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Background: Obesity is a global health crisis with profound implications on various body systems, contributing to a series of comorbidities. Metabolic Bariatric Surgery (MBS) has emerged as an effective treatment option for severe obesity, with significant weight reduction and potential systemic physiological alterations.
Objectives: This narrative review aims to provide a comprehensive analysis of the long-term effects of MBS on a wide array of body systems, including the heart, liver, kidneys, reproductive system, skin, lungs, digestive tract, pancreas, and blood, as well as related cancers of these organs.
Methods: A systematic search was conducted in academic databases (PubMed, ISI Web of Science, and Scopus) for observational studies and reviews published between July 2000 and December 2023, investigating the association between MBS and the subsequent function of different organ systems. High-quality studies were prioritized to ensure reliable evidence synthesis.
Results: MBS has demonstrated favorable outcomes in reducing cardiovascular disease risk, improving cardiac function, and alleviating heart failure symptoms. It has also been associated with improved respiratory function, remission of obstructive sleep apnea, and reduced cancer incidence and mortality. Additionally, MBS has shown benefits in managing gastrointestinal disorders, enhancing glycemic control, and promoting pancreatic beta-cell regeneration in type 2 diabetes mellitus. However, some methods of MBS are associated with a higher risk of cholelithiasis, GERD, and pancreatic exocrine insufficiency.
Conclusion: MBS has far-reaching systemic effects beyond weight loss, offering potential long-term benefits for various organ systems and comorbidities associated with obesity. For many patients with severe obesity, the potential benefits of Metabolic and Bariatric Surgery (MBS) can outweigh the associated risks. However, careful evaluation by a qualified healthcare professional is crucial to determine candidacy and ensure a successful outcome. Further research is needed to fully elucidate the long-term impacts and tailor personalized treatment approaches.
Keywords: Bariatric surgery; Cardiovascular system; Digestive system; Kidney; Liver; Long-term care; Metabolic diseases; Neoplasms; Obesity; Organ systems.
© 2024 The Authors.
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The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Summary of the long-term effects…
Summary of the long-term effects of MBS on various body organs and diseases.
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Clinical challenge: patient with severe obesity bmi 46 kg/m 2.
Obesity causes and exacerbates many disease processes and affects every organ system. Thus it is not surprising that clinical providers are often overwhelmed with the multitude of symptomatology upon initial presentation in patients with obesity. However, despite a “complicated medical history,” a systematic, organized approach in obesity medicine utilizes a personalized-tailored treatment strategy coupled with understanding of the disease state, presence of comorbidities, contraindications, side effects, and patient preferences. Here, we present the case of a young patient with Class 3b severe obesity, several obesity-related complications, and extensive psychological history. Through synergistic and additive treatments (behavioral/nutritional therapy combined with anti-obesity pharmacotherapy and concurrent enrollment in our bariatric surgery program), the patient was able to achieve significant −30.5% total body weight loss with improvement of metabolic parameters. Though these results are not typical of all patients, we must emphasize the need to encompass all available anti-obesity therapies (lifestyle, pharmacotherapy, medical devices, bariatric surgery in monotherapy or combination) in cases of refractory or severe obesity, as we do similarly for other disease modalities such as refractory hypertension or poorly controlled Type 2 diabetes that requires robust escalation in therapy.
A 31 year old patient with a past medical history of Class 3 obesity BMI 46 kg/m 2 , Type 2 diabetes mellitus (A1c <5.7%, well controlled on metformin), polycystic ovarian syndrome, non-alcoholic steatosis of the liver, pulmonary and neurosarcoidosis on infliximab and methotrexate, and chronic worsening pain presents for weight management evaluation. She had a history of opioid use disorder due to the chronic pain, though in remission. She had been on several weight-promoting pain medications for symptom control, including gabapentin, duloxetine and nortriptyline. Contributing factors over the years to her weight gain also included her diagnosis of Bipolar Disorder with antipsychotic medication-induced weight gain (previously trialed aripiprazole, responded to lurasidone with decreasing efficiency, and now finally stable on paliperidone though weight gain promoting). Her highest adult weight was her current weight of 295 pounds with a lowest adult weight of 140 lbs. that pre-dated her Bipolar and sarcoidosis diagnoses several years ago. She had stable eating patterns, and often chose healthy meals such as hummus, vegetables, Greek salads, and lean meats, though had a weakness for sweet cravings. She engaged in structured gym exercise for 30 minutes three times per week despite the chronic pain. Recent stressors included her close aunt who had been diagnosed with cancer. She also suffered from insomnia and had been evaluated closely with sleep therapists and sleep hygiene specialists. Her polysomnogram was negative for sleep apnea.
A. Offer more aggressive intensive lifestyle therapy intervention
B. Trial of anti-obesity medication if option A above becomes ineffective
C. Metabolic and bariatric surgery only as anti-obesity medication would be contraindicated given her history of opioid use
D. Trial of anti-obesity medication for 3 months with concurrent referral to bariatric surgery
The patient depicted in the case has chronic, debilitating severe obesity classification with several inflammatory obesity-related comorbidities and other contributing etiology to her weight gain.
In regards to lifestyle intervention, the patient was started on a healthy low fat high fiber diet with increased consumption of vegetables, while minimizing intake of processed foods, added sugar, trans fats, and refined flours ( 1 ). Nutrient-dense whole foods prepared at home were encouraged. Acceptable macronutrient distribution range is 45–65% carbohydrates, 20–35% total fat of which <10% should be polyunsaturated fats, and 10–35% protein and amino acids 1 . However, obesity-related comorbidities such as type 2 diabetes mellitus, polycystic ovarian syndrome, and non-alcoholic steatosis of the liver suggesting features of insulin resistance need to be taken into consideration when implementing dietary modifications specific to this case. The patient's daily carbohydrate intake should be reduced to 40–50% to combat insulin resistance. Several studies have shown improvement in metabolic parameters and more rapid weight loss when a low carbohydrate diet was implemented initially in the first 3–6 months ( 2 , 3 ). At presentation, the patient's calculated daily protein intake was <20% of total daily intake and increasing her protein intake to 30% reduced her sweet cravings and increased satiety. In addition, she would benefit from at least 150 min per week of structured moderately intensive exercise as tolerated as recommended by The American College of Sports Medicine ( 4 ). Of note, the patient is also under significant stressors. Stress has been very strongly linked to hyperphagia, binging, and obesity ( 5 , 6 ). Stress management would also provide long-term strategies for emotional/stress eating should they arise. Her sleep has been adequately addressed by a specialist multidisciplinary team. Further, the patient was already under intense behavioral therapy given her underlying psychiatric illness. Early behavioral therapy intervention should be strongly considered in patients with adverse psychological factors, eating disorders and underlying psychiatric conditions that would otherwise impede their overall progress toward health goals. However, it may be difficult to promote more aggressive lifestyle intervention alone, especially in a patient with an advanced obesity disease staging who is already making strides to eat healthy and undergoing behavioral therapy.
Furthermore, the patient also meets criteria for initiation of anti-obesity pharmacotherapy (AOM): BMI >27 kg/m 2 plus the presence of one obesity-related comorbidity and/or BMI >30 kg/m 2 in conjunction with lifestyle intervention ( 7 , 8 ). Though the patient has a history of opioid use disorder, it is in remission and there is no active contraindication to AOM. The patient also does not have underlying heart disease, end-stage-renal disease, or acute angle glaucoma that would negate use of several AOM such as phentermine/topiramate, lorcaserin, and naltrexone/bupropion. Liraglutide 3.0 mg would be a first option given its double benefits in patients with severe obesity and diabetes ( 7 ) and other obesity-related comorbidities such as fatty liver ( 9 ) and polycystic ovarian disease ( 10 ). The medication is also generally well-tolerated and safe. Because anti-obesity medications can exert central effects in a patient with Bipolar Disorder, close monitoring and communication with the patient's psychiatrist would be critical. Because her BMI is already very elevated, clinically, both lifestyle changes and pharmacological treatment would be implemented together, rather than separately. Moreover, based on her current body mass index alone of 40 kg/m 2 , the patient meets National Institutes of Health consensus criteria for metabolic and bariatric surgery ( 11 ): BMI 35 kg/m 2 in the presence of at least one obesity-related comorbidity or BMI 40 kg/m 2 . Therefore, it would be prudent to discuss bariatric surgery in this patient given her disease severity.
The correct answer is D. The patient was actually started on AOM with concurrent referral to the institution's bariatric surgery program. Since the patient's insurance did not provide coverage for liraglutide 3.0 mg, she was alternatively prescribed a combination anti-obesity medication therapy (phentermine/topiramate) after discussion with her psychiatrist and other specialists. AOM were instrumental in improving the patient's overall hunger drive, cravings, and satiety. Despite being the best option for her at presentation, the patient was unwilling to undergo the bariatric procedure. Oftentimes, this may be the case in many patients until they consent to surgical intervention or have weight regain on non-surgical therapy. Future guidelines may need to be more definitive about earlier referral to bariatric surgery.
The patient continued AOM long-term, having lost 90 pounds over a 2 year time period ( Figure 1 ). Her BMI now is 28.7 kg/m 2 , weight 205 lbs. (reversed from Class 3 obesity, BMI 46 kg/m 2 , weight 295 lbs.) with improvement in quality of life and obesity-related comorbidities. Liver transaminases that were previously elevated in the context of fatty liver disease normalized along with return of regular menstrual cycles. In the process of losing weight with related attenuation in disease comorbidity and metabolic profile improvement, the patient's neurosarcoidosis continued to show remarkable recovery with stabilization of her mental health conditions and disability. Her specialists reported that this was the best she had been in many years. The patient lost −30.5% of her total body weight, which is typical weight loss achieved by metabolic and bariatric surgery means, through non-surgical intervention.
Figure 1 . Patient's weight graph derived from the electronic health record. The patient lost a total of 90 lbs. over a 2 year time period with adjunctive anti-obesity pharmacotherapy (phentermine/topiramate) in combination with behavioral and lifestyle intervention.
Though these results may not be usual for all patients, it is important to note that all treatment modalities (behavioral, lifestyle, pharmacological, and/or surgical whether as monotherapy or in combination) must be utilized for patients suffering with severe obesity and its devastating consequences on overall health and quality of life. Many of these patients present with complicated disease states and multiple comorbidities. Thus, important health targets include not only weight loss but treatment-enhanced double benefits leading to improvement of comorbidities.
All datasets for this study were directly generated from the patient's electronic health record and are available upon request.
Written informed consent to publish this case report was obtained from the patient.
GS and CA contributed and edited the contents of this manuscript.
No external funding was provided for the creation of this manuscript.
GS served as a consultant for Johnson and Johnson and advisor for Rhythm Pharmaceuticals. CA reports grants from Aspire Bariatrics, Myos, the Vela Foundation, the Dr. Robert C. and Veronica Atkins Foundation, Coherence Lab, Energesis, NIH, and PCORI, grants and personal fees from Orexigen, GI Dynamics, Takeda, personal fees from Nutrisystem, Zafgen, Sanofi-Aventis, NovoNordisk, Scientific Intake, Xeno Biosciences, Rhythm Pharmaceuticals, Eisai, EnteroMedics, Bariatrix Nutrition, and other from Science-Smart LLC, outside the submitted work.
We would like to thank the patient for permission to publish.
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Keywords: anti-obesity medications, weight loss drugs, combination therapy, bariatric surgery, lifestyle intervention
Citation: Srivastava G and Apovian CM (2019) Clinical Challenge: Patient With Severe Obesity BMI 46 kg/m 2 . Front. Endocrinol. 10:635. doi: 10.3389/fendo.2019.00635
Received: 30 April 2019; Accepted: 03 September 2019; Published: 02 October 2019.
Reviewed by:
Copyright © 2019 Srivastava and Apovian. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Gitanjali Srivastava, geet5sri@gmail.com
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Epidemiology and Population Health
International Journal of Obesity volume 44 , pages 1028–1040 ( 2020 ) Cite this article
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Obesity is thought to be the product of over 100 different factors, interacting as a complex system over multiple levels. Understanding the drivers of obesity requires considerable data, which are challenging, costly and time-consuming to collect through traditional means. Use of ‘big data’ presents a potential solution to this challenge. Big data is defined by Delphi consensus as: always digital , has a large sample size, and a large volume or variety or velocity of variables that require additional computing power (Vogel et al. Int J Obes. 2019). ‘Additional computing power’ introduces the concept of big data analytics. The aim of this paper is to showcase international research case studies presented during a seminar series held by the Economic and Social Research Council (ESRC) Strategic Network for Obesity in the UK. These are intended to provide an in-depth view of how big data can be used in obesity research, and the specific benefits, limitations and challenges encountered.
Three case studies are presented. The first investigated the influence of the built environment on physical activity. It used spatial data on green spaces and exercise facilities alongside individual-level data on physical activity and swipe card entry to leisure centres, collected as part of a local authority exercise class initiative. The second used a variety of linked electronic health datasets to investigate associations between obesity surgery and the risk of developing cancer. The third used data on tax parcel values alongside data from the Seattle Obesity Study to investigate sociodemographic determinants of obesity in Seattle.
The case studies demonstrated how big data could be used to augment traditional data to capture a broader range of variables in the obesity system. They also showed that big data can present improvements over traditional data in relation to size, coverage, temporality, and objectivity of measures. However, the case studies also encountered challenges or limitations; particularly in relation to hidden/unforeseen biases and lack of contextual information. Overall, despite challenges, big data presents a relatively untapped resource that shows promise in helping to understand drivers of obesity.
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The ESRC Strategic Network for Obesity was funded via ESRC grant number ES/N00941X/1. The authors would like to thank all of the network investigators ( https://www.cdrc.ac.uk/research/obesity/investigators/ ) and members ( https://www.cdrc.ac.uk/research/obesity/network-members/ ) for their participation in network meetings and discussion which contributed to the development of this paper.
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Emma Wilkins, Ariadni Aravani, Amy Downing & Michelle A. Morris
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Wilkins, E., Aravani, A., Downing, A. et al. Evidence from big data in obesity research: international case studies. Int J Obes 44 , 1028–1040 (2020). https://doi.org/10.1038/s41366-020-0532-8
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Issue Date : May 2020
DOI : https://doi.org/10.1038/s41366-020-0532-8
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Craniopharyngiomas are tumors located in the hypothalamic region which leads to obesity in about 50% of cases. Long-term efficacy and safety of bariatric surgery are lacking in this peculiar population. The aim of this study is to determine the 5-year weight loss and resolution of type 2 diabetes (T2D) after bariatric surgery in patients operated on craniopharyngioma who had developed hypothalamic obesity.
This is a multicenter french retrospective case–control study. Subjects with craniopharyngioma ( n = 23) who underwent sleeve gastrectomy (SG) ( n = 9) or Roux-en-Y gastric bypass (RYGB) ( n = 14) (median age 35 years [25;43] and BMI 44.2 kg/m 2 [40.7; 51.0]; 8/23 with T2D) were individually matched to 2 subjects with common obesity for age, gender, preoperative body mass index, T2D, and type of surgery.
TWL% after 1 and 5 years was lower in the craniopharyngioma group than in the control group: 23.1 [15.4; 31.1] (23/23) vs 31.4 [23.9; 35.3] at 1 year ( p = 0.008) (46/46) and 17.8 [7.1; 21.9] (23/23) vs 26.2 [18.9; 33.9] at 5 years ( p = 0.003) (46/46). After RYGB, TWL% was lower in the craniopharyngioma group compared to the control group ( p < 0.001) and comparable after SG both at 1 and 5 years. No difference between the two groups was observed in T2D remission rate and in early and late adverse events. No hormonal deficiency-related acute disease was reported.
Bariatric surgery induced a significant weight loss in the craniopharyngioma group at 1 and 5 years, but less than in common obesity. SG may be more effective than RYGB but this remains to be demonstrated in a larger cohort.
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The authors express their thanks to Florence Marchelli and Valentine Lemoine of the CRNH and the Institute of Cardiometabolism and Nutrition, Pitié-Salpêtrière Hospital, Paris, France, for assistance with control recruitment and data management. We thank Dr David Marsh for English editing.
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Nutrition Department, French Reference Center for Prader-Willi Syndrome, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, INSERM UMRS NutriOmics, Sorbonne University, 75013, Paris, France
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Department of Endocrinology, Diabetology, and Metabolic Diseases (B.G.), Haut Leveque Hospital, Pessac, University of Bordeaux, 33076, Bordeaux, France
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Specialized Obesity Center and Department of Endocrinology, Diabetology, Nutrition, CHRU-Nancy, Brabois Hospital, Université de Lorraine, 54500, Vandoeuvre-Les-Nancy, France
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Department of Endocrinology, L’Institut Du Thorax, Centre Hospitalier Universitaire de Nantes, 44093, Nantes, France
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Assistance Publique-Hôpitaux de Paris, Hôpital Ambroise Paré, Service d’Endocrinologie Diabétologie Nutrition, 92100, Boulogne-Billancourt, France
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Service Nutrition Clinique, Centre Hospitalier Universitaire de Clermont Ferrand, 63003, Clermont Ferrand, France
Nicolas Farigon
Department of Visceral Surgery, CHU Clermont-Ferrand, 63003, Clermont Ferrand, France
Department of Hepato-Biliary and Pancreatic Surgery, Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, 47-83 Boulevard de l’Hôpital, 75013, Paris, France
Laurent Genser
Assistance Publique-Hôpitaux de Paris (AP-HP), Service de chirurgie digestive, Hôpital Européen Georges Pompidou, 75015, Paris, France
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Department of Surgery and Oncology, Ambroise Paré Hospital, AP-HP, 92100, Boulogne-Billancourt, France
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Clinique de Chirurgie Digestive Et Endocrinienne (CCDE), CHU de Nantes, 44093, Nantes Cedex 1, France
Claire Blanchard
L’institut Du Thorax, Université de Nantes, CHU Nantes, CNRS, INSERM, 44000, Nantes, France
Department of Digestive Surgery, Center of Bariatric Surgery, Hopital Edouard Herriot, Hospices Civils de Lyon, 69437, Lyon, France
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Fédération Hospitalo-Universitaire DO-IT, Centre Intégré Et Spécialisé de L’Obésité de Lyon, CRNH-RA, Hospices Civils de Lyon, Lyon, France
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Bordeaux Medicine University, 33076, Bordeaux, France
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C.P, C.C, S.C, P.F, and A-S.J conceived the original idea and designed the study. All authors gathered and/or delivered data for subjects with craniopharyngioma. M.A. supervised the project. C.P and P.F recruited the subjects of the control group. All authors provided critical feedback. A-S.J. and A.V.S performed the statistical analysis. P.F. drafted the manuscript. All authors approved the final version, had access to the full data in the study, and accept responsibility to submit for publication. P.F., C.P., C.C, and S.C. are guarantors of this work and, as such, had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Correspondence to Pauline Faucher .
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• TWL% after 5 years is 18% in craniopharyngioma group vs 26% in controls
• No difference in type 2 diabetes remission rate at 5 years
• No hormonal deficiency-related acute disease reported
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Faucher, P., Carette, C., Jannot, AS. et al. Five-Year Changes in Weight and Diabetes Status After Bariatric Surgery for Craniopharyngioma-Related Hypothalamic Obesity: a Case–Control Study. OBES SURG 32 , 2321–2331 (2022). https://doi.org/10.1007/s11695-022-06079-9
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Received : 03 February 2022
Revised : 14 April 2022
Accepted : 20 April 2022
Published : 06 May 2022
Issue Date : July 2022
DOI : https://doi.org/10.1007/s11695-022-06079-9
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Sodhi M , Rezaeianzadeh R , Kezouh A , Etminan M. Risk of Gastrointestinal Adverse Events Associated With Glucagon-Like Peptide-1 Receptor Agonists for Weight Loss. JAMA. 2023;330(18):1795–1797. doi:10.1001/jama.2023.19574
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Glucagon-like peptide 1 (GLP-1) agonists are medications approved for treatment of diabetes that recently have also been used off label for weight loss. 1 Studies have found increased risks of gastrointestinal adverse events (biliary disease, 2 pancreatitis, 3 bowel obstruction, 4 and gastroparesis 5 ) in patients with diabetes. 2 - 5 Because such patients have higher baseline risk for gastrointestinal adverse events, risk in patients taking these drugs for other indications may differ. Randomized trials examining efficacy of GLP-1 agonists for weight loss were not designed to capture these events 2 due to small sample sizes and short follow-up. We examined gastrointestinal adverse events associated with GLP-1 agonists used for weight loss in a clinical setting.
We used a random sample of 16 million patients (2006-2020) from the PharMetrics Plus for Academics database (IQVIA), a large health claims database that captures 93% of all outpatient prescriptions and physician diagnoses in the US through the International Classification of Diseases, Ninth Revision (ICD-9) or ICD-10. In our cohort study, we included new users of semaglutide or liraglutide, 2 main GLP-1 agonists, and the active comparator bupropion-naltrexone, a weight loss agent unrelated to GLP-1 agonists. Because semaglutide was marketed for weight loss after the study period (2021), we ensured all GLP-1 agonist and bupropion-naltrexone users had an obesity code in the 90 days prior or up to 30 days after cohort entry, excluding those with a diabetes or antidiabetic drug code.
Patients were observed from first prescription of a study drug to first mutually exclusive incidence (defined as first ICD-9 or ICD-10 code) of biliary disease (including cholecystitis, cholelithiasis, and choledocholithiasis), pancreatitis (including gallstone pancreatitis), bowel obstruction, or gastroparesis (defined as use of a code or a promotility agent). They were followed up to the end of the study period (June 2020) or censored during a switch. Hazard ratios (HRs) from a Cox model were adjusted for age, sex, alcohol use, smoking, hyperlipidemia, abdominal surgery in the previous 30 days, and geographic location, which were identified as common cause variables or risk factors. 6 Two sensitivity analyses were undertaken, one excluding hyperlipidemia (because more semaglutide users had hyperlipidemia) and another including patients without diabetes regardless of having an obesity code. Due to absence of data on body mass index (BMI), the E-value was used to examine how strong unmeasured confounding would need to be to negate observed results, with E-value HRs of at least 2 indicating BMI is unlikely to change study results. Statistical significance was defined as 2-sided 95% CI that did not cross 1. Analyses were performed using SAS version 9.4. Ethics approval was obtained by the University of British Columbia’s clinical research ethics board with a waiver of informed consent.
Our cohort included 4144 liraglutide, 613 semaglutide, and 654 bupropion-naltrexone users. Incidence rates for the 4 outcomes were elevated among GLP-1 agonists compared with bupropion-naltrexone users ( Table 1 ). For example, incidence of biliary disease (per 1000 person-years) was 11.7 for semaglutide, 18.6 for liraglutide, and 12.6 for bupropion-naltrexone and 4.6, 7.9, and 1.0, respectively, for pancreatitis.
Use of GLP-1 agonists compared with bupropion-naltrexone was associated with increased risk of pancreatitis (adjusted HR, 9.09 [95% CI, 1.25-66.00]), bowel obstruction (HR, 4.22 [95% CI, 1.02-17.40]), and gastroparesis (HR, 3.67 [95% CI, 1.15-11.90) but not biliary disease (HR, 1.50 [95% CI, 0.89-2.53]). Exclusion of hyperlipidemia from the analysis did not change the results ( Table 2 ). Inclusion of GLP-1 agonists regardless of history of obesity reduced HRs and narrowed CIs but did not change the significance of the results ( Table 2 ). E-value HRs did not suggest potential confounding by BMI.
This study found that use of GLP-1 agonists for weight loss compared with use of bupropion-naltrexone was associated with increased risk of pancreatitis, gastroparesis, and bowel obstruction but not biliary disease.
Given the wide use of these drugs, these adverse events, although rare, must be considered by patients who are contemplating using the drugs for weight loss because the risk-benefit calculus for this group might differ from that of those who use them for diabetes. Limitations include that although all GLP-1 agonist users had a record for obesity without diabetes, whether GLP-1 agonists were all used for weight loss is uncertain.
Accepted for Publication: September 11, 2023.
Published Online: October 5, 2023. doi:10.1001/jama.2023.19574
Correction: This article was corrected on December 21, 2023, to update the full name of the database used.
Corresponding Author: Mahyar Etminan, PharmD, MSc, Faculty of Medicine, Departments of Ophthalmology and Visual Sciences and Medicine, The Eye Care Center, University of British Columbia, 2550 Willow St, Room 323, Vancouver, BC V5Z 3N9, Canada ( [email protected] ).
Author Contributions: Dr Etminan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Sodhi, Rezaeianzadeh, Etminan.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Sodhi, Rezaeianzadeh, Etminan.
Critical review of the manuscript for important intellectual content: All authors.
Statistical analysis: Kezouh.
Obtained funding: Etminan.
Administrative, technical, or material support: Sodhi.
Supervision: Etminan.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was funded by internal research funds from the Department of Ophthalmology and Visual Sciences, University of British Columbia.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Data Sharing Statement: See Supplement .
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Drugs like Ozempic and Wegovy, known as GLP-1 receptor agonists, have surged in popularity as treatment for weight loss and management. The increase involves not only adults but also adolescents, along with bariatric surgery patients . Michael Kochis, Ed.M. ’19, M.D. ’20, a resident in the Department of Surgery at Massachusetts General Hospital, realized that little research had been done regarding the use of these drugs on adolescent bariatric surgery patients. Kochis and his team examined practice patterns across the nation, and he spoke to the Gazette about the group’s recent study as well as safety issues for youth generally. This interview has been edited for length and clarity.
Have these drugs been found to be safe, both for adults and adolescents?
There is increasing evidence that these can be safely used, especially in adults but more recently in pediatrics. Studies happen before drugs get licensed to make sure that they’re safe enough to go to market, and that factors into FDA approval. After approval, they’re still monitored.
And I think it’s important to note that safety can mean different things to different people. And so while there are no glaring problems that would withdraw these drugs from the market — which has happened in the past with other medications related to obesity — there are side effects that aren’t well-tolerated by everyone, like nausea or feeling like you’re full all the time. They’re not a “cure all” drug with all benefits and no risk.
For pediatrics specifically, there’s far less data on their use in children and young adults because they’re not as frequently prescribed in the first place. It’s harder to get studies where we can collect tons of data on adolescents.
One of the areas that this research is highlighting is the fact that these drugs are being used in the pediatric population. It’s really important that we collect data to make sure there’s nothing different about the drugs’ use in this population, compared to what we know from adults.
For your study, why did you choose to look at bariatric surgery patients as opposed to just general adolescents who might be using these drugs?
Our research group has a specialty in bariatric surgery. We’re hearing more and more and more about these drugs and that sparked our interest.
But secondly, the use of these medications in the context of pediatric bariatric surgery has a few unique considerations beyond safety. Those relate to the many physiologic changes that happen as a result of bariatric surgery, not just to weight loss.
The surgeries themselves change the body’s metabolism and hormone balances. It’s unknown how the changes from surgery might relate to the hormone balances that these medications affect. And so the questions are relevant before surgery, during surgery, and after surgery in regard to the effects of these medications on patients. We asked questions in all three domains.
“More likely than not, you’re doing things differently than your colleagues. So why don’t we start talking about it and sharing our experiences to try to come to the best practices?” Michael Kochis
What did your study find in terms of the usage of these medications?
There were two really big-picture findings. One is that, yes, these medications are being used for adolescents with obesity who are undergoing bariatric surgery. So essentially the cat’s out of the bag, it’s already happening.
And then the second finding is that there’s a lot of uncertainty and variation in the exact practice patterns across institutions. There’s a recognition that we’re doing it this way at our place, and they’re doing it that way at that place. And no one really knows what the right answer or the best answer is. We’re in uncharted territories.
That creates an opportunity for deliberate convening amongst these different groups and data-sharing so we can try to establish best practices. That can be based on consensus regarding what experts think the best approach is or hopefully — in time — an evidence-based approach. But that might take time.
What are the benefits and potential dangers of realizing there’s so much variation?
I think overall, it’s sparking discussion and increasing awareness. A lot of these pediatric bariatric centers have to be really good at what they do. We specifically looked at the larger centers throughout the country, which are often reference points for entire regions.
My hunch is that people come to their practices based on what they think is going to be helpful for their patients, not realizing that other places do it differently. This study highlights that and will hopefully spark a discussion so different providers will start talking with their peers and asking questions.
More likely than not, you’re doing things differently than your colleagues. So why don’t we start talking about it and sharing our experiences to try to come to the best practices?
The problem with this is there might be the recognition that one approach is better than others. If you have variety, the implication is that there might be variations in the quality of care. Once we do have a better understanding of optimal use of these medications in the pre-op, peri-op, and post-op setting, there will be opportunities for standardization of care.
What do we still need to learn?
Above all, there’s a need for more data. I also hope this highlighted an opportunity for different institutions to come together and collaborate. We’re working on both of those things.
Pediatric surgery in general is relatively small; fortunately, a lot of times kids and adolescents don’t need operations as frequently as adults do. So it’s a great space for collaboration and gathering knowledge.
There are a couple collaboratives of pediatric hospitals and surgeon networks throughout the country; we at Mass General are currently working to establish another collaborative specifically focused on pediatric metabolic and bariatric surgery. We’re working on creating databases where we can pool all of our data from our separate institutions — about how we treat these patients before they’re getting surgery, what we do during the surgical context, and then how they do after surgery — to get on the same page about what data we’re collecting and how we can assess it in the long term.
We can ask some really good research questions that we would never be able to get the answers to (with as much level of detail and discernment) if any one of our institutions did that exact same study alone. More efforts like that will be helpful in providing the high-level evidence we need to make informed decisions about the optimal care for patients.
Is there anything that parents should be aware of when considering these medications for their children?
I’m glad you brought that up. One of the findings from the study is that some providers’ practices — in the absence of strict guidelines or criteria — were informed partially by patients or families.
The use of these medications should be a multidisciplinary discussion with the patient’s pediatrician, primary care doctor, obesity medicine physician, and potentially with a surgeon, if that’s applicable.
Every patient has unique circumstances. So I would say to parents that if they see advertisements for this on the news or see these medications on social media, it’s great that they can be informed about what’s out there. But then bring that background knowledge to an informed discussion with your doctors. Understand that just because you heard some celebrities have used them and had certain experiences it does not mean that they are for everybody or should be applied in your circumstance. You can really only discern that based on a comprehensive discussion with your doctors.
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Lunt N, Smith RD, Mannion R, et al. Implications for the NHS of inward and outward medical tourism: a policy and economic analysis using literature review and mixed-methods approaches. Southampton (UK): NIHR Journals Library; 2014 Jan. (Health Services and Delivery Research, No. 2.2.)
Chapter 10 bariatric surgery case study.
An area that has seen rapid growth in the numbers of patients travelling abroad, as well as patients in the UK undergoing surgery, is bariatric or weight loss surgery. 194 The UK, like many other countries globally, has seen a rapid increase in the numbers of overweight and obese patients, with the Department of Health estimating that one-quarter of the UK population is now clinically obese, that is, with a body mass index (BMI) of ≥ 30 kg/m 2 . 195 Obesity has several long-term health effects including an increased incidence of diabetes and cardiovascular disease. In addition to behavioural interventions such as exercise, counselling and pharmacological interventions (appetite suppressants), several surgical procedures are available to assist weight loss.
The two most common procedures are a gastric band and a gastric bypass. A ‘band’ is the less invasive procedure. It limits food intake by placing a restrictive string around the top end of the stomach. This band has to be regularly adjusted to allow patients to consume food while maintaining weight loss. When a band is too tight it can prevent patients from eating, whereas a loose band means that patients can eat as much as they wish. The bypass is a much more invasive procedure in which part of the patient’s stomach is partitioned and his or her capacity to absorb food is limited. As a result of a bypass, patients need to monitor their food intake carefully to ensure that they receive the nutrition that they require. Given the body’s reduced capacity to absorb nutrients and specific vitamins and minerals, supplements have to be taken by patients for the rest of their lives to ensure adequate nutrition. 196
In the UK, bariatric surgery is a relatively new field of surgery. It is available as treatment on the NHS and National Institute for Health and Care Excellence (NICE) guidelines 197 recommend or make available bariatric surgery in individuals with a BMI > 40 kg/m 2 . However, the implementation and interpretation of the guidelines depend on the PCT and on the assessment by a GP. Research has indicated a reluctance by GPs to prescribe such surgery. 195
In this research, 13 in-depth interviews were conducted with patients who travelled abroad for bariatric surgery. These discussed the themes explored in the patient interviews described in Chapter 9 , for example patients’ experiences of the NHS before and after treatment, and how they identified the treatment provider abroad. In addition, three professionals from organisations working in bariatric surgery in the UK were interviewed to gain further understanding.
Although many issues identified across our sample of patients were common to bariatric patients’ motivation to travel (such as issues relating to distance and eligibility), there were also clear differences within each subtheme identified that were specific to bariatric tourism. These hold important lessons when trying to understand and address the specific factors determining bariatric patients’ travel and follow-up needs.
As with many other medical tourists, bariatric surgery patients were keen to stress that cost had not been the only factor in them choosing to travel for surgery, and only 2 of the 13 patients interviewed cited this as their sole motivation. More than for any other group interviewed, expertise (in bariatric surgery) was the biggest pull factor. In total, 11 out of the 13 had travelled to Belgium, which was perceived to be more advanced in the field of bariatric surgery at the time that the patients interviewed had undertaken treatment (between 2004 and 2009). In several cases patients specifically described how the surgery that they had opted for had not been available to them within the NHS, or that surgeons in the UK had conducted only a small number of procedures, or that there was only limited expertise in these areas.
Of the 13 patients interviewed, half reported that the surgeon having conducted the procedure many times before was a key factor in their decision-making. The experience of the surgeon was contrasted in some cases with a general distrust of the NHS:
[My motivation for travel was] mainly the cost but also because the surgeon was very highly recommended. Also in general all-round the whole experience. I mean, there’s quite a big issue with MRSA [methicillin-resistant Staphylococcus aureus ] which they didn’t have at all abroad. BT4
Several issues relating to the availability of treatment were factors in the decision of where to seek treatment. This relates to bariatric surgery specifically, as it is a comparatively new field in the UK (see also p. 69). For example, two patients from Northern Ireland reported that, at the time of their surgery, it was not available in the province and surgery would have required them to travel (to mainland Britain) in any case. Similarly, a patient from Scotland reported that she would have had to travel to England to receive the procedure under the NHS.
Patients also mentioned that they had seen a NHS doctor and had been judged eligible but that the waiting time for the operation had put them off having it done on the NHS. In some cases this appeared to be the actual reported waiting times; in others it was unclear if the patient had just anticipated the long wait.
As in other cases, such as fertility surgery, several patients reported that they had been found to be ineligible for treatment on the NHS. Although NICE guidelines exist that recommend or make available bariatric surgery for individuals with a BMI > 40 kg/m 2 , 197 the implementation and interpretation of these guidelines depends on the PCT and on assessment by the GP. Several patients interviewed referred to the resulting inequities and the sense of a ‘postcode lottery’. In some cases this was because people were deemed to have a BMI considered too low to qualify for surgery, or patients were considered healthy despite having a very high BMI and fearing for their long-term health. This may in part be the result of GPs looking at bariatric surgery as a ‘last resort’ and an expense rather than a cost-saving treatment. A recent survey of GPs conducted by the Office of Health Economics 195 found that the vast majority try to avoid prescribing surgery for obesity, regardless of BMI.
As with other patients, distance played a key role in decision-making. Specific to bariatric patients was that Belgium, as a centre of expertise in bariatric surgery at the time that interviewees had travelled (between 2004 and 2009), was easily accessible via Eurostar. Ten of the 13 people interviewed had travelled to Belgium: several mentioned its proximity, including specifically the ease of access by Eurostar. This has particular relevance for weight loss surgery, as some patients are cautioned against flying following the procedure.
Based on this analysis, the decision by patients to travel for weight loss surgery was rarely the result of a single motivating factor; rather, it was a combination of cost, expertise, availability and distance, with different patients giving different weight to each of these. Unique to this group was the specific emphasis given to the experience of the surgeon. This was a direct result of bariatric surgery being a newer field of investigation in the UK; as expertise grows in the UK it is likely that these differences will disappear or become less pronounced. A representative of a Royal College working on these issues highlighted that bariatric surgery had been a very new field in the UK in 2004, but that the field was rapidly growing now with increasing expertise in the UK.
The treatment pathway for bariatric patients did not vary greatly from the general model set out in Chapter 9 , with most patients describing the use of the internet to identify and research providers.
What did set the experience of bariatric patients somewhat apart from the general experience was the level of complications and aftercare required for most procedures. Of the 13 patients interviewed, four experienced complications directly relating to the surgery and had to be resubmitted to hospital for additional surgery while still abroad. Many of the patients interviewed experienced long-term health problems relating to the surgery undertaken or the longer-term care needs resulting from these. However, what resonated across accounts of immediate complications and longer-term issues was the responsibility that patients took for the health outcomes of their procedures. This again seemed to be specific to bariatric patients in the study sample.
The most common procedures for which patients travelled abroad, gastric banding and gastric bypass, both require lifelong follow-up care and maintenance. In the case of a gastric band, this has to be adjusted to ensure that patients continue to lose weight while being able to consume enough food to obtain the nutrition that they require to survive. The gastric band is an elastic band filled with fluid that can be adjusted to tighten or loosen it. People with a gastric band are required to have the band adjusted at regular intervals.
In the case of a gastric bypass, although the procedures may vary, a part of a person’s gut is removed and his or her capacity to absorb minerals and vitamins is limited. Therefore, patients who have undergone a gastric bypass have to rely on supplements to avoid malnutrition and patients have to undergo regular blood tests to monitor this. A professional interviewed for this research referred to the ‘maintenance’ that patients require following bariatric surgery and how this is a lifelong condition.
Aftercare and follow-up from bariatric surgery can be divided into the needs immediately following surgery and the ongoing maintenance of the results achieved from the procedure.
Several patients reported complications with their bands. One patient had a ‘faulty’ band emptied and removed because of the problems that she experienced with it; this interviewee reported that the replacement was also problematic.
Two patients reported more severe long-term health consequences. One (who had had a gastric bypass) reported having been hospitalised for 2 years following a life-threatening complication and was still unable to work. Although the patient had returned to the original surgeon abroad to have the complication dealt with, she was now unable to afford further follow-up visits to him. Despite the complication arising from the original surgery, the patient retained a greater trust in the original surgeon’s abilities than in the NHS as he had been able to resolve the issue whereas the NHS had been unable to:
Now, unfortunately two years down the line and I’m still not 100 per cent. I’m still on morphine every day and I’m still underweight. So I still have long-term problems so I don’t know if that will ever be sorted out. BT6
The other described how the long-term consequences of a bypass had led to severe health issues, including tears and fistulas.
Continuity of care emerged as a clear challenge for all patients. However, in bariatric surgery this differed between the complications resulting from the surgery and the long-term care needs resulting from the surgery. Some of the complications experienced were severely debilitating, while the need for aftercare and ‘maintenance’ of a gastric band make continuity of care more important than for some of the other areas of surgery for which people travelled and which are reviewed here.
The specific clinical requirements of aftercare for bariatric treatment also led to specificities in the industry models. Many of the Belgian providers offered aftercare services to English patients (such as the filling of bands) in London or other UK locations at an additional cost. This was specific to providers of bariatric services.
Unlike other groups of patients, all patients interviewed had been in contact with the NHS (specifically their GP) in relation to their weight before and after the surgery. Six patients specifically recounted the refusal by their GP to refer them for surgery; two of these explicitly mentioned that they were eligible for the surgery according to NICE guidelines but that their GP had told them that no funding was available.
Overall, the vast majority of patients reported limited support from GPs. This was more common than in other groups of patients interviewed. In many cases patients reported that this may be based on limited knowledge. One interviewee summed it up as follows:
The GP that was here just used to look at me blank if I mentioned my obesity. They didn’t offer anything at all, no support whatsoever [. . .] It’s not that they’re not supportive they just don’t know what to do. They don’t know anything about them. BT7
Interviewees also reported a difference in attitude between surgeons and GPs, which they felt was mainly due to surgeons’ greater knowledge of bariatric surgery.
Moreover, all patients interviewed reported that insufficient services were provided within the remit of the NHS for overweight and obese patients. There was a clear sense that the approach by NHS staff had been cautious in relation to surgery and that as a result the patients interviewed for the research felt that the treatment that they required was unavailable to them.
Compared with the overall sample of medical tourists, there were several distinct aspects to bariatric tourism. Three key factors were uncommon compared with other patients’ experiences. First, all bariatric patients interviewed had been in contact with the NHS before making their decision to travel for treatment. Second, the lack of expertise within the NHS was a greater factor for motivating bariatric patients than for motivating other medical tourists. Third, the need for aftercare and the high level of complications experienced by bariatric surgery patients set this group apart. It underlines the need for better information and a full understanding of risk amongst this group of medical tourists before they travel. This has also led to specific industry developments by providers, with follow-up consultations in London, and equally specific requirements of the NHS when maintenance is not provided by the original clinic.
Bariatric surgery outcomes have long-term consequences; as this is a comparatively ‘young field’ some of these and the effects of treatment abroad will likely emerge only in the future. The SurgiCal Obesity Treatment Study (SCOTS) at the University of Glasgow (a longitudinal study of bariatric surgery patients) 198 will in the future provide important results in this respect.
Across the interviews there was a sense that patients felt that they lacked the entitlement for surgery on the NHS as their weight was a result of their own ‘behaviour’. Some of the patients addressed this explicitly and described how their interactions with the NHS had left them feeling this way; most patients had had some contact with the NHS about weight loss and felt abandoned, with the NHS not recognising the value of weight loss surgery. Even when patients described this negative experience as an example of policy that had to change, they were equally keen to convey a sense of responsibility that they had taken on through their actions, that is, choosing to travel and have surgery to address a health issue, which all of them felt would have become worse otherwise. In addition, even in cases in which weight loss surgery may be inadvisable from a medical perspective, the fact that patients felt compelled to travel indicated that current approaches to overweight and obesity by the NHS are not working. Many patients reported a sense of frustration as they felt that they had saved the NHS substantive future health-care expenditure related to being overweight and obese. Patients had a sense of being judged for being overweight or obese.
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World Journal of Emergency Surgery volume 19 , Article number: 28 ( 2024 ) Cite this article
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Laparoscopic surgery is widely used in abdominal emergency surgery (AES), and the possibility of extending this approach to the more recent robotic surgery (RS) arouses great interest. The slow diffusion of robotic technology mainly due to high costs and the longer RS operative time when compared to laparoscopy may represent disincentives, especially in AES. This study aims to report our experience in the use of RS in AES assessing its safety and feasibility, with particular focus on intra- and post-operative complications, conversion rate, and surgical learning curve. Our data were also compared to other experiences though an extensive literature review.
We retrospectively analysed a single surgeon series of the last 10 years. From January 2014 to December 2023, 36 patients underwent urgent or emergency RS. The robotic devices used were Da Vinci Si (15 cases) and Xi (21 cases).
36 (4.3%) out of 834 robotic procedures were included in our analysis: 20 (56.56%) females. The mean age was 63 years and 30% of patients were ≥ 70 years. 2 (5.55%) procedures were performed at night. No conversions to open were reported in this series. According to the Clavien-Dindo classification, 2 (5.5%) major complications were collected. Intraoperative and 30-day mortality were 0%.
Our study demonstrates that RS may be a useful and reliable approach also to AES and intraoperative laparoscopic complications when performed in selected hemodynamically stable patients in very well-trained robotic centers. The technology may increase the minimally invasive use and conversion rate in emergent settings in a completely robotic or hybrid approach.
Abdominal Emergency Surgery (AES) can be defined as a procedure requiring to deal with an acute threat to life, organ, trauma, acute disease process, acute exacerbation of a chronic disease process, or complication of a surgical or other interventional procedure, normally within hours of decision to operate [ 1 , 2 ].
Further, “expedited surgery” refers to the clinical situation exemplified by a patient in need of prompt treatment but not in imminent danger to life or organ survival; this procedure often takes place a few days after the decision to operate [ 3 ].
Nowadays, minimally invasive laparoscopic approach to urgent abdominal surgery (cholecystitis, acute appendicectomies, bowel perforation or obstruction, etc.) represents the standard of care in many cases and recent guidelines recommend it [ 4 , 5 , 6 , 7 ].
Nevertheless, after more than 20 years from clinical introduction, Robotic Surgery (RS) represents the most important technological evolution and a revolutionary concept of computer-assisted technology in minimally invasive surgery [ 8 ]. It allows to overcome many limits of conventional laparoscopy and to expand the use of minimally invasive approaches.
Its peculiar features include a three-dimensional high-definition view, articulated instruments, tremor eradication, and improved ergonomics for surgeons, enable the performance of extremely accurate procedures (micro-sutures, fine dissections, etc.) with consequently lowering conversion rates and postoperative complications, particularly in case of challenging surgical procedures [ 9 , 10 , 11 ]. In addition, compared to traditional laparoscopic surgery, RS demonstrated shorter learning curves for several complex procedures [ 12 , 13 ]. On the other hand, the main drawbacks of robotic technology are linked to its limited diffusion also due to expensive costs [ 14 , 15 , 16 , 17 , 18 , 19 , 20 ].
Nevertheless, robotic surgical technologies have expanded and evolved over the past 20 years, bringing new devices, and improving the most established ones [ 21 , 22 ].
The spreading of robotic platforms and their easier management led to increased RS applications in all abdominal surgical specialities including upper gastrointestinal surgery [ 15 , 23 , 24 , 25 ], colorectal surgery [ 26 , 27 , 28 ], HBP surgery [ 14 , 18 , 29 , 30 , 31 ], abdominal wall surgery and many others [ 7 ].
Despite the huge diffusion of RS in all surgical fields, its application in urgent scenarios has never been investigated representing a new field of interest, with limited literature experiences [ 32 ].
So considering that our experience in RS has been implemented since 2002 and it raised from general to major complex surgery [ 33 , 34 , 35 , 36 , 37 , 38 ], we aim to set the state of art of Robotic Emergency Surgery sharing our experience through the analysis of our peri-operative outcomes and indications in RS. Furthermore, due to the limited evidence available, we have as a secondary endpoint an extensive analysis of previous literature experiences.
We retrospectively reviewed a prospectively collected database of patients undergoing RS at General and Robotic Surgery Unit of San Giovanni Battista Hospital (Foligno, Italy) and General Surgery Unit of San Donato Hospital (Arezzo, Italy) from January 2014 to December 2023.
The patients’ data were analyzed according to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) [ 39 ]. All patients signed an informed consent allowing the anonymous scientific use of clinical data and images. The study was carried out according to the Declaration of Helsinki guidelines and was approved by the Institutional Review Board of the University of Molise (protocol number 10/21, approved date: May 12, 2021).
In all participating centres, data were prospectively collected from electronic patient records.
We selected 834 consecutive robotic procedures for abdominal surgery performed by both centres. Patients were divided into two cohorts: elective surgery and urgent or emergency surgery groups.
Urgent surgery was defined as a condition requiring surgery within 72 h in stable patients, but not suitable for discharge. Moreover, emergency surgery was defined as a clinical scenario requiring within 24 h in stable patients, with a low risk of deterioration. All patients < 18 years old and affected by hemodynamical instability were excluded.
Criteria adopted to assess baseline characteristics of patients, surgical issues and technologies that allow to benefit of RS in urgent and emergency settings are summarized in Table 1 .
Furthermore, to analyze the diagnosis and intraoperative data we carried out a specialities classification as reported in Table 2 .
Our experience with RS started in September 2002 with the da Vinci S ® platform (Intuitive Surgical, Sunnyvale, California, USA), and over time, its application in abdominal surgery grew as well as platform technologies. During the study period, the da Vinci Si ® platform (Intuitive Surgical, Sunnyvale, California, USA) and, since 2017, da Vinci Xi ® (Intuitive Surgical, Sunnyvale, California, USA) were available at our institutions.
Beginning from colorectal surgery, hiatal hernia repairs and cholecystectomies, our surgical team have gradually selected more challenging procedures by carrying out liver and pancreatic resections, oesophageal benign and malignant disorders, bariatric surgery, abdominal wall hernia repairs and nephrectomies [ 14 , 15 , 25 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ].
All procedures were performed by a well-trained surgeon in minimally invasive surgery (G.C.) with 10 years of previous experience in RS.
36 (4.3%) out of 834 robotic procedures were included in our analysis and treated as urgent or emergent procedures.
All patients signed an informed consent allowing the anonymous scientific use of clinical data and images. The study was carried out according to the Declaration of Helsinki guidelines and was approved by the Institutional Review Board of the University of Molise (protocol number 10/21, approved date: 12 May 2021).
The collected data included demographic characteristics such as age, sex, and preoperative comorbidities classified according to the Charlson comorbidity Index (CCI) [ 48 ]. The anesthetic risk assessment was performed thanks to the American Society of Anesthesiologists (ASA) score [ 49 ].
We reviewed pre-operative diagnosis, main and associated surgical procedures, operative time and intraoperative complications, and conversion to open rate. Postoperative complications were stratified according to the Clavien-Dindo classification [ 50 ] and were considered severe when ≥ 3. Patients were monitored until their 30th postoperative day.
Categorical variables were expressed as frequencies and percentages, while quantitative data were collected as means or medians and interquartile ranges.
We performed literature research on the PubMed Dataset (US National Library of Medicine, http://www.ncbi.nlm.nih.gov/PubMed ), using the subsequent keywords: “robotic surgery”, “urgent surgery”, and “emergency surgery”. We selected only English studies. Original articles, case reports and case series were included, while editorials, letters, and reviews were excluded. Number of treated patients does not represent an exclusion criterion. Articles were first evaluated by title and abstract examination, then a full-text read was performed. More than 50 studies described RS in AES. An extensive analysis was performed to summarize similarities and differences among RS approaches according to abdominal surgery specialities.
36 (4.3%) out of 834 robotic procedures were included in our analysis. Baseline characteristics of patients are listed in Table 3 .
According to surgical procedures, Fig. 1 shows AES performed thanks to RS compared to elective surgery.
Over the cohort of 36 patients treated, 16 (44.44%) were males while 20 (56.56%) were females. The mean age was 63.20 years (range: 43–88 years): 30.55% [ 11 ] of patients were ≥ 70 years. The mean Body Mass Index was 26.68 kg/m 2 (range: 23–42). According to the ASA score, 8 (22.22%) patients were classified as ASA 3. No ASA 4 was treated. Patients’ CCI are listed in Table 3 . The da Vinci Si platform was used for the first 15 (41.67%) cases, while Xi for the last 21 (58.33%). 2 (5.55%) procedures were performed at night. No conversions to open were reported in this series. According to Clavien-Dindo grade, 2 (5.55%) major complication was collected: 1 after urgent surgery and 1 after emergency setting. Two minor complications requiring conservative treatments were observed: both complications were related to primary disorders and not to RS. Intraoperative and 30-day mortality were 0%. The mean length of stay was 4.92 days (range: 1–21). The mean follow-up was 26.53 months (range: 7–68).
Number of elective and urgent/emergency procedures ( A ) and percentage of overall surgical procedures performed in emergency settings ( B ) according to abdominal surgery specialities. Abbreviations: HPB, Hepatopancreatic and Biliary Surgery;
Our experience demonstrates the safety and feasibility of RS also in urgent and emergency abdominal settings in patients not affected by hemodynamic instability. To date, the minimally invasive approaches in emergency scenarios are mainly validated for laparoscopy, as reported by several literature experiences included in the last WSES review [ 51 ]. Despite the diagnostic role of MIS, authors demonstrated several benefits of laparoscopic approaches in hemodynamically stable patients undergone AES, including trauma. However, patient selection, surgeons’ expertise as well as specific surgical training represent crucial key points [ 51 ].
In literature, RS in AES studies is related to high-volume centres, and well-trained surgeons’ experiences and their optimal outcomes should encourage further applications and Randomized Clinical Trials [ 32 , 52 ]. We further analyzed short- and long-term outcomes of RS in AES according to specialties (Table 4 ).
In the literature, RS in the emergency setting is reported by a limited number of experiences, especially case reports and case series.
The urologist experience described by Capibaribe et al. [ 53 ] demonstrated the safety and efficacy of robotic treatment in the case of vesicourethral anastomotic stenosis after open radical prostatectomy, providing better continence results, without pubectomy.
Globally, the major barrier to RS adoption is due to limited device access resulting from a shared use policy by several surgical teams (gynaecologists, general surgeons, thoracic surgeons, and urologists). Furthermore, the lack of dedicated teams (surgeons, nurses, and anaesthesiologists) during the night shift might further limit RS.
On the other hand, in emergency settings, the “time-sparing” concept is largely known. Commonly, to avoid useless costs due to waste disposable instruments, a hybrid approach should be discussed by the whole surgical team: before robotic docking, a laparoscopic exploration could be the first surgical step to verify clinical environments for doing RS.
A crucial issue is represented by frequent operating table position changes, especially during explorative steps (tilting, Trendelenburg, or reverse-Trendelenburg positions) and rapid conversion to open surgery when necessary [ 54 ]. It could be underlined that quick and safe docking and undocking are performed by skilled teams and well-trained surgeons in elective procedures [ 54 , 55 ].
In the last years, the RS technologies have also impacted operative time [ 56 ]: The Xi robot represents a radical evolution from the Si robot. Literature experiences demonstrated better docking ability during Da Vinci Xi surgery when compared to previous robotic systems (Da Vinci S, Si, X) [ 57 , 58 ]. These features were due to laser targeting and improved cannula mounts that resulted in a simplified “linear” port configuration and an abbreviated docking time.
Besides, the ability to exchange the robotic camera from port-to-port increased versatility for multi-quadrant surgeries thanks to the smaller 8 mm camera [ 59 , 60 ]. The multi-quadrant operations represent challenges due to the axis of visualization shift up to 360°. This procedure requires undocking the robot and rotating it on the axis. It is crucial for many colorectal surgeries that require access to the entire abdomen such as subtotal colectomy and total proctocolectomy.
Furthermore, it was reported that the Xi system’s better fluency is also due to thinner robotic arms that reduce their collisions during surgery and synchronous movements with the operating Table [ 56 ]. In addition, Da Vinci Xi integrates the Indocyanine-Green technology that could be easily used to better identify bile duct during cholecystectomy in patients affected by acute cholecystitis, to assess organ vascularization during their resections and anastomosis, as reported in our experience.
Bianchi et al. [ 61 ] performed an extensive comparison of Da Vinci Si and Xi systems to define their advantages and disadvantages. 89 patients (64 in the Si system vs. 25 in the Xi system group) who underwent liver surgery were included. The Si system group experienced a greater total incisional length (+ 8.99 mm; p < 0.0001) due to a higher number of robotic/laparoscopic ports. Nevertheless, no differences were described regarding operative time, conversion rate, estimated blood loss, postoperative complications, mortality, use of analgesics, and costs. The authors concluded that da Vinci Xi represents an effective technological advancement.
Hill et al. [ 62 ] hypothesized that Da Vinci Xi will allow for greater efficiency and result in shorter operative times if compared to Da Vinci Si. To validate their hypothesis, the authors performed a retrospective review of patients undergoing sigmoid colon resection or Low Anterior Rectal resection. A total of 93 patients underwent sigmoid resection thanks to RS (Si, n = 52 vs. Xi, n = 41). The Xi group had significantly shorter surgical times for Low Anterior Rectal and sigmoid resection (162 vs. 238 min, p = 0.0001). Nowadays, no data are available on the Da Vinci Si and Xi comparison in AES.
However, according to the type of procedures, the mean operative times of Da Vinci Xi were superimposable to the Si group in our experience.
The robotic technology in hemodynamically stable patients could potentially reduce the conversion to open rate (0% in our short series), thanks to high-definition view and accuracy of dissection and fine micro-sutures.
In 2022, the World Society of Emergency Surgery (WSES) published a position paper on RS in AES after the literature evaluation by a steering committee and an international expert panel [ 32 ]. Ten studies (3 case reports, 3 case series, and 4 retrospective comparative cohort articles) were found and 6 statements were proposed. Experts concluded that RS can be considered safe, and feasible in selected cases represented by hemodynamically stable patients. It should be emphasized that the WSES team reported some RS drawbacks: it is mandatory to perform dedicated surgical training, RS showed longer operative times, higher costs and difficult availability and accessibility represent the main issues during night shifts [ 32 ].
These aspects probably may change in the future with RS diffusion and new robotic devices in the health market.
In our experience, the mean age of patients was 63 years. Therefore, more than 30% of patients were older than 70 years (range: 43–88 years) and it is in line with RS literature experiences that showed good outcomes also in the elderly population [ 28 , 41 ]. Nevertheless, operative time represents a crucial point in this frail cohort. Despite RS showing longer operative time when compared to open and laparoscopic surgery, this disadvantage may be offset by lower postoperative complication rates, shorter hospital stays, and lower conversion rates [ 28 , 41 , 63 , 64 , 65 ].
Another key aspect is represented by enhanced vision through near-infrared imaging. It may be useful in AES in case of tissue perfusion evaluations or biliary tree identification in challenging procedures. This feature is not routinely available in laparoscopic surgery [ 66 , 67 ].
Figure 2 shows an emergency scenario due to splenic artery aneurysm repair thanks to RS.
The robotic approach during Emergency Setting for patients affected by splenic artery aneurysms using a vessel resection and end-to-end vascular anastomosis
One of the earliest studies on RS in AES was published in 2012 [ [ 68 ]]: Sudan et al. experience in complex bariatric surgery involved 2 patients affected by a stomach stricture and an acute abdomen due to perforation with biliary peritonitis after biliopancreatic diversion, respectively. The perforation was treated through an initial laparoscopic investigation followed by a handsewn robotic stitch reparation of duodenal stump dehiscence.
In 2020, Cubas et al. [ 69 ] presented an RS procedure for incarcerated Morgagni Hernia in a 29-year-old male. The hernia defect (reported as 10 × 7 cm) was corrected via mesh placement. Patient discharge was possible on POD 5. No recurrence was detected at 1-year follow-up.
During the same year, Ceccarelli et al. [ 45 ] published a series of 5 patients affected by strangulated Giant Hiatal Hernia: 3 (60%) patients experienced RS while 2 (40%) laparoscopic approach. The authors described an easier incarcerated stomach management thanks to RS, maybe due to better surgeon ergonomic position and more accurate dissection preserving pleural integrity and vagus nerve.
Kim et al. [ 70 ] reported a case of robotic transthoracic repair of a right-sided traumatic diaphragmatic rupture in a 45-year-old male with a history of chronic obstructive pulmonary disease presented as a restrained driver in a low-speed motor vehicle collision. The patient was effectively operated after a 48-hour observation.
In 2021, 300 USA hospitals were involved in retrospective data collection of adult patients affected by Hiatal Hernia and treated in elective and urgent/emergency scenarios from 2015 to 2017 [ 71 ]. Data analysis revealed that laparoscopy (64%) was the most frequent approach used during AES, followed by open surgery (30%). A limited number of patients (6%) experienced RS. After cost evaluations and outcomes analysis, authors declared the technical feasibility of minimally invasive approaches when compared to open surgery due to lower cost, lower length of hospital stay, complications, and mortality.
Robinson et al. [ 72 ], in 2021, performed a statistical analysis of “in-room-to-surgery-start time” in a retrospective cohort study of 44 patients affected by emergent perforated gastrojejunal ulcers. The comparison between RS and laparoscopic (24 and 20 cases respectively) showed encouraging results for RS (25 versus 31 min, p = 0.01). Furthermore, no statistical differences were observed in terms of intra- and post-operative outcomes (operative time, complication rate, complication severity, hospital length of stay, discharge to home, and 30-day readmission). Despite RS showing higher surgical costs, authors concluded that emergency gastric perforation could be safely approached thanks to RS.
No complications were reported in all studies reported in our review [ 69 , 70 , 71 , 72 ].
Nowadays, emergency laparoscopy represents a safe and valid approach to colorectal disorders such as perforated diverticulitis with generalized peritonitis [ 73 ], iatrogenic colonoscopy perforations [ 74 ], bowel obstructions and anastomotic leaks management [ 75 , 76 , 77 ].
In 2012, Pedraza et al. [ 78 ] showed successful robotic colectomy due to iatrogenic colon perforation following colonoscopy.
Two years later, Felli et al. [ 79 ] described a case of an 86-year-old woman admitted to the emergency unit for massive intestinal bleeding due to ascending colon cancer. After patient resuscitation thanks to blood transfusions, surgeons carried out a robotic right colectomy. The postoperative period was uneventful.
Several series compared laparoscopic and robotic outcomes in patients who underwent elective colorectal surgery [ 80 , 81 , 82 ], suggesting the potential role of RS in this surgical field. Nevertheless, an interesting analysis was performed by Beltzer et al. [ 83 ] in 2019. 106 patients were treated for uncomplicated, complicated, or recurrent diverticulitis. The authors concluded that RS achieves better outcomes when compared to laparoscopic surgery in challenging cases (abscess or relapsing diverticulitis).
Three monocentric experiences reported by Kudsi et al. [ 84 , 85 , 86 ] showed the effectiveness of urgent RS for the treatment of obstructive transverse colon cancer, bleeding sigmoid diverticulosis and caecal volvulus.
However, RS could represent a crucial approach also in colorectal autoimmune diseases. Concerning this field, Anderson et al. [ 87 ] in 2020 reported a matched case-control study of 6 patients treated by urgent subtotal colectomy for ulcerative colitis using the robotic platform. In addition, authors compared patients who underwent RS to laparoscopic urgent procedures (6 versus 13 cases) concluding that no differences in perioperative outcomes were observed.
According to Yang et al. [ 88 ] estimation, more than 17 millions of patients were affected by appendicitis in 2019, making it the most common surgical emergency worldwide. Nevertheless, regarding urgent robotic appendectomies, only 5 literature experiences reported robotic approaches [ 89 , 90 , 91 , 92 , 93 ]. A total of 11 patients were collected and 3 (27.27%) required an appendix stump suture. No complications or conversions were reported. Moreover, Hüttenbrink et al. [ 94 ] described incidental appendicectomy during robotic prostatectomy.
Figure 3 shows our experience during RS for complicated sigmoid diverticulitis with sigmoid-bladder fistula.
Lunardi et al. [ 95 ] presented an interesting analysis of temporal trends in the use of minimally invasive surgery in Abdominal Emergency and Urgent Settings. The authors compared 89,098 emergency colectomies performed between 2013 and 2021. The increase per year for robotic colectomy was 0.9% (from 1.4% of total procedures in 2013 to 8.8% in 2021). As a result of this increase, a 0.7% decrease was registered for the open approach. Furthermore, patients who underwent RS were older, had more comorbidities and had higher BMI when compared to laparoscopic and open groups. Intraoperative outcomes were encouraging for RS: after Propensity Score Matching, a conversion rate of 25.5% (860/3,375 patients) was registered during laparoscopic surgery, while in 11.2% (379/3,375 patients) of RS cases, a conversion to open was required ( p < 0.001). After Propensity Score Marching of patients underwent Emergency surgery only, RS demonstrated advantages in terms of conversion to open (27.5% vs. 12% in laparoscopic and robotic groups respectively, p < 0.001) and post-operative LOS (7.12 vs. 6.85 days respectively, p = 0.001).
In conclusion, conventional open surgery should be recommended for unstable and frail patients who require time-critical surgery. Nevertheless, it could be underlined that stable and frail patients may benefit from an enhanced recovery after surgery associated with RS in the acute setting when compared to open surgery.
Robotic approach during emergency setting for patients affected by complicated sigmoid diverticulitis with sigmoid-bladder fistula. We performed a fistula resection and bladder suture in double-layer barbed suture
Another interesting field of application in AES may be the biliary tree and gallbladder diseases including cholecystitis, Mirizzi syndromes, biliary fistulas, iatrogenic diseases and common bile duct stones.
In 2016, Kubat et al. [ 96 ] published a retrospective series of 150 consecutive robotic single-site cholecystectomies (74 versus 76 cases treated in emergency scenarios and elective settings respectively). The mean operative time for ES cohort was significantly longer (95.0 ± 4.4 versus 71.9 ± 2.6 min; p < 0.001). Both cohorts required 1 conversion to open (1.35% for the emergency group and 1.31% for the elective group). One bile duct injury (0.7%) was reported in patients treated in emergency conditions. The authors concluded that robotic single-site cholecystectomy can be performed safely and effectively in both elective and urgent scenarios with a learning curve of about 48 cases to reach acceptable perioperative outcomes.
Mirizzi syndrome represents one of the most challenging complications of cholelithiasis [ 97 , 98 , 99 ].
In 2014, Lee et al. [ 97 ] evaluated the outcomes of five patients treated by endoscopic biliary stent placement and subsequent robotic partial cholecystectomy due to Mirizzi syndrome. No conversion to open was reported and all patients experienced an uneventful postoperative course.
In 2017 Magge et al. [ 98 ] reported a 6-patient series. All cases were treated performing a combined endoscopic and robotic approaches. In 3 cases (50%) a Roux-en-Y hepatico-jejunostomy was carried out. In these challenging scenarios, RS showed relevant benefits when compared to laparoscopy, facilitating complex dissections, and reducing conversion to open rate.
The most representative cohort of patients was described by Gangemi et al. [ 100 ] in 2017. Authors compared a large series of 676 patients receiving a robotic cholecystectomy with 284 treated by conventional laparoscopy: data analysis showed a significantly lower conversion to open in RS group, especially in patients affected by acute or gangrenous cholecystitis.
A 3-patient experience was described by Milone et al. [ 101 ] in 2019, achieving good perioperative outcomes in acute cholecystitis treatment.
Major bile duct injuries after cholecystectomy require complex surgical repairs that are usually performed with a conventional open approach [ 102 ]. This field may represent an interesting application of RS to safety perform biliary anastomosis. Cubisino et al. presented a systematic review of 13 literature experiences on minimally invasive biliary anastomosis after iatrogenic bile duct injury [ 103 ]. 198 patients were included. 135 patients (63.1%) underwent laparoscopic biliary anastomosis, while 73 (36.1%) received an analogue robotic procedure. According to Strasberg’s classification [ 104 ], all Bile Duct Injuries were types D and E (E1–E5). No conversions occurred in the RS series, while 4 patients required conversion to open surgery among the laparoscopic ones. Postoperative complications were superimposable (18.7% and 19.7% in laparoscopic and robotic approaches, respectively). Nevertheless, the overall reoperation rate was 4.4%, 5.5% in laparoscopic and 2.6% in robotic repairs.
During the follow-up period (median 24.6 months), 9 patients developed an anastomotic stricture: 5 (3.70%) in laparoscopic and 4 (5.48%) in robotic series that required a redo-anastomosis in 60% and 25% respectively.
When compared to open and laparoscopic cholecystectomy in AES, RS showed an increase of 0.7% per year in Lunardi et al. cohort of 793’800 cholecystectomies [ 95 ], ranging from 2.5 to 8.8% between 2013 and 2021. It could be underlined that conversion rate and LOS were statistically lower in RS group ( p < 0.001). Despite these findings, laparoscopic cholecystectomy yet represents the preferred approach in AES.
Only a few studies analyzed urgent hernia operations treated using robotic surgery.
In 2020, Bou-Ayash et al. [ 105 ] published a retrospective series of 19 patients (including 23 surgical procedures) affected by inguinal hernia, treated from 2013 to 2020. The authors concluded that the robotic approach represents a safe procedure in selected patients, with a short length of stay and a low complication rate compared to open and laparoscopic surgery.
In 2021, Kudsi et al. [ 106 ] described perioperative outcomes of RS in a 34-patient cohort treated between 2013 and 2019. All patients experienced robotic ventral and incisional hernia repair in an emergency setting. 20% of patients were classified as Clavien-Dindo I or II, while about 11% Clavien-Dindo III and IV. Only 3% of the population experienced a recurrence.
Muysoms et al. [ 107 ] performed an extensive analysis of robotic cost. They retrospective evaluate laparoscopic (272 procedures of which 6 were emergency cases) and robotic (404 procedures of which 8 were emergency cases) inguinal hernia repairs. As reported in other literature experiences, authors concluded that Robotic inguinal hernia repair was significantly ( p < 0.001) more expensive if compared to laparoscopic surgery (mean cost €2612 versus €1963, respectively). Nevertheless, in the robotic group, a larger number of patients were treated as outpatients with lower postoperative complications.
Regarding inguinal and ventral hernia repair, the analysis conducted by Lunardi et al. [ 95 ] showed encouraging data for RS approach: from 2013 to 2021 RS increased of 1.9% per year and 1.1% per year respectively. After propensity score matching, authors reported superimposable data in terms of CCI and BMI, comparing laparoscopic and robotic approaches. Nonetheless, RS showed benefits also in these fields: lower conversion rates were reported both in inguinal hernia repairs (18.1% vs. 3.8%, p < 0.001) and in ventral hernia repair (16.2% vs. 4.8%, p < 0.001). In addition, a statistically significant shorter postoperative LOS was registered in the RS group (the mean LOS in the inguinal hernia group was 3.34 vs. 3 days in laparoscopic and robotic approaches respectively, and the mean LOS in the ventral hernia group was 3.87 vs. 3.73 days, respectively).
A rare indication for urgent RS was post-traumatic splenic bleeding reported by Giulianotti et al. [ 108 ].
Until now, no reports of RS in adhesive intestinal obstruction have been published.
A possible and useful application of RS is represented by telementoring and telesurgery [ 32 , 109 , 110 , 111 ]. The original aim of RS and the recent COVID-19 pandemic gave an important incentive in these directions. The advantage of telementoring and telepresence of an expert surgeon in a virtual way is nowadays possible and may be improved thanks to the modern and future highspeed internet connection (5G networks) as well as the telesurgery in ultra-remote countries, in low-volume centers and in an emergent civil or battlefield surgical scenarios [ 112 , 113 , 114 ].
The development of new modular robotic platforms may contribute to increase RS applications in emergency settings. Nowadays, several different robotic platforms are approved for human use, such as CMR Versius (Cambridge Medical Robotics, Cambridge, UK), Distalmotion Dexter (Distalmotion, Epalinges, Switzerland) and Medtronic Hugo (Medtronic Inc., Minneapolis, USA). Most of them share the opportunity of switching from a conventional laparoscopic setting to a robot-assisted one.
The main bias of our study was represented by hospital organisations: RS devices are available in the same building as the General Surgery Unit at San Donato Hospital (Arezzo, Italy) facilitating emergency surgical procedures. On the other hand, Da Vinci Xi is situated in a separate building specifically dedicated to RS at the General and Robotic Surgery Unit of San Giovanni Battista Hospital (Foligno, Italy).
Furthermore, these findings represented a limit when the surgeons’ team wanted to perform a laparoscopic exploration to validate a minimally invasive robotic approach in emergency scenarios.
In our experience, it should also underline that the COVID-19 era has contributed to limiting RS adoption.
Future shreds of evidence from randomized clinical trials with long-term follow-up are required to define the potential role of RS in AES. Nevertheless, the unavailable data on the cost-effectiveness of RS in AES are linked to lower use of robotic devices if compared to laparoscopic approaches. Our experience suggested that RS costs are superimposable to laparoscopic surgery if we analyse LOS and conversion rate data. To optimize the delivery of robotic technology in AES, a well-coordinated effort among health systems, clinicians, payers, and policymakers and dedicated training program for robotic teams are imperative.
Our study demonstrates that RS may be an useful and reliable approach also to emergency surgical procedures, especially when performed in selected patients in very well trained robotic centers allowing a safe managing of surgical challenging procedures as main indications for this technology, reducing the conversion rate when compared to laparoscopy.
As for laparoscopy the patient selection for robotic approach need hemodinamically stable condition and require a sharing of the surgical strategy by all the team: surgeons, nurses and anaesthesiologists. All the staff need to be trained in laparoscopic and robotic elective surgery, including technology functioning. The hybrid use of robotic/laparoscopic technology may be taken into consideration (a laparoscopic exploration may be the first step) to decide the following approach. The robotic approach may be reserved to challenging steps of the operation (suture/microsuture/dissections).
The availability of the device is the sine qua non condition for emergent and of course urgent use. The current organization in which the platform is shared by different teams, represent for the diffusion of its use in the emergent setting.
The cost reduction of platforms and instruments, together with new robotic devices in the health market, may represent a future perspective for emergencies use of robotic technology. So, the robotic technology may be one of the tools available in every operating theatre, to use in selected cases according to patient condition and surgical team experience.
No datasets were generated or analysed during the current study.
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Department of General Surgery, “San Giovanni Battista” Hospital, USL Umbria 2, Foligno, Perugia, Italy
Graziano Ceccarelli, Fabio Rondelli & Michele De Rosa
Division of General Surgery, Bufalini Hospital, Cesena, Italy
Fausto Catena
Department of General Surgery and Hepatobiliary and Pancreatic Surgery Unit, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
Pasquale Avella & Aldo Rocca
Department of Medicine and Health Science “V. Tiberio”, University of Molise, Campobasso, Italy
Pasquale Avella, Germano Guerra & Aldo Rocca
Department of General Surgery, Singapore General Hospital, Singapore, Singapore
Brian WCA Tian
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G.C.: study conception and design, literature search, data acquisition, interpretation and analysis; drafting and critically revising the article for important intellectual content; final approval of the version to be published. P.A.: literature search, data acquisition, interpretation and analysis; drafting and critically revising the article for important intellectual content; final approval of the version to be published. F.C.: drafting and critically revising the article for important intellectual content; final approval of the version to be published. B.W.T.: data acquisition, interpretation and analysis; final approval of the version to be published. F.R.: study conception and design, literature search, data acquisition, interpretation and analysis; final approval of the version to be published. All authors: data acquisition, interpretation, and analysis; final approval of the version to be published. A.R.: supervision, drafted and critically revised the article for important intellectual content; final approval of the version to be published.
Correspondence to Pasquale Avella .
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Ceccarelli, G., Catena, F., Avella, P. et al. Emergency robotic surgery: the experience of a single center and review of the literature. World J Emerg Surg 19 , 28 (2024). https://doi.org/10.1186/s13017-024-00555-6
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A case study of a 62-year-old man in the US provides a prime example of why it's so important to keep a close eye on rapid weight loss while juggling medications.
At 132 kg (291 lbs), the man qualified as obese, a factor that may have contributed to his development of type 2 diabetes and may have been linked closely with another of his conditions, an underactive thyroid gland.
Consequently his family doctor prescribed him with daily insulin injections, as well as a daily dose of a thyroid hormone replacement drug called levothyroxine . He was also told to take a weekly dose of the diabetes and weight loss drug tirzepatide (sold under the brand name Zepbound).
Tirzepatide is one of a growing number of popular weight loss drugs that mimic the hormones GLP-1 (glucagon-like peptide-1) and GIP (gastric inhibitory polypeptide) to manage blood sugar levels and appetite.
The treatment was so effective the man's weight dropped by 39 kg (86 lbs), or almost 30 percent of his body weight, in just six months.
Unfortunately, his weight loss came with a sting in the tail. Shortly after, the man presented himself to an emergency department suffering from "palpitations, excessive sweating, confusion, fever , and hand tremors", according to the case study written up by a team from the University of Colorado.
After getting checked out, it was revealed that the palpitations were a sign of atrial fibrillation ; an irregular heartbeat condition that can trigger strokes and heart attacks. Further tests showed this had been brought on by thyrotoxicosis , which is an overabundance of a hormone produced by the thyroid.
Or, in this case, a medication designed to look just like it.
Dosages for many medications are weight based. So as the man lost weight, the relative dosage of levothyroxine crept higher. At his initial weight he was takening 1.5 μg per kilogram of his weight. By the end that had inadvertantly jumped to 2.15 μg per kilogram.
All of this could have been prevented if the man had adjusted his other medications in relation to his changing weight. The levothyroxine should have been adjusted as his weight changed to avoid the thyrotoxicosis and atrial fibrillation, according to the case study authors.
The man also missed a scheduled follow-up appointment with his doctor due to traveling, which may have played a part in this lapse in monitoring.
Losing a lot of weight quickly does come with potential risks , as well as all the health benefits, and previous studies have shown it's important to maintain good health in other areas while trying to shed the pounds.
Tirzepatide has proved very effective in tackling obesity – but when it comes to any extreme weight loss strategy, patients (and their existing medications) need to be closely monitored to prevent other health problems from arising.
"With the increasing use of tirzepatide and other GLP-1 analogues for the treatment of patients with obesity, we recommend evaluating patients using tirzepatide closely (every 4 to 6 weeks initially) for assessment of therapy response, adverse events, and possible dose adjustment of other concomitant medications," write the case study authors.
The research has been published in JAMA Internal Medicine .
IMAGES
COMMENTS
The 12-year results of this controlled, prospective study show that Roux-en-Y gastric bypass offered long-term durability of weight loss and was associated with fewer obesity-related coexisting ...
Sjoström et al. 10 published 2-and 10-year data from the Swedish Obese Subjects (SOS) study of 4,047 morbidly obese subjects who underwent bariatric surgery and matched control subjects. At the end of 2 years, the incidence of diabetes in subjects who underwent bariatric surgery was 1.0%, compared to 8.0% in the control subjects.
Bariatric surgery results in weight loss and health improvements in adults and adolescents. However, whether outcomes differ according to the age of the patient at the time of surgery is unclear. W...
Substantial short- and long-term weight loss after bariatric surgery was a notable outcome in this study. Consistent with previous meta-analyses on weight reduction after bariatric surgery, our findings showed that RYGB and SG offer superior weight reduction outcomes compared to GB or MT [30,31,32]. Long-term outcomes showed that RYGB was the ...
In this multicenter, prospective study of bariatric surgery in adolescents, we found significant improvements in weight, cardiometabolic health, and weight-related quality of life at 3 years after ...
The patient was evaluated by the bariatric multidisciplinary team at Sibley Memorial Hospital and approved for surgery. The patient underwent a minimally invasive Roux-en-Y gastric bypass using the latest camera technology. After her procedure, a new technique was used to test the gastro-jejunal anastomosis for any signs of a leak.
Participants in our study had a pre-surgical mean BMI of 52 kg/m 2. Patients with a pre-surgical BMI of ≥ 50 kg/m 2 are more likely to regain weight, while a lower pre-surgical BMI has been associated with more successful weight loss outcomes 12 to 36 months after surgery [ 48 ]. These findings and the fact that our sample had a mean BMI > 50 ...
Obesity Surgery is a premier interdisciplinary and international forum for the dissemination of research and clinical knowledge on all aspects of bariatric/metabolic surgery.. Welcomes papers from all disciplines involved in the surgical treatment and care of patients suffering from severe obesity. With our focus on promoting inclusiveness, we aim to increase awareness of obesity and ...
The results found in this meta-analysis indicated that the highest prevalence of WR was observed in cross-sectional studies and case-control studies compared to cohort studies (52% versus 48%) with high overall ... Weight regain after bariatric surgery—a Multicentre study of 9617 patients from Indian bariatric surgery outcome reporting group. ...
A Detailed Case Study of Bariatric Surgery in Kaiser Permanente Southern California. Pouya Shafipour, MS, MD, Jack K Der-Sarkissian, ... generally referred to as bariatric surgery. Most bariatric surgery studies have shown excellent weight-loss rates for up to two years after surgery, with patients losing an average of 61 % of their excess ...
The purpose of this Evidence Analysis Library systematic review is to provide an evidence-based summary of nutrition-related practices in bariatric surgery. The systematic review methodology of the Academy of Nutrition and Dietetics was applied. A total of 27 research studies were included, analyzed, and assessed for risk of bias by trained ...
Bariatric surgery is effective for the treatment of patients with morbid obesity and type 2 diabetes mellitus (T2DM), for body weight loss and glycemic control. However, in Japan, there has been no previous report of the effectiveness bariatric surgery in a case of morbid obesity associated with acute onset type 1 diabetes mellitus (T1DM), in which pancreatic β-cells were destroyed and ...
Purpose: Craniopharyngiomas are tumors located in the hypothalamic region which leads to obesity in about 50% of cases. Long-term efficacy and safety of bariatric surgery are lacking in this peculiar population. The aim of this study is to determine the 5-year weight loss and resolution of type 2 diabetes (T2D) after bariatric surgery in patients operated on craniopharyngioma who had developed ...
CASE STUDY. B. L. is a 15-year-old male adolescent who was referred to the weight clinic with a body mass index (BMI) of 50. He was referred based on his history of severe obesity and nonalcoholic fatty liver disease for a discussion of weight loss surgery. B. L. has experienced obesity since childhood. B.
By 2030, the number of overweight adults is projected to be 2.16 billion, with 1.12 billion obese individuals if recent trends continue, represent-ing more than 86% of adults (Kelly, Yang, Chen, Reynolds, & He, 2008). The high prevalence of obesity is associated with an increase in the prevalence of obesity comorbidities.
Background: Obesity is a global health crisis with profound implications on various body systems, contributing to a series of comorbidities. Metabolic Bariatric Surgery (MBS) has emerged as an effective treatment option for severe obesity, with significant weight reduction and potential systemic physiological alterations.
Other options for individual weight control include bariatric surgery and drugs. The release of semaglutide (brand name Wegovy) has rekindled interest in drug therapy for obesity (Wilding et al., 2021). A prospective study of 1,961 adults followed by Wilding and colleagues for more than a year showed that a weekly injection of semaglutide reduced
The patient continued AOM long-term, having lost 90 pounds over a 2 year time period ( Figure 1 ). Her BMI now is 28.7 kg/m 2, weight 205 lbs. (reversed from Class 3 obesity, BMI 46 kg/m 2, weight 295 lbs.) with improvement in quality of life and obesity-related comorbidities. Liver transaminases that were previously elevated in the context of ...
Observational studies have shown improvement in patients with type 2 diabetes mellitus after bariatric surgery. In this randomized, nonblinded, single-center trial, we evaluated the efficacy of int...
Case Study 2 used highly robust data from the NHS, Public Health England and ONS, which importantly included objective data on obesity diagnoses, surgery, cancer incidences and deaths.
Purpose Craniopharyngiomas are tumors located in the hypothalamic region which leads to obesity in about 50% of cases. Long-term efficacy and safety of bariatric surgery are lacking in this peculiar population. The aim of this study is to determine the 5-year weight loss and resolution of type 2 diabetes (T2D) after bariatric surgery in patients operated on craniopharyngioma who had developed ...
The 2008 AACE/ASMBS/TOS guidelines for bariatric surgery identify a lack of comprehension of risks, benefits, expected outcomes, alternatives, and lifestyle changes required with bariatric surgery as a contraindication [1] and the updated 2013 guidelines focus on the need for informed consent [2]. Such contraindications were also noted, in part, by the National Institutes of Health consensus ...
"Bariatric surgery is an effective treatment for people with severe and complex obesity, but is definitely not an easy option, ... Case Study: Maritza Cruz Rivera, 64.
To examine this possibility, investigators retrospectively compared outcomes between nearly 1000 adults with moderate-to-severe OSA who underwent bariatric surgery for a body-mass index (BMI) of 35-70 kg/m 2 and nearly 13,000 patients with OSA and obesity who did not undergo surgery. The primary endpoint was the first occurrence of MACE ...
Glucagon-like peptide 1 (GLP-1) agonists are medications approved for treatment of diabetes that recently have also been used off label for weight loss. 1 Studies have found increased risks of gastrointestinal adverse events (biliary disease, 2 pancreatitis, 3 bowel obstruction, 4 and gastroparesis 5) in patients with diabetes. 2-5 Because such patients have higher baseline risk for ...
Drugs like Ozempic and Wegovy, known as GLP-1 receptor agonists, have surged in popularity as treatment for weight loss and management. The increase involves not only adults but also adolescents, along with bariatric surgery patients.Michael Kochis, a resident in the Department of Surgery at Massachusetts General Hospital, realized that little research had been done regarding the use of these ...
An area that has seen rapid growth in the numbers of patients travelling abroad, as well as patients in the UK undergoing surgery, is bariatric or weight loss surgery.194 The UK, like many other countries globally, has seen a rapid increase in the numbers of overweight and obese patients, with the Department of Health estimating that one-quarter of the UK population is now clinically obese ...
Robotics in emergency upper-GI and bariatric surgery. One of the earliest studies on RS in AES was published in 2012 [ ]: Sudan et al. experience in complex bariatric surgery involved 2 patients affected by a stomach stricture and an acute abdomen due to perforation with biliary peritonitis after biliopancreatic diversion, respectively. The ...
A case study of a 62-year-old man in the US provides a prime example of why it's so important to keep a close eye on rapid weight loss while juggling medications.. At 132 kg (291 lbs), the man qualified as obese, a factor that may have contributed to his development of type 2 diabetes and may have been linked closely with another of his conditions, an underactive thyroid gland.
Type 2 diabetes and obesity, particularly when they occur together, carry the long-term risk of cardiovascular disease. Studies have shown that losing at least 15% of a person's body weight can ...