Re-operations after Secondary Bariatric Surgery: a Systematic Review

Duodeno-ileal diversion with self-forming magnets in a sutureless neodymium anastomosis procedure (SNAP) for weight recidivism after sleeve gastrectomy: feasibility and 9-month results

BACKGROUND

The sleeve gastrectomy (SG) has become the most common bariatric procedure worldwide. However, insufficient weight loss or weight recidivism is frequent, which may require effective and safe revisional procedures.

OBJECTIVE

To determine the technical feasibility and safety of a minimally invasive, duodeno-ileal side-to-side anastomosis using a Sutureless Neodymium Anastomosis Procedure (SNAP) for patients with weight recidivism or inadequate weight loss following SG.

METHODS

This is a prospective, single-arm, open-label pilot study that enrolled patients with obesity to assist in weight reduction following an SG performed > 12 months prior. For the SNAP, self-assembling magnets were deployed into the ileum (laparoscopically) and duodenum (per-oral endoscopy). Magnets were coupled under laparoscopic and fluoroscopic guidance to create a compression anastomosis. The primary endpoints were technical feasibility, weight loss, and rate of serious adverse events (SAEs).

RESULTS

Successful duodeno-ileal diversions were created with SNAP in 27 participants (mean age: 50.6 ± 9.1, mean BMI: 38.1 ± 4.6 kg/m2) with no device-related serious adverse events. Upper endoscopy at 3 months confirmed patent, healthy anastomoses in all patients. At 9 months, patients (n = 24) experienced 11.9 ± 6.2%, 14.5 ± 10.8%, and 17.0 ± 13.9% TBWL at 3, 6, and 9 months, respectively. There were no device-related SAEs.

CONCLUSION

The SNAP is technically feasible and relatively safe, with all patients presenting widely patent anastomosis at 3 months. Patients experienced a progressive, clinically meaningful weight loss. Further studies are needed to confirm our findings.

Revisional surgery after restrictive surgery: midterm outcomes of a tertiary center

INTRODUCTION

Revisional bariatric surgery (RBS) is a challenging type of procedure for the surgeons due to its specific morbidity and efficiency. The RBS has a higher prevalence nowadays and this study may help to improve scarce data upon this specific topic.

METHODS

Data from 252 patients undergoing RBS after laparoscopic adjustable gastric banding (LAGB) or laparoscopic sleeve gastrectomy (LSG) between 2005 and 2019, were analyzed at 2 years of follow up. A subgroup analysis of third procedure was also performed.

RESULTS

Overall morbidity occurred in 35 patients (37%) in the LSG group and 40 patients (25%) in the LAGB group (p = 0.045). At 2 years of RBS, mean weight was 92.8 ± 26.7 kg, BMI was 33.1 ± 8.56 kg/m2 for patients who had RBS after LSG. When RBS was performed after LAGB, mean weight at 2 years was 90.1 ± 20.7 kg and BMI was 32.5 ± 6.45 kg/m2. TWL for RBS performed after LSG was 12.7 ± 16.4% versus 25.5 ± 10.3% after LAGB (p < 0.001).

CONCLUSION

RBS after LSG seems to lead to higher overall morbidity whereas RBS after LAGB lead to more perioperative issues.

Tubularization of the gastric pouch helps sustain weight loss after transoral outlet reduction for post-Roux-en-Y gastric bypass weight recurrence

Background and study aims Traditional transoral outlet reduction (TORe) is a minimally invasive endoscopic approach focused on reducing the aperture of the gastrojejunal (GJ) anastomosis, while the tubular transoral outlet reduction (tTORe) consists of tabularization of the distal pouch utilizing an O-shape gastroplasty suturing pattern. The primary aim of this study was to compare short-term weight loss between TORe and tTORe. Patients and methods Retrospective analysis of a prospectively maintained database was conducted at a tertiary care bariatric center of excellence. The study included patients with history of Roux-en-Y gastric bypass (RYGB) who had an endoscopic revision by TORe or tTORe and had follow-up data in their electronic medical record. The primary outcome was percent total body weight loss (%TBWL). Results A total of 128 patients were included (tTORe=85, TORe=43). At 3 and 6 months, the tTORe and TORe cohorts presented similar %TBWL (3 months: 8.5±4.9 vs. 7.3±6.0, P = 0.27 and 6 months: 8.1±7.4 vs. 6.8±5.6, P = 0.44). At 9 months, there was a trend toward greater weight loss in the tTORe cohort (9.7±8.6% vs. 5.1±6.8%, P = 0.053). At 12 months, the %TBWL was significantly higher in the tubularization group compared to the standard group (8.2±10.8 vs. 2.3±7.3%, P = 0.01). Procedure time was significantly different between both groups (60.5 vs. 53.4 minutes, P = 0.03). The adverse events rate was similar between groups (8.2% vs. 7.0% for tTORe and TORe, respectively, P = 0.61). Conclusions The tTORe enhances efficacy and durability of the standard procedure without adding significant procedure-related risks.

Bariatric Surgeon Perspective on Revisional Bariatric Surgery (RBS) for Weight Recurrence

BACKGROUND

Weight recurrence (WR) after bariatric surgery occurs in nearly 20% of patients. Revisional bariatric surgery (RBS) may benefit this population but remains controversial among surgeons.

OBJECTIVES

Explore surgeon perspectives and practices for patients with WR after primary bariatric surgery (PBS).

SETTING

Web-based survey of bariatric surgeons.

METHODS

A 21-item survey was piloted and posted on social media closed groups (Facebook) utilized by bariatric surgeons. Survey items included demographic information, questions pertaining to the definition of suboptimal and satisfactory response to bariatric surgery, and general questions related to different WR management options.

RESULTS

One hundred ten surgeons from 19 countries responded to the survey. Ninety-eight percent responded that WR was multifactorial, including behavioral and biological factors. Failure of PBS was defined as excess weight loss < 50% by 31.4%, as excess weight loss <25% by 12.8%, and as comorbidity recurrence by 17.4%. Surgeon responses differed significantly by gender (P = .036). 29.4% believed RBS was not successful, while 14.1% were unsure. Nevertheless, 73% reported that they would perform RBS if sufficient evidence of benefit existed. Most frequently performed revisional procedures included conversion of sleeve gastrectomy to Roux-en-Y gastric bypass (RYGB), adjustable gastric band to RYGB, and RYGB revision (21.9% versus 18.2% versus 15.3%, respectively).

CONCLUSIONS

This survey demonstrates significant variability in surgeon perception regarding causes and the effectiveness of RBS. Moreover, they disagree on what constitutes a nonsatisfactory response to PBS and to whom they offer RBS. These findings may relate to limited available clinical evidence on best management options for this patient population. Clinical trials investigating the comparative effectiveness of various treatment options are needed.

Long-term follow-up after transoral outlet reduction following Roux-en-Y gastric bypass: Back to stage 0?

Background and study aims  Significant weight regain affects up to one-third of patients after Roux-en-Y gastric bypass (RYGB) and demands treatment. Transoral outlet reduction (TORe) with argon plasma coagulation (APC) alone or APC plus full-thickness suturing TORe (APC-FTS) is effective in the short term. However, no study has investigated the course of gastrojejunostomy (GJ) or quality of life (QOL) data after the first post-procedure year. Patients and methods  Patients eligible for a 36-month follow-up visit after TORe underwent upper gastrointestinal endoscopy with measurement of the GJ and answered QOL questionnaires (RAND-36). The primary aim was to evaluate the long-term outcomes of TORe, including weight loss, QOL, and GJ anastomosis (GJA) size. Comparisons between APC and APC-FTS TORe were a secondary aim. Results  Among 39 eligible patients, 29 returned for the 3-year follow-up visit. There were no significant differences in demographics between APC and APC-FTS TORe groups. At 3 years, patients from both groups regained all the weight lost at 12 months, and the GJ diameter was similar to the pre-procedure assessment. As to QOL, most improvements seen at 12 months were lost at 3 years, returning to pre-procedure levels. Only the energy/fatigue domain improvement was kept between the 1- and 3-year visits. Conclusions  Obesity is a chronic relapsing disease. Most effects of TORe are lost at 3 years, and redilation of the GJA occurs. Therefore, TORe should be considered iterative rather than a one-off procedure.

The role of adjuvant pharmacotherapy with liraglutide for patients with inadequate weight loss following bariatric surgery

PURPOSE

Despite the benefits of bariatric surgery for many patients, there are a proportion of patients who do not achieve adequate weight loss. We evaluate the role of liraglutide as adjuvant pharmacotherapy in those who respond poorly to weight loss surgery.

MATERIALS AND METHODS

A non-controlled, prospective, open-label cohort study in which participants are prescribed liraglutide following inadequate response to weight loss surgery. The efficacy and tolerability of liraglutide was measured through measurement of BMI and monitoring of side effect profile.

RESULTS

A total of 68 partial responders to bariatric surgery were included in the study, 2 participants were lost to follow-up. Overall 89.7% lost weight on liraglutide, with 22.1% showing a good response (>10% total body weight loss). There were 41 patients who discontinued liraglutide mainly due to cost.

CONCLUSION

Liraglutide is efficacious in achieving weight loss and reasonably well tolerated in patients who have inadequate weight loss post-bariatric surgery.

[Non-surgical treatment of staple-line suture leakage after redo sleeve gastrectomy]

Redo bariatric procedures are common. However, redo sleeve gastrectomy is not a frequent case of repeated bariatric surgery and can be performed rather as a necessary measure in difficult intraoperative conditions. We report a patient who underwent laparoscopic adjustable gastric band placement, its blockage and surgical removal, sleeve gastrectomy and redo sleeve gastrectomy. After that, staple-line suture failure developed that required endoscopic clipping.

Endoscopic Management of Weight Recurrence Following Bariatric Surgery

Metabolic and bariatric surgery is the most effective therapy for weight loss and improving obesity-related comorbidities, comprising the Roux-en-Y gastric bypass (RYGB), gastric banding, sleeve gastrectomy (SG), and biliopancreatic diversion with duodenal switch. While the effectiveness of weight loss surgery is well-rooted in existing literature, weight recurrence (WR) following bariatric surgery is a concern. Endoscopic bariatric therapy presents an anatomy-preserving and minimally invasive option for managing WR in select cases. In this review article, we will highlight the endoscopic management techniques for WR for the most commonly performed bariatric surgeries in the United States -RYGB and SG. For each endoscopic technique, we will review weight loss outcomes in the short and mid-terms and discuss safety and known adverse events. While there are multiple endoscopic options to help address anatomical issues, patients should be managed in a multidisciplinary approach to address anatomical, nutritional, psychological, and social factors contributing to WR.

Single Anastomosis Duodenoileal Bypass or Roux-en-Y Gastric Bypass After Failed Sleeve Gastrectomy: Medium-Term Outcomes

Background

Although the sleeve gastrectomy (SG) has good short-term results, it comes with a significant number of patients requiring revisional surgery because of insufficient weight loss or functional complications.

Objective

To investigate the effectiveness of the single anastomosis duodenoileal bypass (SADI-S) versus the Roux-en-Y gastric bypass (RYGB) on health outcomes in (morbidly) obese patients who had previously undergone SG, with up to 5 years of follow-up.

Methods

Data from patients who underwent revisional SADI-S or RYGB after SG were retrospectively compared on indication of surgery, weight loss, quality of life, micronutrient deficiencies, and complications.

Results

From 2007 to 2017, 141 patients received revisional laparoscopic surgery after SG in three specialized Dutch bariatric hospitals (SADI-S n=63, RYGB n=78). Percentage total weight loss following revisional surgery at 1, 2, 3, 4, and 5 years was 22%, 24%, 22%, 18%, and 15% for SADI-S and 10%, 9%, 7%, 8%, and 2% for RYGB (P<.05 for 1–4 years). Patients who underwent RYGB surgery for functional complications experienced no persistent symptoms of GERD or dysphagia in 88% of cases. No statistical difference was found in longitudinal analysis of change in quality of life scores or cross-sectional analysis of complication rates and micronutrient deficiencies.

Conclusion

Conversion of SG to SADI-S leads to significantly more total weight loss compared to RYGB surgery with no difference in quality of life scores, complication rates, or micronutrient deficiencies. When GERD in sleeve patients has to be resolved, RYGB provides adequate outcomes.

Graphical abstract

Is One Anastomosis Gastric Bypass with a Biliopancreatic Limb of 150 cm Effective in the Treatment of People with Severe Obesity with BMI > 50?

Purpose

The treatment of people with severe obesity and BMI > 50 kg/m² is challenging. The present study aims to evaluate the short and mid-term outcomes of one anastomosis gastric bypass (OAGB) with a biliopancreatic limb of 150 cm as a primary bariatric procedure to treat those people in a referral center for bariatric surgery.

Material and Methods

Data of patients who underwent OAGB for severe obesity with BMI > 50 kg/m² between 2010 and 2017 were collected prospectively and analyzed retrospectively. Follow-up comprised clinical and biochemical assessment at 1, 3, 6, 12, 18, and 24 months postoperatively, and once a year thereafter.

Results

Overall, 245 patients underwent OAGB. Postoperative mortality was null, and early morbidity was observed in 14 (5.7%) patients. At 24 months, the percentage total weight loss (%TWL) was 43.2 ± 9, and percentage excess weight loss (%EWL) was 80 ± 15.7 (184 patients). At 60 months, %TWL was 41.9 ± 10.2, and %EWL was 78.1 ± 18.3 (79 patients). Conversion to Roux-en-Y gastric bypass was needed in three (1.2%) patients for reflux resistant to medical treatment. Six patients (2.4%) had reoperation for an internal hernia during follow-up. Anastomotic ulcers occurred in three (1.2%) patients. Only two patients (0.8%) underwent a second bariatric surgery for insufficient weight loss.

Conclusion

OAGB with a biliopancreatic limb of 150 cm is feasible and associated with sustained weight loss in the treatment of severe obesity with BMI > 50 kg/m². Further randomized studies are needed to compare OAGB with other bariatric procedures in this setting.

Graphical abstract

Revision of Mason's procedure (vertical banded gastroplasty) to Roux-en-Y gastric bypass: role of an associated fundectomy in weight loss outcomes

BACKGROUND

Vertical banded gastroplasty (VBG) presents a significant rate of long-term complications, and revisions are often necessary. Conversion to Roux-en-Y gastric bypass (RYGB) seems to be preferred, but literature data remain limited.

OBJECTIVES

To analyze the indications, safety, results of conversions from VBG to RYGB, and to identify predictive factors of success or failure.

SETTING

Two specialized centers of bariatric surgery.

METHODS

This bicentric retrospective study included all the patients who benefited from a conversion from VBG to RYGB between 2008 and January 2020. Demographic characteristics, indications, preoperative workups, intraoperative data, complications, and weight loss results were analyzed.

RESULTS

During the study period, 85 patients underwent a conversion to RYGB. The mean body mass index (BMI_ before conversion was 40.6 kg/m². 82.3% of the patients were converted because of weight loss failure and 17.6% because of a complication of their VBG. The global rate of complications was 25%. After an average follow-up of 35 months and a rate of loss to follow-up of 33%, the mean BMI was 33.5 kg/m. The weight loss success rate according to Reinhold's criteria was 64.7%, and resolution of complications was obtained in 89.1%. The association of a fundectomy was a predictive factor of weight loss (odds ratio, .27; P = .04), whereas primary failure of the VBG was a predictive factor of failure.

CONCLUSION

Conversion from VBG to RYGB remains the procedure of choice to achieve satisfying weight loss and resolution of functional complications. The addition of a fundectomy appeared to have a significant positive impact on weight loss outcomes.

Argon plasma coagulation alone versus argon plasma coagulation plus full-thickness endoscopic suturing to treat weight regain after Roux-en-Y gastric bypass: a prospective randomized trial (with videos)

BACKGROUND AND AIMS

A significant number of patients regain weight after Roux-en-Y gastric bypass. Ablation with argon plasma coagulation (APC) plus endoscopic full-thickness suturing (FTS-APC) and ablation alone have been reported for treating weight regain when associated with gastrojejunostomy (GJ) dilation. However, comparative controlled data are still lacking.

METHODS

This was a pilot single-center open-label randomized trial comparing the effectiveness and safety of APC alone versus FTS-APC for transoral outlet reduction. Patients with at least 20% weight regain from the nadir, and GJ ≥15 mm were considered eligible. The primary outcome was percentage total weight loss (%TWL) at 12 months. Secondary outcomes were the incidence of adverse events, amelioration of metabolic laboratory parameters, and improvement in quality of life and eating behavior.

RESULTS

Forty patients meeting the eligibility criteria were enrolled from October 2017 to July 2018. Technical and clinical success rates were similar between the groups. At 12 months, the mean %TWL was 8.3% ± 5.5% in the APC alone group versus 7.5% ± 7.7% in the FTS-APC group (P = .71). The pre-revisional % solid gastric retention at 1 hour positively correlated with the probability of achieving ≥10% TWL at 12 months. Both groups experienced significant reductions in low-density lipoprotein and triglyceride levels at 12 months, and improvement in eating behavior and quality of life at 3 months. There were 2 cases of stenoses (1 from each group), which were successfully treated with endoscopic balloon dilation.

CONCLUSION

APC alone is similar to FTS-APC in terms of technical and clinical outcomes within 1 year of follow-up. (Clinical trial registration number: NCT03094936.).

Reoperations After Bariatric Surgery in 26 Years of Follow-up of the Swedish Obese Subjects Study

Importance

Bariatric surgery is an established treatment for obesity, but knowledge on the long-term incidence of revisional surgery is scarce.

Objective

To determine the incidence and type of revisional surgery after bariatric surgery in 26 years of follow-up of participants in the Swedish Obese Subjects (SOS) study.

Design, Setting, and Participants

The SOS study is a prospective nonrandomized controlled study comparing bariatric surgery (banding, vertical banded gastroplasty [VBG], and gastric bypass [GBP]) with usual care. The bariatric surgeries in the SOS study were conducted at 25 public surgical departments in Sweden. Men with body mass index values of 34 or higher and women with body mass indexes of 38 or higher were recruited to the surgery group of the SOS study between September 1, 1987, and January 31, 2001, and follow-up continued until December 31, 2014. Data analysis occurred from November 2016 to April 2018.

Interventions

Banding, VBG, or GBP.

Main Outcomes and Measures

Revisional surgeries, analyzed using data from questionnaires, hospital records, and the Swedish National Patient register through December 31, 2014.

Results

A total of 2010 participants underwent surgery. The age range was 37 to 60 years. A total of 376 participants underwent banding (18.7%), while 1365 had VBG (67.9%) and 266 had GBP (13.2%). During a median follow-up of 19 years, 559 participants (27.8%) underwent first-time revisional surgery, including 354 conversions to other bariatric procedures (17.6%), 114 corrective surgeries (5.6%), and 91 reversals to normal anatomy (4.5%). Revisional surgeries (conversions, corrective surgery, and reversals) were common after banding (153 of 376 [40.7%]) and VBG (386 of 1365 [28.3%]) but relatively rare after GBP (20 of 266 [7.5%]). Patients who had banding and VBG primarily underwent conversions to GBP or reversals. Incidence of reversals was 5 times higher after banding than after VBG (40.7% vs 7.5%; unadjusted hazard ratio, 5.19 [95% CI, 3.43-7.87]; P < .001). Corrective surgeries were equally common irrespective of the index surgery (72 of 1365 patients who had VBG [5.3%]; 23 of 376 patients who had banding [6.1%]; 19 of 266 patients who had GBP [7.1%]). Revisional surgery indications, including inadequate weight loss, band-associated complications (migration, stenosis, and slippage), staple-line disruptions, and postsurgical morbidity, varied depending on index surgery subgroup. Most corrections occurred within the first 10 years, whereas conversions and reversals occurred over the entire follow-up period.

Conclusions and Relevance

Corrective surgeries occur mainly within the first 10 years and with similar incidences across all 3 surgical subgroups, but indications varied. Conversions (mainly to GBP) and reversals occurred after many years and were most frequent after banding and VBG, reflecting a higher overall revisional surgery demand after these operations.

Bariatric surgery is a cost-saving treatment for obesity-A comprehensive meta-analysis and updated systematic review of health economic evaluations of bariatric surgery

Demand for bariatric surgery to treat severe and resistant obesity far outstrips supply. We aimed to comprehensively synthesise health economic evidence regarding bariatric surgery from 1995 to 2018 (PROSPERO registration number: CRD42018094189). Meta-analyses were conducted to calculate the annual cost changes "before" and "after" surgery, and cumulative cost differences between surgical and nonsurgical groups. An updated narrative review also summarized the full and partial health economic evaluations of surgery from September 2015. N = 101 studies were eligible for the qualitative analyses since 1995, with n = 24 studies after September 2015. Quality of reporting has increased, and the inclusion of complications/reoperations was predominantly contained in the full economic evaluations after September 2015. Technical improvements in surgery were also reflected across the studies. Sixty-one studies were eligible for the quantitative meta-analyses. Compared with no/conventional treatment, surgery was cost saving over a lifetime scenario. Additionally, consideration of indirect costs through sensitivity analyses increased cost savings. Medication cost savings were dominant in the before versus after meta-analysis. Overall, bariatric surgery is cost saving over the life course even without considering indirect costs. Health economists are hearing the call to present higher quality studies and include the costs of complications/reoperations; however, indirect costs and body contouring surgery are still not appropriately considered.

Long-Term Inpatient Hospital Utilisation and Costs (2007-2008 to 2015-2016) for Publicly Waitlisted Bariatric Surgery Patients in an Australian Public Hospital System Based on Australia's Activity-Based Funding Model

BACKGROUND

Within the Australian public hospital setting, no studies have previously reported total hospital utilisation and costs (pre/postoperatively) and costed patient-level pathways for primary bariatric surgery and surgical sequelae (including secondary surgery) informed by Australia's Independent Hospital Pricing Authority's activity-based funding (ABF) model.

OBJECTIVE

We aimed to provide our Tasmanian state government partner with information regarding key evidence gaps about the resource use and costs of bariatric surgery (including pre- and postoperatively, types of surgery and comorbidities), the costs of surgical sequelae and policy direction regarding the types of bariatric surgery offered within the Tasmanian public hospital system.

METHODS

Hospital inpatient length of stay (days), episodes of care (number) and aggregated cost data were extracted for people who were waiting for and subsequently received bariatric surgery (for the fiscal years 2007-2008 to 2015-2016) from administrative sources routinely collected, clinically coded/costed according to ABF. Aggregated ABF costs were expressed in 2016-2017 Australian dollars ($A). Sensitivity (cost outliers) and subgroup analyses were conducted.

RESULTS

A total of 105 patients entered the study. Total costs (pre/postoperative over 8 years) for all inpatient episodes of care (n = 779 episodes of care) were $A6,018,349. When the ten cost outliers were omitted from the total cost, this cost reduced to $A4,749,265. Mean costs for primary laparoscopic adjustable gastric band (LAGB) and sleeve gastrectomy (SG) bariatric surgery were $A14,622 and $A15,014, respectively. The average cost/episode of care for people with diabetes decreased in the first year postoperatively, from $A7258 to $A5830/episode of care. In total, 27 LAGB patients (30%) required surgery due to surgical sequelae (including revisional/secondary surgery; n = 58 episodes of care) and 56% of these episodes of care were secondary LAGB device related (mostly port/reservoir related), with a mean cost of $A6267.

CONCLUSIONS

Taking into account our small SG sample size and the short time horizon for investigating surgical sequalae for SG, costs may be mitigated in the Tasmanian public hospital system by substituting LAGB with SG when clinically appropriate due to costs associated with the LAGB device for some patients. At 3 years postoperatively versus preoperatively, episodes of care and costs reduced substantially, particularly for people with diabetes/cardiovascular disease. We recommend that a larger confirmatory study of bariatric surgery including LAGB and SG be undertaken of disaggregated ABF costs in the Tasmanian public hospital system.

Outcomes in conventional laparoscopic versus robotic-assisted revisional bariatric surgery: a retrospective, case-controlled study of the MBSAQIP database

Introduction

Revisional bariatric surgery is being increasingly performed and is associated with higher operative risks. Optimal techniques to minimize complications remain controversial. Here, we report a retrospective review of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant User Files (PUF) database, comparing outcomes between revision RBS and LBS.

Methods

The 2015 and 2016 MBSAQIP PUF database was retrospectively reviewed. Revision cases were identified using the Revision/Conversion Flag. Selected cases were further stratified by surgical approach. Subgroup analysis of sleeve gastrectomy and gastric bypass cases was performed. Case–controlled matching (1:1) was performed of the RBS and LBS cohorts, including gastric bypass and sleeve gastrectomy cohorts separately. Cases and controls were match by demographics, ASA classification, and preoperative comorbidities.

Results

26,404 revision cases were identified (93.3% LBS, 6.7% RBS). 85.6% were female and 67% white. Mean age and BMI were 48 years and 40.9 kg/m². 1144 matched RBS and LBS cases were identified. RBS was associated with longer operative duration (p < 0.0001), LOS (p = 0.0002) and a higher rate of ICU admissions (1.3% vs 0.5%, p = 0.05). Aggregate bleeding and leak rates were higher in the RBS cohort. In both gastric bypass and sleeve gastrectomy cohorts, the robotic-assisted surgery remain associated with longer operative duration (p < 0.0001). In gastric bypass, rates of aggregate leak and bleeding were higher with robotic surgery, while transfusion was higher with laparoscopy. For sleeve gastrectomy cases, reoperation, readmission, intervention, sepsis, organ space SSI, and transfusion were higher with robotic surgery.

Conclusion

In this matched cohort analysis of revision bariatric surgery, both approaches were overall safe. RBS was associated with longer operative duration and higher rates of some complications. Complications were higher in the robotic sleeve cohort. Robotic is likely less cost-effective with no clear patient safety benefit, particularly for sleeve gastrectomy cases.

Revisional Gastric Bypass for Failed Restrictive Procedures: Comparison of Single-Anastomosis (Mini-) and Roux-en-Y Gastric Bypass

BACKGROUND

Ten to 50% of patients who received restrictive bariatric operations may require reoperation for unsatisfactory weight loss or weight regain. Failed restrictive procedures are usually managed with conversion to another bariatric procedure with a favor of conversion to laparoscopic gastric bypass. Our aim is to evaluate two different bypass techniques, laparoscopic RY gastric bypass (RYGB) versus single-anastomosis (mini-) gastric bypass (SAGB) as a revision option (R-RYGB and R-SAGB) for failed restrictive bariatric operations.

MATERIAL AND METHODS

From May 2001 to December 2015, a total of 116 patients with failed restrictive bariatric operations underwent laparoscopic revisional bypass surgery (81 R-SAGB and 35 R-RYGB). Among them, 81 were failed after vertical banded gastroplasty (VBG) and 35 were after adjustable gastric band (AGB). The demographic data, surgical parameters, and outcomes were studied.

RESULTS

The average age at revision surgery was 35.7 years (range 22-56), and the average body mass index (BMI) before reoperation was 37.2 kg/m² (29.0-51.8). Revision surgery was performed after 58.8 months from the primary surgery on average (14-180 months). The main reasons for the revisions were weight regain (50.9%), inadequate weight loss (31%), and intolerance (18.1%). All of the procedures were completed laparoscopically as one-stage procedure. R-RYGB had significantly longer operative times than R-SAGB. Major complication occurred in 12 (10%) patients without significant difference between R-SAGB group and R-RYGB group. At 1 year follow-up, weight loss was better in R-SAGB than R-RYGB (76.8 vs. 32.9% EWL; p = 0.001). At 5 year follow-up, a significantly lower hemoglobin level was found in R-SAGB group (p = 0.03).

CONCLUSION

Both SAGB and RYGB are acceptable options for revising a restrictive type of bariatric procedures with equal safety profile. R-SAGB was shown to be a simpler procedure with better weight reduction than R-RYGB but anemia is a considerable complication at long-term follow-up.

Psychological and Behavioral Aspects of Primary and Reoperative Surgery: a 6-Month Longitudinal Study

BACKGROUND

Problematic eating behaviors and general psychopathology have been associated with poor weight loss after bariatric surgery. However, little is known about how these aspects impact weight loss outcomes for the increasing number of patients undergoing reoperative surgeries. This study compares disordered eating and weight-related outcomes before and 6 months after surgery in patients undergoing primary (P-Group) and reoperative bariatric surgery (R-Group).

METHODS

This longitudinal study assessed 122 P-Group and 116 R-Group patients before and 6 months after surgery. The assessment included the eating disorder examination diagnostic items, and a set of self-report measures assessing eating disorder symptomatology, grazing, depression, anxiety, and negative urgency.

RESULTS

Preoperatively, no differences were found between the R- and P-Groups in terms of disordered eating-related variables (except for shape concern, which was higher for the R-Group). At 6 months after surgery, the R-Group revealed significantly higher values for restraint (F(1,219) = 5.84, p = 0.016), shape (F(1,219) = 5.59, p = 0.019), weight concerns (F(1,219) = 13.36, p = 0.000), depression (F(1,219) = 7.17, p = 0.008), anxiety (F(1,219) = 6.94, p = - 0.009), and compulsive grazing (F(1,219) = 6.13, p = 0.014). No significant pre- or post-surgery predictors of weight loss were found for the P-Group (χ2 = 0.70, p = 0.872). In the R-Group, post-surgery anxiety (Waldχ²(1) = 6.19, p = 0.01) and the post-surgery number of days with grazing in the previous month (Waldχ²(1) = 3.90, p = 0.04) were significant predictors of weight loss.

CONCLUSION

At 6 months after surgery, the R-Group presented more problematic eating and general psychological distress, which may put these patients at greater risk of poorer long-term weight outcomes.

A qualitative investigation of the health economic impacts of bariatric surgery for obesity and implications for improved practice in health economics

Obesity is an economic problem. Bariatric surgery is cost-effective for severe and resistant obesity. Most economic evaluations of bariatric surgery use administrative data and narrowly defined direct medical costs in their quantitative analyses. Demand far outstrips supply for bariatric surgery. Further allocation of health care resources to bariatric surgery (particularly public) could be stimulated by new health economic evidence that supports the provision of bariatric surgery. We postulated that qualitative research methods would elicit important health economic dimensions of bariatric surgery that would typically be omitted from the current economic evaluation framework, nor be reported and therefore not considered by policymakers with sufficient priority. We listened to patients: Focus group data were analysed thematically with software assistance. Key themes were identified inductively through a dialogue between the qualitative data and pre-existing economic theory (perspective, externalities, and emotional capital). We identified the concept of emotional capital where participants described life-changing desires to be productive and participate in their communities postoperatively. After self-funding bariatric surgery, some participants experienced financial distress. We recommend a mixed-methods approach to the economic evaluation of bariatric surgery. This could be operationalised in health economic model conceptualisation and construction, through to the separate reporting of qualitative results to supplement quantitative results.

Endoscopic Treatment of Weight Regain Following Roux-en-Y Gastric Bypass: a Systematic Review and Meta-analysis

Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric procedure. Despite its high efficacy, some patients regain part of their lost weight. Several endoscopic therapies have been introduced as alternatives to treat weight regain, but most of the articles are relatively small with unclear long-term data. To systematically assess the efficacy of endoscopic therapies for weight regain after RYGB. We searched MEDLINE, EMBASE, Scopus, Web of Science, Cochrane, OVID, CINAHL/EBSCo, LILACS/Bireme, and gray literature. Primary outcomes were absolute weight loss (AWL), excess weight loss (EWL), and total body weight loss (TBWL). Thirty-two studies were included in qualitative analysis. Twenty-six described full-thickness (FT) endoscopic suturing and pooled AWL, EWL, and TBWL at 3 months were 8.5 ± 2.9 kg, 21.6 ± 9.3%, and 7.3 ± 2.6%, respectively. At 6 months, they were 8.6 ± 3.5 kg, 23.7 ± 12.3%, and 8.0 ± 3.9%, respectively. At 12 months, they were 7.63 ± 4.3 kg, 16.9 ± 11.1%, and 6.6 ± 5.0%, respectively. Subgroup analysis showed that all outcomes were significantly higher in the group with FT suturing combined with argon plasma coagulation (APC) (p < 0.0001). Meta-analysis included 15 FT studies and showed greater results. Three studies described superficial-thickness suturing with pooled AWL of 3.0 ± 3.8, 4.4 ± 0.07, and 3.7 ± 7.4 kg at 3, 6, and 12 months, respectively. Two articles described APC alone with mean AWL of 15.4 ± 2.0 and 15.4 ± 9.1 kg at 3 and 6 months, respectively. Full-thickness suturing is effective at treating weight regain after RYGB. Performing APC prior to suturing seems to result in greater weight loss. Head-to-head studies are needed to confirm our results. Few studies adequately assess effectiveness of other endoscopic techniques.