Bariatric surgery and relevant comorbidities: a systematic review and meta-analysis

Abstract

Background: Obesity is a growing epidemic in the United States, and with this, has come an increasing volume of metabolic surgery operations. The ideal management of obesity-associated medical conditions surrounding these operations is yet to be determined. This review sought to investigate the routine use of intraoperative cholangiogram (IOC) with cholecystectomy during or after a bypass-type operation, the ideal management of post-sleeve gastrectomy gastroesophageal reflux disease (GERD), and the optimal bariatric operation in patients with known inflammatory bowel disease (IBD).

Methods: Using medical literature databases, searches were performed for randomized controlled trials (RCTs) and non-randomized comparative studies from 1990 to 2022. Each study was screened by two independent reviewers from the SAGES Guidelines Committee for eligibility. Data were extracted while assessing the risk of bias using the Cochrane Risk of Bias 2.0 Tool and the Newcastle-Ottawa Scale for RCTs and cohort studies, respectively. A meta-analysis was performed using random effects.

Results: Routine use of IOC was associated with a significantly decreased rate of common bile duct injury and a trend towards decreased intraoperative complications, perioperative complications, and mortality. The rates of reoperation, postoperative pancreatitis, cholangitis, and choledocholithiasis were low in the routine use of the IOC group, but no non-routine use studies evaluated these outcomes. After sleeve gastrectomy, GERD-specific quality of life was significantly higher in the surgically treated group compared to the medically treated group. Bypass-type operations had worse outcomes of IBD sequelae than sleeve gastrectomy, including pain, patient perception, and fistula formation. Sleeve patients had lower mortality and fewer short- and long-term complications.

Conclusions: Low-quality data limited the conclusions that were drawn; however, trends were observed favoring the routine use of IOC during cholecystectomy for patients with bypass-type anatomy, surgical treatment of GERD post-sleeve gastrectomy, and sleeve gastrectomy in IBD patients. Future research proposals are suggested to further answer the questions posed.

Keywords: Bariatric; Cholangiogram; Comorbidities; GERD; IBD; Metabolic surgery.

Fig. 1

PRISMA diagram for KQ 1

Fig. 2

Stoplight chart of risk of bias for the included studies

Fig. 3

PRISMA diagram for KQ 2

Fig. 4

Stoplight diagram for studies included in KQ2

Fig. 5

Forest plots evaluating comparisons of complication rates in MSA versus RYGB (A) and RYGB versus medical treatment (B)

Fig. 6

Comparative studies evaluating MSA versus medical treatment (A), medical treatment versus RYGB (B), and MSA versus RYGB (C)

Fig. 7

PRISMA diagram for KQ3

Fig. 8

Stoplight diagram for KQ3 studies demonstrating the risk of bias

Fig. 9

Forest plot demonstrating the comparative studies demonstrating non-significant favoring of sleeve gastrectomy

Fig. 10

Forest plot of comparative studies for IBD worsening requiring medical treatment of pain

Fig. 11

Forest plot of comparative studies for IBD worsening that is patient reported

Fig. 12

Forest plot of comparative studies of long-term complications

Fig. 13

Forest plot of comparative studies that evaluated mortality

Fig. 14

Forest plot of comparative studies evaluating perioperative complications

Fig. 15

Forest plot of the comparative studies evaluating reoperation rates