Laparoscopic Conversion of One Anastomosis Gastric Bypass to a Standard Roux-en-Y Gastric Bypass

Bile reflux and marginal ulcers after one-anastomosis gastric bypass (OAGB). A narrative review

One-anastomosis gastric bypass has now become the third most commonly performed bariatric technique worldwide. However, as a consequence of the configuration of this surgery, it can present some chronic complications (anastomotic mouth ulcers and biliary reflux) that physicians must come to better understand and assess. In this narrative review, we aimed to update our knowledge of both the diagnosis and treatment of these two complications in the context of bariatric surgeries. We concluded that a series of pre-, intra-, and postoperative preventive strategies should be considered by surgeons to help reduce the appearance of these complications.

Surgical Management of Gastro-oesophageal Reflux Disease After One Anastomosis Gastric Bypass - a Systematic Review

Gastro-oesophageal reflux disease (GORD) after one anastomosis gastric bypass (OAGB) remains a concern. We reviewed the current literature on revisional surgery after OAGB for GORD. MEDLINE, EMBASE, and PubMed databases were searched. We identified 21 studies, appraising 13,658 OAGB patients. A total of 230 (1.6%) patients underwent revisional surgery for GORD. Revision to Roux-en-Y configuration was performed in 211 (91.7%) patients. Six (2.6%) patients had a Braun entero-enterostomy added to the OAGB. Thirteen (5.6%) patients underwent excluded stomach fundoplication (ESF). Reflux symptoms resolved in 112 (48.6%) patients, persisted in 13 (5.6%) patients, and were not reported in 105 (45.6%) patients. Revisional surgery after OAGB for GORD appears to be rare, and when required, conversion to Roux-en-Y configuration is the commonest choice.

Bile or Acid Reflux Post One-Anastomosis Gastric Bypass: What Must We Do? Still an Unsolved Enigma

Obesity is a global scourge, affecting over 15% of the world's population [...].

One-Anastomosis Gastric Bypass Revision for Gastroesophageal Reflux Disease: Long Versus Short Biliopancreatic Limb Roux-en-Y Gastric Bypass

PURPOSE

One-anastomosis gastric bypass (OAGB) may be associated with refractory gastroesophageal reflux disease (GERD). The nature of this GERD remains unclear. This complication can be treated either with an additional enteroenterostomy without shortening of gastric pouch (long biliopancreatic limb Roux-en-Y gastric bypass (L-BPL-RYGB)) or revision to conventional short biliopancreatic limb Roux-en-Y gastric bypass (S-BPL-RYGB). The objective of this study is to compare the aforementioned procedures in terms of efficacy on GERD symptoms.

MATERIALS AND METHODS

Retrospective analysis between October 2012 and June 2020.

RESULTS

Fifty-two patients underwent OAGB revision to S-BPL-RYGB (n = 21) or L-BPL-RYGB (n = 31) secondary to GERD. Investigation with pH impedance prior to revision was performed in 15 patients showing biliary reflux (BR) in 7 (46.6%), acid reflux (AR) in 6 (40%), and no confirmation in 2. Patients with AR had a revision to S-BPL-RYGB, whereas patients with BR underwent L-BPL-RYGB. Among the patients without pH metry results (n = 37), S-BPL-RYGB was performed for associated disabling digestive disorders or nutritional deficiencies. GERD was treated in 68% of patients with L-BPL-RYGB versus 95% of patients after S-BPL-RYGB. Patients, whose decision for revisional procedure was based on the results of pH impedance testing, did not reveal refractory GERD.

CONCLUSION

L-BPL-RYGB seems appropriate in patients with BR, whereas conversion to S-BPL-RYGB should be preferred if AR is present.

Applying an Anti-reflux Suture in the One Anastomosis Gastric Bypass to Prevent Biliary Reflux: a Long-Term Observational Study

INTRODUCTION

The one anastomosis gastric bypass (OAGB) is an effective treatment to induce sustained weight loss in morbidly obese patients. Concerns remain regarding the development of reflux. The aim of this study was to investigate the effect of an "anti-reflux suture" as anti-reflux modification to prevent reflux.

METHOD

This is a single-center retrospective cohort study of patients who underwent a primary OAGB at the Center Obesity North-Netherlands (CON) between January 2015 and December 2016. Reflux was defined as symptoms of acid/bilious regurgitation or pyrosis. This was consequently asked and reported at each follow-up visit. Outcomes of patients with an anti-reflux suture were compared to those without.

RESULTS

In 414 (59%) of the 703 included patients, an anti-reflux suture was applied. Follow-up at 3 years was 74%. The incidence of reflux did not differ between patients with or without an anti-reflux suture (57 versus 56%, respectively; P = 0.9). The presence of an anti-reflux suture was significantly associated with a lower incidence of conversion to Roux-en-Y gastric bypass (RYGB) for reflux (OR 0.56, 95%CI 0.34-0.91). Patients preoperatively diagnosed with gastroesophageal reflux disease (GERD) were 5.2 times more likely to need a conversion to RYGB for reflux (95%CI 2.7-10.1).

CONCLUSION

The presence of preoperative GERD should be weighted heavily in the decision to perform an OAGB as this is a major risk factor for conversion surgery due to reflux. The anti-reflux suture might be a valuable addition to the procedure of the OAGB because it results in fewer conversion surgeries for reflux.

Short-term outcomes of the conversion of one anastomosis gastric bypass to Roux-en-Y gastric bypass in symptomatic reflux patients without revising the size of the gastric pouch

Background:

Revising the size of the gastric pouch during the conversion of one anastomosis gastric bypass (OAGB)/mini-gastric bypass to Roux-en-Y gastric bypass (RYGB) is an important point. Even in patients undergoing RYGB, marginal ulcer is regarded as a known complication.

Materials and Methods:

In our Centre of Excellence in Bariatric and Metabolic Surgery, 2492 patients underwent OAGB from February 2012 to January 2019. Twelve of 2492 patients were enrolled in this clinical case series because of persistent gastroesophageal reflux-like symptoms which underwent conversional RYGB. All patients regularly received proton-pump inhibitors (PPIs) for 6 months after the surgery. After this period, the cases with symptomatic reflux were invited to be visited in the clinic by a bariatric surgeon and a gastroenterologist and received 6 months of PPI therapy until their symptoms disappeared. Twelve refractory reflux cases underwent conversional RYGB after 1 year. An enteroenterostomy was created in all the patients 75 cm distal to the gastrojejunostomy without resizing the gastric pouch, and the jejunal loop was cut just before the gastrojejunostomy.

Results:

Before conversional surgery, mean ± standard deviation (SD) body mass index (BMI) and gastroesophageal reflux disease (GERD)-Q score were found to be 26.45 ± 2.34 kg/m² and 10.08 ± 0.56, respectively. At 1 year after conversion, mean ± SD BMI in the patients was 28.12 ± 4.71, and GERD-Q score was 5.08 ± 1.5.

Conclusion:

It seems that resizing the gastric pouch is not necessary during the conversion of OAGB to RYGB.

Revisional surgery after one anastomosis/mini gastric bypass: A narrative review

One anastomosis gastric bypass (OAGB)/mini gastric bypass is now considered to be a safe and efficient method for morbidly obese patients but has complications and adverse events such as other surgical procedures. The present paper outlines the need for and the nature of revisional surgery in the long-term following OAGB in accordance with the preferred reporting items for systematic reviews and meta-analysis guidelines. A literature search was carried out in PubMed. All articles on OAGB for which the authors described a patient needing revisional surgery in the long term after OAGB were examined.

Unexpected Biliopancreatic Limb Obstruction after Gastric Bypass Revision

INTRODUCTION

Biliopancreatic limb obstruction is a surgical emergency in patients who have undergone gastric bypass surgery. This case report presents an unexpected cause of biliopancreatic limb obstruction and the importance of prompt intervention.

MATERIAL AND METHODS

A 37-year-old woman presented with complaints of weight regain (BMI increased from 27 to 33.3 kg/m²) and bile reflux and was found to have marginal ulcers on endoscopy. She had undergone loop gastric bypass with Braun anastomosis in 2009 at another center for morbid obesity (BMI = 43 kg/m²). Roux-en-Y gastric bypass (RYGB) was created after the separation of gastro-jejunostomy (GJ) and jejuno-jejunostomy (JJ). On the fifth postoperative day, the patient was readmitted with signs of peritonitis. Urgent relaparoscopy showed Biliopancreatic limb (BP) obstruction. It was then and that we understood intraoperatively the uncut Roux-en-Y caused stricture between the previous GJ and JJ staple lines. Side-to-side jejuno-jejunostomy between the proximal dilated and the distal collapsed biliopancreatic limb was performed.

RESULT

The patient recovered uneventfully and was discharged after drain removal.

CONCLUSION

Biliopancreatic limb obstruction requires prompt decision for relaparoscopy. Timely intervention is necessary to prevent postoperative morbidity. Reviewing the operative video or notes of the primary surgery can minimize the chance of mismanagement during revision surgery.

One-anastomosis gastric bypass as an alternative procedure of choice in morbidly obese patients

One-anastomosis gastric bypass is an attractive bariatric procedure. It is effective in weight loss and comorbidity resolution. It is a relatively simple and fast operation with low complication rates that make it a suitable option in super-obese individuals. Although not proven yet, there are some concerns about its long-term safety profile in terms of biliary reflux, marginal ulcer, and esophagogastric malignancy. In this article, we review the technique of this procedure and discuss about some practical surgical highlights. Furthermore, we overview studies performed about this procedure and compare it to some other well-established bariatric operations, while providing a detailed study about the facts related to its outcomes and complications.