic and bariatric surgical (MBS) procedure worldwide. Despite the desired effect of SG on weight loss and remission of obesity-associated medical problems, there are some concerns regarding the need to do revisional/conversional surgeries after SG. This study aims to make an algorithmic clinical approach based on an expert-modified Delphi consensus regarding redo-surgeries after SG, to give bariatric and metabolic surgeons a guideline that might help for the best clinical decision. Methods: Forty-six recognized bariatric and metabolic surgeons from 25 different countries participated in this Delphi consensus study in two rounds to develop a consensus on redo-surgeries after SG. An agreement/disagreement ≥ 70.0% on statements was considered to indicate a consensus. Results: Consensus was reached for 62 of 72 statements and experts did not achieve consensus on 10 statements after two rounds of online voting. Most of the experts believed that multi-disciplinary team evaluation should be done in all redo-procedures after SG and there should be at least 12 months of medical and supportive management before performing redo-surgeries after SG for insufficient weight loss, weight regain, and gastroesophageal reflux disease (GERD). Also, experts agreed that in case of symptomatic GERD in the presence of adequate weight loss, medical treatment for at least 1 to 2 years is an acceptable option and agreed that Roux-en Y gastric bypass is an appropriate option in this situation. There was disagreement consensus on efficacy of omentopexy in rotation and efficacy of fundoplication in the presence of a dilated fundus and GERD. Conclusion: Redo-surgeries after SG is still an important issue among bariatric and metabolic surgeons. The proper time and procedure selection for redo-surgery need careful considerations. Although multi-disciplinary team evaluation plays a key role to evaluate best options in these situations, an algorithmic clinical approach based on the expert's consensus as a guideline can help for the best clinical decision-making.
- Enhanced Recovery After Surgery (ERAS) protocol in bariatric and metabolic surgery (BMS)-analysis of practices in nutritional aspects from five continentsPublication . Rossoni, C; Oliveira Magro, D; Santos, ZC; Cambi, MP; Patias, L; Bragança, R; Pellizzaro, D; Parmar, C; Ribeiro, RThis study aims to understand the prevalent practices on the nutritional aspects of the enhanced recovery after surgery (ERAS) protocol based on the knowledge and practice of surgeons, nutritionists, and anesthesiologists who work in the bariatric and metabolic surgery (BMS) units worldwide. This cross-sectional study enrolled BMS unit professionals from five continents-Africa, America, Asia, Europe, and Oceania. An electronic questionnaire developed by the researchers was provided to evaluate practices about the three nutritional aspects of ERAS protocol in BMS (Thorel et al. 2016): preoperative fasting, carbohydrate loading, and early postoperative nutrition. Only surgeons, nutritionists, and anesthesiologists were invited to participate. One hundred twenty-five professionals answered the questionnaires: 50.4% from America and 39.2% from Europe. The profile of participating professionals was bariatric surgeons 70.2%, nutritionists 26.4%, and anesthesiologists 3.3%. Approximately 47.9% of professionals work in private services, for about 11 to 20 years (48.7%). In all continents, a large majority were aware of the protocol. Professionals from the African continent reported having implemented the ERAS bariatric protocol 4.0 ± 0 years ago. It is worth mentioning that professionals from the five continents implemented the ERAS protocol based on the published literature (p = 0.012). About preoperative fasting abbreviation protocol, a significant difference was found between continents and consequently between services (p = 0.000). There is no uniformity in the conduct of shortening of fasting in the preoperative period and the immediate postoperative period. Early postoperative (PO) period protein supplementation is not performed in a standard fashion in all units globally. ERAS principles and practices are partial and insufficiently implemented on the five continents despite the prevalent knowledge of professionals based on evidence. Moreover, there is no uniformity in fasting, immediate postoperative diet, and early protein supplementation practices globally.
- Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60 kg/m2): a Modified Delphi StudyPublication . Ponce de Leon-Ballesteros, G; Pouwels, S; Romero-Velez, G; Aminian, A; Angrisani, L; Bhandari, M; Brown, W; Copaescu, C; De Luca, M; Fobi, M; Ghanem, OM; Hasenberg, T; Herrera, MF; Herrera-Kok, JH; Himpens, J; Kow, L; Kroh, M; Kurian, M; Musella, M; Narwaria, M; Noel, P; Pantoja, JP; Ponce, J; Prager, G; Ramos, A; Ribeiro, R; Ruiz-Ucar, E; Salminen, P; Shikora, S; Small, P; Stier, C; Taha, S; Taskin, EH; Torres, A; Vaz, C; Vilallonga, R; Verboonen, S; Zerrweck, C; Zundel, N; Parmar, CBackground: 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.
- Outcomes of Long Pouch Gastric Bypass (LPGB): 4-Year Experience in Primary and Revision CasesPublication . Ribeiro, R; Pouwels, S; Parmar, C; Pereira, J; Manaças, L; Guerra, AC; Borges, N; Ribeiro, J; Viveiros, OBackground: One of the most important complications of the one anastomosis gastric bypass (OAGB) is enterobilio acid reflux (EBAR). We report the concept of the long pouch Roux-en-Y gastric bypass (LPRYGB) meaning a Roux-en-Y with a long pouch and a 100-cm alimentary limb to avoid EBAR, with a long biliopancreatic limb to increase metabolic effects. Methods: A total of 300 LPRYGB cases in a 4-year period, with a 90% follow-up rate, were analysed. Anthropometric, technical feasibility, morbidity, weight loss and comorbidity outcomes were analysed. Results: The percentage total weight loss (%TWL) was 30.5% at 4 years of follow-up (32.3% in primary and 28.3% in revisions). Six intra-operative (2%) and 28 postoperative complications (9.3%) were seen. Out of this 28 complications, 11 (3.6%) were late complications. Reoperations were performed in 15 patients (5.0%). Clinically relevant EBAR was present in 3 cases only (1%) 4 years after the operation. Conclusions: The LPRYGB combines the main advantages of the OAGB (light restriction and moderate malabsorption) with the anti-reflux effect from the Roux-en-Y diversion.
- Patient Selection in One Anastomosis/Mini Gastric Bypass—an Expert Modified Delphi ConsensusPublication . Kermansaravi, M; Parmar, C; Chiappetta, S; Shahabi, S; Abbass, A; Abbas, SI; Abouzeid, M; Antozzi, L; Asghar, ST; Bashir, A; Bhandari, M; Billy, H; Caina, D; Campos, FJ; Carbajo, MA; Chevallier, JM; Jazi, AH; de Gordejuela, AG; Haddad, A; ElFawal, MH; Himpens, J; Inam, A; Kassir, R; Kasama, K; Khan, A; Kow, L; Kular, KS; Lakdawala, M; Layani, LA; Lee, WJ; Luque-de-León, E; Loi, K; Mahawar, K; Mahdy, T; Musella, M; Nimeri, A; González, JC; Pazouki, A; Poghosyan, T; Prager, G; Prasad, A; Ramos, AC; Rheinwalt, K; Ribeiro, R; Ruiz-Úcar, E; Rutledge, R; Shabbir, A; Shikora, S; Singhal, R; Taha, O; Talebpour, M; Verboonen, JS; Wang, C; Weiner, R; Yang, W; Vilallonga, R; De Luca, MPurpose: 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/m2 as a one-stage procedure," "as the second stage of a two-stage bariatric surgery after Sleeve Gastrectomy for BMI > 50 kg/m2 (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/m2) with associated metabolic problems, and patients with BMIs more than 50 kg/m2 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.