Laparoscopic hand-sewn revisional gastrojejunal plication for weight loss failure after Roux-en-Y gastric bypass

Prospective evaluation of transoral outlet reduction (TORe) after Roux-en-Y gastric bypass (RYGB) failure

BACKGROUND AND AIMS

Weight regain after RYGB is multifactorial including dilatation of the gastro-jejunal anastomosis. Transoral outlet reduction (TORe) procedure is a minimally invasive alternative to surgical anastomotic revision.

METHODS

We conducted a prospective, multicenter, simple blind, randomized study in patients with weight regain following RYGB, comparing the efficacy of conventional nutritional and behavioral management associated with a TORe procedure (TORe group) with conventional management alone and a Sham procedure (Sham group). The main objective of this study was to evaluate the percentage of excess weight loss (%EWL) at 12 months after endoscopy.

RESULTS

From January 2015 to January 2019, 73 subjects were randomized in four French Bariatric centers. The final analysis involved 50 subjects, 25 in each group, 44 women, 6 men, with an average BMI of 40.6 kg/m2. At 12 months, the average %EWL was significantly higher in the TORe group than in the Sham group (13.5 ± 14.1 vs. - 0.77 ± 17.1; p = 0.002). Cohen's d was 0.91, indicating a large effect size of the procedure on the %EWL. There was no significant difference between groups concerning the improvement of obesity-related comorbidities (diabetes and dyslipidemia) and quality of life at 12 months. We report frequent adverse events in the TORe group (20% had adverse events related to the procedure). Three adverse events were serious, including two perforations of the gastro-jejunal anastomosis after TORe group that led to the premature termination of the study.

CONCLUSIONS

After RYGBP failure linked to the dilatation of the gastro-jejunal anastomosis, TORe procedure with nutritional management results in significantly higher %EWL at 12 months compared to patients with nutritional management alone. As surgery, this minimally invasive endoscopic procedure can be associated with severe adverse events.

Endoscopic versus surgical gastrojejunal revision for weight regain in Roux-en-Y gastric bypass patients: 5-year safety and efficacy comparison

BACKGROUND AND AIMS

An enlarged gastrojejunal anastomosis (GJA) is associated with weight regain after Roux-en-Y gastric bypass (RYGB) and can be corrected with endoscopic or surgical revision; however, there has been no direct comparison between techniques. This study aims to compare serious adverse event (AE) rates and weight loss profiles between endoscopic and surgical revisional techniques over a 5-year period.

METHODS

This is a retrospective matched cohort study of RYGB patients who underwent endoscopic or surgical revision for weight regain with an enlarged GJA (>12 mm). Patients who underwent endoscopic revision (ENDO group) were matched 1:1 to those undergoing surgical revision (SURG group) based on completion of 5-year follow-up, age, sex, body mass index, initial weight loss, and weight regain. Demographics, GJA size, serious AEs, and weight profiles were collected. The primary outcome was comparison of serious AE rates between groups. Secondary outcomes included weight loss comparisons. A Fisher exact test was used to compare the serious AE rate, and a Student t test was used for weight comparisons.

RESULTS

Sixty-two RYGB patients with weight regain and an enlarged GJA (31 ENDO, 31 matched SURG) were included. Baseline characteristics were similar between groups. The AE rate in the ENDO group (6.5%) was lower than the SURG group (29.0%, P = .043). Zero and 6 (19.4%) serious (severe) AEs occurred in the ENDO and SURG groups, respectively (P = .02). There was no significant difference in weight loss at 1, 3, and 5 years.

CONCLUSIONS

Endoscopic revision of the GJA is associated with significantly fewer total and serious AEs and similar long-term weight loss when compared with surgical revision.

Surgical therapy of weight regain after Roux-en-Y gastric bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is a well-established surgical method for morbid obesity; however, weight regain (WR) after initially good results may be considered an issue, the treatment of which has found no consensus yet.

OBJECTIVES

The aim of this study was to compare the different surgical methods treating WR after RYGB that are used at the Vienna Medical University in a larger number of patients, concerning further weight loss, complications, and reoperations.

SETTING

University hospital, Austria.

METHODS

This study includes all patients with RYGB who were reoperated due to WR at the Vienna Medical University by December 2016 (n = 84). The follow-up rate was 93%. The following 4 approaches to treating WR after RYGB were taken: (1) pouch resizing, (2) pouch banding, (3) pouch resizing plus pouch banding, and (4) common limb shortening (i.e., distalization).

RESULTS

The mean maximum excess weight loss referring to the WR procedure in the 4 groups was as follows: group 1: 69.0% ± 35.2%, group 2: 62.8% ± 39.5%, group 3: 83.1% ± 30.9%, and group 4: 81.5% ± 41.6%. Reoperations occurred in the following different groups: group 1 had 2 balloon dilations (20%), groups 2 (n = 13) and 3 (n = 29) had 5 (38% and 17%) band removals each, and group 4 had 9 reversal procedures due to malnutrition (30%).

CONCLUSIONS

There are nonsignificant differences in terms of additional weight loss between the different methods. However, differences lay in the areas of adverse symptoms and further reoperations. While there was no risk of malnutrition with pouch resizing, there was with distalization. Pouch banding (with or without resizing) poses a higher risk of dysphagia.

Weight regain after gastric bypass: etiology and treatment options

Roux-en-Y gastric bypass (RYGB) is one of the most common operations performed for the patients with morbid obesity. Weight regain (WR) is a complication that may decrease efficiency of the surgical treatment and demand further interventions. Different factors including lifestyle, mental health, hormonal/metabolic and surgical plays role in WR after RYGB. Various treatment options have been proposed for WR. Conservative treatment is less effective than surgery. Endoscopic refashioning of gastric pouch/stoma fails to achieve sustainable weight loss. Surgical reduction of pouch has acceptable short-term results, but WR after 3 years is substantial. Banded gastric bypass achieves good short-term results, but long-term follow-up data are needed. Distalization of RYGB has a high risk of protein calorie malnutrition (PCM) and conversion to BP diversion (BPD)/duodenal switch (DS) is a technically demanding procedure. Both procedures achieve sustainable long-term weight loss. More studies are needed to explore long-term results of various surgical interventions for WR after RYGB.