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Athanasiadis DI, Giannopoulos S, Selzer D, Stefanidis D. Does the length of bypassed bowel during distal gastric bypass affect weight loss? Surg Endosc 2024:10.1007/s00464-024-11188-w. [PMID: 39266753 DOI: 10.1007/s00464-024-11188-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 08/17/2024] [Indexed: 09/14/2024]
Abstract
INTRODUCTION Weight recurrence (WR) affects > 20% of patients following Roux-en-Y gastric bypass (RYGB). Shortening of the common channel (CC) after RYGB (distal bypass) has been proposed for additional weight loss in patients with WR, but results vary, and concerns for vitamin deficiencies/malnutrition exist. Our aim was to determine whether the percentage of bowel bypassed after distal bypass is associated with the amount of postoperative weight loss. METHODS Patients undergoing distal bypass between 2018 and 2022 were reviewed. Small bowel limb lengths before and after distal bypass were measured, and the percentage of bypassed bowel was calculated (= bypassed biliopancreatic limb/total small bowel length). Patients were dichotomized into two groups based on the percentage bypassed bowel (≤ 50% vs. > 50%). Weight loss (measured as excess BMI loss; EBIL%), comorbidities resolution, complications, and nutritional deficiencies were reviewed. RESULTS Thirty female patients underwent distal bypass during the study period. After distal bypass, the Roux was lengthened to 150 cm (75-175 cm) from 75 cm (20-200 cm), and the CC shortened to 150 cm (100-310 cm) from 510 cm (250-1000 cm). These changes resulted in an increase in the size of the bypassed biliopancreatic limb from 40 cm (15-90 cm) to 330 cm (180-765 cm) and a total alimentary limb (TALL; Roux + CC) shortening from 590 cm (400-1075 cm) to 300 cm (250-400 cm). The group with > 50% bowel bypassed had higher EBIL%. Overall EBIL% was 36.9 ± 14.7%, 53.3 ± 25.6%, and 62.1 ± 36.9% at 0.5, 1, and 2 years, respectively. There were minimal vitamin deficiencies. Diabetes resolved in 100% (n = 3/3), HTN in 67% (n = 10/15), and GERD in 73% (n = 11/15). Complication rate was 23%. No reintervention for malnutrition or vitamin deficiencies was required. CONCLUSIONS Distal bypass effectively leads to considerable weight loss and comorbidity improvement in patients with WR after RYGB, but the amount of weight loss depends on the percentage of bypassed bowel. An exact threshold of bypassed bowel that optimizes weight loss outcomes and simultaneously minimizes the nutritional complications needs to be determined. Meanwhile, close monitoring for vitamin deficiencies is recommended.
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Affiliation(s)
| | | | - Don Selzer
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
- Section of Minimally Invasive and Bariatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Dimitrios Stefanidis
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
- Section of Minimally Invasive and Bariatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
- Department of Surgery, Indiana University School of Medicine, 545 Emerson Hall, EH 130, Indianapolis, IN, 46202, USA.
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Huang CK, Hsin MC, Patel A, Katakwar A, Patel A, Yagnik VD. Reoperation After Loop Duodenojejunal Bypass with Sleeve Gastrectomy: A 9-Year Experience. Obes Surg 2024; 34:2914-2922. [PMID: 38869832 DOI: 10.1007/s11695-024-07348-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 06/03/2024] [Accepted: 06/03/2024] [Indexed: 06/14/2024]
Abstract
PURPOSE Loop duodenojejunal bypass with sleeve gastrectomy (LDJBSG) is effective for weight loss and resolution of obesity-related associated medical problems. However, a description of the reoperative surgery following LDJBSG is lacking. MATERIAL AND METHODS In this retrospective study, we analyzed the surgical complications and reoperation (conversion or revision) following LDJBSG from 2011 to 2019 in a single institution. RESULTS A total of 337 patients underwent LDJBSG during this period. Reoperative surgery (RS) was required in 10LDJBSG patients (3%). The mean age and BMI before RS were 47 ± 9 years and 28.9 ± 3.6 kg/m2, respectively. The mean interval between primary surgery and RS for early (n = 5) and late (n = 5)complications was 8 ± 11 days and 32 ± 15.8 months, respectively. The conversion procedures were Roux-en-Y gastric bypass(n = 5), followed by Roux-en-Y duodenojejunal bypass (n = 2) and one-anastomosis gastric bypass (n = 1); other revision procedures were seromyotomy (n = 1) and re-laparoscopy (n = 1). Perioperative complications were observed in four patients after conversion surgery such as multiorgan failure (n = 1), re-laparoscopy (n = 1), marginal ulcer (n = 1), GERD (n = 1), and dumping syndrome (n = 1). CONCLUSION LDJBSG has low reoperative rates and conversion RYGB could effectively treat the early and late complications of LDJBSG. Because of its technical demands and risk of perioperative complications, conversion surgery should be reserved for a selected group of patients and performed by an experienced metabolic bariatric surgical team.
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Affiliation(s)
- Chih-Kun Huang
- Department of Body Science and Metabolic Disorders International Medical Center, China Medical University Hospital, Yude Rd., North Dist, Taichung, Taiwan
| | - Ming-Che Hsin
- Department of Body Science and Metabolic Disorders International Medical Center, China Medical University Hospital, Yude Rd., North Dist, Taichung, Taiwan
| | - Anand Patel
- Departmentof Bariatric and Gastrointestinal Surgery, Noble Gastro Hospital, Ahmedabad, India.
| | - Abhishek Katakwar
- Department of Obesity and Metabolic Therapy, AIG Hospitals (Unit of Asian Institute of Gastroenterology), Hyderabad, India
| | - Apurva Patel
- Department of Laparoscopic and Bariatric Surgery, IRIS Hospital, Anand, Gujarat, India
| | - Vipul D Yagnik
- Department of Surgery, Banas Medical College and Research Institute, Palanpur, Gujarat, India
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Sampath K, Hassan KM, Dawod E, Mintz M, Abu-Hammour MN, Simons M, Sharaiha RZ. Endoscopic Ultrasound-guided Jejunocolostomy for Management of Refractory Severe Obesity in a Post-gastric Bypass Patient. Obes Surg 2024; 34:3137-3139. [PMID: 38965187 DOI: 10.1007/s11695-024-07276-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 05/06/2024] [Accepted: 05/09/2024] [Indexed: 07/06/2024]
Abstract
Obesity is a complex disease process, which often requires multifactorial, patient-tailored strategies for effective management. Treatment options include lifestyle optimization, pharmacotherapy, endobariatrics, and bariatric metabolic endoscopy. Obesity-based interventions can be challenging in patient populations with severe obesity, particularly post-gastric bypass. We report the case of a non-surgical patient with a failed remote open gastric bypass, who underwent an endoscopic small bowel diversion procedure, resulting in partial caloric diversion, via the creation of an EUS-guided jejunocolostomy (EUS-JC). The procedure is an extension of prior reported EUS-guided and magnet-based small bowel bypass procedures, in this case, for the purposes of weight loss (Kahaleh et al., 1; Jonica et al. Gastrointest Endosc. 97(5):927-933, 2; Machytka et al. Gastrointest Endosc. 86(5):904-912, 3;). The procedure was performed without peri-procedural complications, with effective weight loss during follow-up. Endoscopic bariatric interventions that target the small bowel, such as EUS-JC, offer promising tools for obesity management and should be studied further. Numerous factors including lifestyle, psychosocial, genetic, behavioral, and secondary disease processes contribute to obesity. Severe obesity (defined as a BMI > 50 kg/m2) is associated with increased morbidity and mortality with a significantly reduced response to treatment (Flegal et al. JAMA. 309(1):71-82, 4;). Weight regain can be noted in up to 50% of patients post-RYGB. In populations with severe obesity, there is an associated 5-year surgical failure rate of 18% (Magro et al. Obesity Surg. 18(6):648-51, 5;). These patients may not be surgical candidates for revision or can develop post-revision chronic protein-caloric malnutrition (Shin et al. Obes Surg. 29(3):811-818, 6;). Lifestyle, modification, pharmacotherapy, or endoscopic transoral reduction (TORe) can be effective generally; however, in patients with severe obesity, the total desired excess body weight loss may not likely be accomplished solely by these strategies. An endoscopic small bowel intervention that diverts a portion of caloric intake from small bowel absorption can potentially promote weight loss similar to a surgical lengthening of the Roux limb (Shah et al. Obes Surg. 33(1):293-302, 7; Hamed et al. Annal Surg. 274(2):271-280, 8;), in the sense that there is a reduction in the total small bowel surface area for absorption. Roux limb distalization can be effective for weight regain for post bypass patients. The EUS-JC technique aims to work similarly by reducing the total small bowel surface area utilized for absorption. Since this patient was deemed a non-surgical candidate, an EUS-guided jejunocolostomy was offered. Prior to the procedure, the patient established longitudinal care with our bariatric nutritionist and obesity medicine services. Extensive pre-bariatric labs were screened to rule out confounders for recurrent severe obesity. Intra-procedure, the patient received one dose of 500 mg intravenous levofloxacin. Post-procedure, loperamide was prescribed every 8 h as needed for post-procedure diarrhea. Within 2 weeks, the patient was no longer taking anti-diarrheals. The post-procedure diet consisted of a liquid diet for 2 days before advancement to a low-residue diet for 1 month, and then a regular diet.
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Affiliation(s)
- Kartik Sampath
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, 1305 York Avenue, 4th Floor, New York, NY, 10021, USA
| | - Kamal M Hassan
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, 1305 York Avenue, 4th Floor, New York, NY, 10021, USA.
| | - Enad Dawod
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, 1305 York Avenue, 4th Floor, New York, NY, 10021, USA
| | - Michael Mintz
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, 1305 York Avenue, 4th Floor, New York, NY, 10021, USA
| | - Mohamad-Noor Abu-Hammour
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, 1305 York Avenue, 4th Floor, New York, NY, 10021, USA
| | - Malorie Simons
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, 1305 York Avenue, 4th Floor, New York, NY, 10021, USA
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Department of Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, 1305 York Avenue, 4th Floor, New York, NY, 10021, USA
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Roulet M, Phocas C, Becouarn G, Finel JB, Topart P. Long-term results of conversion of Roux-en-Y to biliopancreatic diversion with duodenal switch. Surg Obes Relat Dis 2024; 20:571-576. [PMID: 38342720 DOI: 10.1016/j.soard.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/24/2023] [Accepted: 12/25/2023] [Indexed: 02/13/2024]
Abstract
BACKGROUND Despite the fact Roux-en-Y gastric bypass (RYGB) is one of the most efficient bariatric procedures, postoperative weight regain still can be seen. OBJECTIVES To retrospectively assess the early outcomes and up to 10-year weight results of the conversion of RYGB to biliopancreatic diversion with duodenal switch (BPD-DS). SETTING French private hospital, 2-surgeon practice in a bariatric surgery center with an experience of >20 RYGB procedures. METHODS Analysis was conducted on patients who had a conversion of RYGB to BPD-DS performed since 2010 for a percentage of excess weight loss (%EWL) <50% with a small gastric pouch. RESULTS A total of 65 females and 9 males aged 46.8 ± 8.8 years had an RYGB procedure done 110.6 ± 38.8 months earlier for a body mass index of 47.4 ± 7.8 kg/m2. Conversion was always performed in 1 stage and laparoscopically for 93% of the patients. The 30-day complication rate was 25.7%, with 14.8% of patients undergoing reoperation. Maximum results were seen 2 years after conversion, outranging RYGB: %EWL of 78.3% ± 24% with percent total weight loss (%TWL) of 35.9% ± 11.9% and %EWL of 72% ± 24.1% with %TWL of 32.6% ± 11%, respectively. The 5-year weight of all the patients (85.7% follow-up) remained lower than the pre-conversion weight. Over time, 1 reversal and 4 revisions were required, and frequent stools and gastroesophageal reflux were the most frequent complaints. CONCLUSION Despite its complexity, conversion of RYGB to BPD-DS can be performed in 1 stage, although the use of an unconventional technique could not reduce the high complication rate. BPD-DS remains an efficient procedure after RYGB in selected patients, comparable to distalization of RYGB, which can be less risky.
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Affiliation(s)
- Maxime Roulet
- Société de chirurgie viscérale, clinique de l'Anjou, Angers, France
| | - Carine Phocas
- Société de chirurgie viscérale, clinique de l'Anjou, Angers, France
| | | | | | - Philippe Topart
- Société de chirurgie viscérale, clinique de l'Anjou, Angers, France.
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Dang JT, Hider AM, Barajas-Gamboa JS, Mocanu V, Shin T, Romero-Velez G, Lee Y, Navarrete S, Rodriguez J, Kroh M. Safety of limb lengthening after Roux-en-Y gastric bypass: an analysis of the MBSAQIP database. Surg Obes Relat Dis 2024; 20:564-570. [PMID: 38316579 DOI: 10.1016/j.soard.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 11/29/2023] [Accepted: 12/25/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Roux-en-Y gastric bypass (RYGB) effectively treats severe obesity, but some patients may require revisional surgery like limb lengthening (LL) for postoperative weight gain. OBJECTIVES This study aims to compare 30-day serious complications and mortality rates between LL and primary RYGB, given limited safety data on LL. METHODS Patients who underwent LL and RYGB were identified from the 2020 and 2021 MBSAQIP databases, the only years in which LL data were available. Baseline characteristics and 30-day rates of serious complications and mortality were analyzed. RESULTS A total of 86,990 patients underwent RYGB and 455 underwent LL. Patients undergoing RYGB were younger (44.4 versus 49.8 yr, P < .001), had a higher body mass index (BMI) (45.5 versus 41.8 kg/m2, P < .001) and higher rates of comorbidities including diabetes (30.0 versus 13.6%, P < .001). RYGB and LL had similar operative duration (125.3 versus 123.2 min, P = .5). There were no statistical differences between cohorts for length of stay (LOS) (1.6 RYGB versus 1.6 LL d, P = .6). After LL, there were higher 30-day rates of reoperation (3.3 versus 1.9%, P = .03) and deep surgical site infections (1.3 versus .5%, P = .03) compared to RYGB. There were no differences in overall serious complications (5.1 LL versus 5.0% RYGB, P = 1.0) and mortality (.2 LL versus .1% RYGB, P = .5). Multivariable logistic regression adjustment found that previous venous thromboembolism was associated with serious complications after LL. CONCLUSIONS When compared to primary RYGB, LL has a favorable safety profile with similar 30-day rates of serious complications and mortality.
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Affiliation(s)
- Jerry T Dang
- Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Ahmad M Hider
- Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Juan S Barajas-Gamboa
- Digestive Diseases Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Valentin Mocanu
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Thomas Shin
- Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Yung Lee
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | | | - John Rodriguez
- Digestive Diseases Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Matthew Kroh
- Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio
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Nadal E, Benito E, Ródenas-Navarro AM, Palanca A, Martinez-Hervas S, Civera M, Ortega J, Alabadi B, Piqueras L, Ródenas JJ, Real JT. Machine Learning Model in Obesity to Predict Weight Loss One Year after Bariatric Surgery: A Pilot Study. Biomedicines 2024; 12:1175. [PMID: 38927382 PMCID: PMC11200726 DOI: 10.3390/biomedicines12061175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/13/2024] [Accepted: 05/21/2024] [Indexed: 06/28/2024] Open
Abstract
Roux-en-Y gastric bypass (RYGB) is a treatment for severe obesity. However, many patients have insufficient total weight loss (TWL) after RYGB. Although multiple factors have been involved, their influence is incompletely known. The aim of this exploratory study was to evaluate the feasibility and reliability of the use of machine learning (ML) techniques to estimate the success in weight loss after RYGP, based on clinical, anthropometric and biochemical data, in order to identify morbidly obese patients with poor weight responses. We retrospectively analyzed 118 patients, who underwent RYGB at the Hospital Clínico Universitario of Valencia (Spain) between 2013 and 2017. We applied a ML approach using local linear embedding (LLE) as a tool for the evaluation and classification of the main parameters in conjunction with evolutionary algorithms for the optimization and adjustment of the parameter model. The variables associated with one-year postoperative %TWL were obstructive sleep apnea, osteoarthritis, insulin treatment, preoperative weight, insulin resistance index, apolipoprotein A, uric acid, complement component 3, and vitamin B12. The model correctly classified 71.4% of subjects with TWL < 30% although 36.4% with TWL ≥ 30% were incorrectly classified as "unsuccessful procedures". The ML-model processed moderate discriminatory precision in the validation set. Thus, in severe obesity, ML-models can be useful to assist in the selection of patients before bariatric surgery.
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Affiliation(s)
- Enrique Nadal
- Instituto Universitario de Ingeniería Mecánica y Biomecánica (I2MB), Universitat Politècnica de València, 46022 Valencia, Spain;
| | - Esther Benito
- CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), 28040 Madrid, Spain; (E.B.); (B.A.); (L.P.); (J.T.R.)
| | - Ana María Ródenas-Navarro
- Endocrinology and Nutrition Service, Clinical University Hospital of Valencia, 46010 Valencia, Spain; (A.M.R.-N.); (A.P.); (M.C.)
| | - Ana Palanca
- Endocrinology and Nutrition Service, Clinical University Hospital of Valencia, 46010 Valencia, Spain; (A.M.R.-N.); (A.P.); (M.C.)
- INCLIVA Biomedical Research Institute, 46010 Valencia, Spain;
| | - Sergio Martinez-Hervas
- CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), 28040 Madrid, Spain; (E.B.); (B.A.); (L.P.); (J.T.R.)
- Endocrinology and Nutrition Service, Clinical University Hospital of Valencia, 46010 Valencia, Spain; (A.M.R.-N.); (A.P.); (M.C.)
- INCLIVA Biomedical Research Institute, 46010 Valencia, Spain;
- Department of Medicine, University of Valencia, 46010 Valencia, Spain
| | - Miguel Civera
- Endocrinology and Nutrition Service, Clinical University Hospital of Valencia, 46010 Valencia, Spain; (A.M.R.-N.); (A.P.); (M.C.)
- INCLIVA Biomedical Research Institute, 46010 Valencia, Spain;
| | - Joaquín Ortega
- INCLIVA Biomedical Research Institute, 46010 Valencia, Spain;
- General Surgery Service, University Hospital of Valencia, 46010 Valencia, Spain
- Department of Surgery, University of Valencia, 46010 Valencia, Spain
| | - Blanca Alabadi
- CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), 28040 Madrid, Spain; (E.B.); (B.A.); (L.P.); (J.T.R.)
- Endocrinology and Nutrition Service, Clinical University Hospital of Valencia, 46010 Valencia, Spain; (A.M.R.-N.); (A.P.); (M.C.)
- INCLIVA Biomedical Research Institute, 46010 Valencia, Spain;
| | - Laura Piqueras
- CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), 28040 Madrid, Spain; (E.B.); (B.A.); (L.P.); (J.T.R.)
- INCLIVA Biomedical Research Institute, 46010 Valencia, Spain;
- Department of Pharmacology, University of Valencia, 46010 Valencia, Spain
| | - Juan José Ródenas
- Instituto Universitario de Ingeniería Mecánica y Biomecánica (I2MB), Universitat Politècnica de València, 46022 Valencia, Spain;
| | - José T. Real
- CIBER de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Instituto de Salud Carlos III (ISCIII), 28040 Madrid, Spain; (E.B.); (B.A.); (L.P.); (J.T.R.)
- Endocrinology and Nutrition Service, Clinical University Hospital of Valencia, 46010 Valencia, Spain; (A.M.R.-N.); (A.P.); (M.C.)
- INCLIVA Biomedical Research Institute, 46010 Valencia, Spain;
- Department of Medicine, University of Valencia, 46010 Valencia, Spain
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Estrada A, Rodriguez-Quintero JH, Pereira X, Moran-Atkin E, Choi J, Camacho D. Gastric bypass revisional surgery: percentage total body weight loss differences among three different techniques. Langenbecks Arch Surg 2024; 409:151. [PMID: 38703235 DOI: 10.1007/s00423-024-03342-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 04/29/2024] [Indexed: 05/06/2024]
Abstract
INTRODUCTION Suboptimal weight loss or weight regain may occur after Roux-en-Y gastric bypass (RYGB). For this reason, revisional surgery has gained increasing interest. We aimed to compare the percentage of total body weight loss (%TBWL) at one-year follow-up among three different techniques: Jejuno-jejunostomy distalization (JJD), Sleeve resection of the gastrojejunostomy and gastric pouch (SRGJP), and the combination of both (JJD + SRGJP). METHODS This retrospective cohort study included all patients who underwent revisional surgery after RYGB (2020-2021). The cohort was stratified by the type of revisional technique performed. Postoperative bariatric outcomes and nutritional deficiencies were compared among groups. RESULTS A total of 78 patients underwent revisional surgery after RYGB: JJD was performed in 8 (10.3%), SRGJP in 34 (43.6%), and JJD + SRGJP in 36 (46.1%) patients. The most common indication for surgery was weight regain, in 72 (92.3%) patients. The median lengths of the BP limbs before and after distalization, were 50 cm (IQR 40-75 cm) and 175 cm (IQR 150-200 cm), respectively. The median length of the new common limb (NCL) and total alimentary limb length (TALL) were 277 cm (IQR 250-313 cm) and 400 cm (IQR 375-475 cm), respectively. Median percentage of total body weight loss (%TBWL) at one year was 15% (IQR 15-19%) for JJD, 20% (IQR 13-26%) for SRGJP, and 21% (IQR 15- 28%) for JJD + SRGJP (p = 0.40). CONCLUSIONS In this study, the combined procedure (JJD + SRGJP) exhibited higher %TBWL at one year, however no statistically significant difference was identified among the three techniques.
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Affiliation(s)
- Arturo Estrada
- Department of Surgery, Montefiore Medical Center/ Albert Einstein College of Medicine, 111 E 210thSt, Bronx, NY, 10467, USA.
| | | | - Xavier Pereira
- Department of Surgery, Montefiore Medical Center/ Albert Einstein College of Medicine, 111 E 210thSt, Bronx, NY, 10467, USA
| | - Erin Moran-Atkin
- Department of Surgery, Montefiore Medical Center/ Albert Einstein College of Medicine, 111 E 210thSt, Bronx, NY, 10467, USA
| | - Jenny Choi
- Department of Surgery, Montefiore Medical Center/ Albert Einstein College of Medicine, 111 E 210thSt, Bronx, NY, 10467, USA
| | - Diego Camacho
- Department of Surgery, Montefiore Medical Center/ Albert Einstein College of Medicine, 111 E 210thSt, Bronx, NY, 10467, USA
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Bhatia M, Azir E, El-Hasanii S. Letter to the editor for "Distalization of Standard Roux-en-Y Gastric Bypass: Indications, Technique, and Long-Term Results". Obes Surg 2023; 33:3311. [PMID: 37580523 DOI: 10.1007/s11695-023-06774-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 06/11/2023] [Accepted: 06/16/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Mohit Bhatia
- Princess Royal University Hospital, Orpington, London, United Kingdom.
| | - Elia Azir
- Princess Royal University Hospital, Orpington, London, United Kingdom
| | - Shamsi El-Hasanii
- Princess Royal University Hospital, Orpington, London, United Kingdom
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Aleassa EM, Papasavas P, Augustin T, Khorgami Z, Benson-Davies S, Ghiassi S, Carter J, Nimeri A. American Society for Metabolic and Bariatric Surgery literature review on the effect of Roux-en-Y gastric bypass limb lengths on outcomes. Surg Obes Relat Dis 2023; 19:755-762. [PMID: 37268517 DOI: 10.1016/j.soard.2023.04.298] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 04/02/2023] [Indexed: 06/04/2023]
Abstract
This literature review is issued by the American Society for Metabolic and Bariatric Surgery regarding limb lengths in Roux-en-Y gastric bypass (RYGB) and their effect on metabolic and bariatric outcomes. Limbs in RYGB consist of the alimentary and biliopancreatic limbs and the common channel. Variation of limb lengths in primary RYGB and as a revisional option for weight recurrence after RYGB are described in this review.
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Affiliation(s)
- Essa M Aleassa
- Department of General Surgery, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.
| | | | - Toms Augustin
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Zhamak Khorgami
- Department of Surgery, University of Oklahoma College of Community Medicine, Tulsa, Oklahoma
| | - Sue Benson-Davies
- Department of Surgery, Sanford School of Medicine, University of South Dakota, Vermillion, South Dakota
| | - Saber Ghiassi
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Jonathan Carter
- Department of Surgery, University of California, San Francisco, California
| | - Abdelrahman Nimeri
- Department of Surgery, Carolinas Medical Center, University of North Carolina, Charlotte, North Carolina
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Ngomba Muakana JA, Thissen JP, Loumaye A, Thoma M, Deswysen Y, Navez B. Distalization of Standard Roux-en-Y Gastric Bypass: Indications, Technique, and Long-Term Results. Obes Surg 2023; 33:1373-1381. [PMID: 36892751 DOI: 10.1007/s11695-023-06524-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/12/2023] [Accepted: 02/15/2023] [Indexed: 03/10/2023]
Abstract
INTRODUCTION Weight loss failure or weight regain after primary Roux-en-Y gastric bypass (RYGB) is a challenge for bariatric surgeons. Failure to achieve a body mass index (BMI) <35 kg/m2 after RYGB occurs in up to 40.0%. The aim of this study was to evaluate long-term results of a novel technique for distalization of Roux-en-Y gastric bypass (DRYGB) as a revisional procedure. METHODS Retrospective data were reviewed for 22 patients who had undergone RYGB and failed to achieve an excess weight loss (EWL) >50% or BMI <35 kg/m2 and underwent limb distalization between 2013 and 2022. For this DRYGB procedure, the length of the common channel was 100 cm, and the lengths of the biliopancreatic limb and the alimentary limb were 1/3 and 2/3 of the remaining bowel, respectively. RESULTS The mean BMI values before and after DRYGB were 43.7 kg/m2 and 33.5 kg/m2, respectively. Five years after DRYGB, mean % EWL was 74.3% and mean % total weight loss (TWL) was 28.8%. Mean % EWL and mean % TWL of the two procedures (RYGB and DRYGB) after 5 years were 80.9% and 44.7%, respectively. Three patients experienced protein calorie malnutrition. One was reproximalized and the others were treated with parenteral nutrition with no recurrence. There was a significant decrease in the incidence of diabetes type 2 and dyslipidemia after DRYGB. CONCLUSION The DRYGB procedure results in substantial and sustained long-term weight loss. Due to the risk of malnutrition, patients must be strictly followed for life after the procedure.
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Affiliation(s)
- Judith A Ngomba Muakana
- Oesogastroduodenal and Bariatric Unit, Department of Abdominal Surgery and Transplantation, Saint-Luc University Hospital, 10 Avenue Hippocrate, 1200, Brussels, Belgium
| | - Jean-Paul Thissen
- Department of Endocrinology, Saint-Luc University Hospital, 10 Avenue Hippocrate, 1200, Brussels, Belgium
| | - Audrey Loumaye
- Department of Endocrinology, Saint-Luc University Hospital, 10 Avenue Hippocrate, 1200, Brussels, Belgium
| | - Maximilien Thoma
- Oesogastroduodenal and Bariatric Unit, Department of Abdominal Surgery and Transplantation, Saint-Luc University Hospital, 10 Avenue Hippocrate, 1200, Brussels, Belgium
| | - Yannick Deswysen
- Oesogastroduodenal and Bariatric Unit, Department of Abdominal Surgery and Transplantation, Saint-Luc University Hospital, 10 Avenue Hippocrate, 1200, Brussels, Belgium
| | - Benoit Navez
- Oesogastroduodenal and Bariatric Unit, Department of Abdominal Surgery and Transplantation, Saint-Luc University Hospital, 10 Avenue Hippocrate, 1200, Brussels, Belgium.
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11
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Dang JT, Vaughan T, Mocanu V, Mubashir H, Barajas-Gamboa JS, Codina RC, Rodriguez J, Karmali S, Kroh M. Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass: Indications, Prevalence, and Safety. Obes Surg 2023; 33:1486-1493. [PMID: 36922465 PMCID: PMC10017068 DOI: 10.1007/s11695-023-06546-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 02/28/2023] [Accepted: 03/07/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Sleeve gastrectomy (SG) frequently requires conversion to Roux-en-Y gastric bypass (RYGB) due to gastroesophageal reflux disease (GERD) or weight recurrence. Current evidence evaluating the safety of conversion from SG to RYGB and its indications is limited to single centers. METHODS The objective was to determine the rate of serious complications and mortality of conversion of SG to RYGB (SG-RYGB) compared to primary RYGB (P-RYGB). This was a retrospective analysis of the MBSAQIP database which includes 30-day outcomes. Individuals undergoing P-RYGB or SG-RYGB were included. Multivariable logistic regression was performed to determine if revisional surgery was an independent predictor of serious complications or mortality. RESULTS In 2020 and 2021, 84,543 (86.3%) patients underwent P-RYGB and 13,432 (13.7%) underwent SG-RYGB. SG-RYGB cohort had lower body mass index, lower rates of diabetes and hypertension, and higher rates of GERD. GERD was the most common indication for revision (55.3%) followed by weight regain (24.4%) and inadequate weight loss (12.7%). SG-RYGB had longer operative times (145 vs. 125 min, p < 0.001) and a higher rate of serious complications (7.2 vs. 5.0%, p < 0.001). This included higher rates of anastomotic leak (0.5 vs. 0.4%, p = 0.002), bleeding (2.0 vs. 1.6%, p < 0.001), and reoperation (3.0 vs. 1.9%, p < 0.001) but not death (0.1 vs. 0.1%, p = 0.385). On multivariable analysis, SG-RYGB was independently predictive of serious complications (OR 1.21, 95%CI 1.12 to 1.32, p < 0.001) but not mortality (p = 0.316). CONCLUSIONS While SG-RYGB is safe with a low complication rate, SG-RYGB was associated with a higher rate of serious complications compared to P-RYGB.
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Affiliation(s)
- Jerry T Dang
- Digestive Diseases & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Tiffany Vaughan
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Valentin Mocanu
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Hadika Mubashir
- Digestive Diseases & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Juan S Barajas-Gamboa
- Digestive Diseases Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | | | - John Rodriguez
- Digestive Diseases Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Shahzeer Karmali
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Matthew Kroh
- Digestive Diseases & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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12
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McLennan S, Verhoeff K, Mocanu V, Jogiat U, Birch DW, Karmali S, Switzer NJ. Characteristics and outcomes for patients undergoing revisional bariatric surgery due to persistent obesity: a retrospective cohort study of 10,589 patients. Surg Endosc 2023:10.1007/s00464-023-09951-6. [PMID: 36859722 DOI: 10.1007/s00464-023-09951-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/12/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND Revisional bariatric surgery in an option for patients who experience weight regain or inadequate weight loss after primary elective bariatric procedures. However, there is conflicting data on safety outcomes of revisional procedures. We aim to characterize patient demographics, procedure type, and safety outcomes for those undergoing revisional compared to initial bariatric interventions to guide management of these patients. METHODS The 2020 Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) registry was analyzed, comparing primary elective to revisional bariatric procedures for inadequate weight loss. Bivariate analysis was performed to determine between group differences. Multivariable logistic regression determined factors associated with serious complications or mortality. RESULTS We evaluated 158,424 patients, including 10,589 (6.7%) revisional procedures. Patients undergoing revisional procedures were more like to be female (85.5% revisional vs. 81.0% initial; p < 0.001), had lower body mass index (43.6 ± 7.8 kg/m2 revisional vs. 45.2 ± 7.8 kg/m2 initial; p < 0.001), and less metabolic comorbidities than patients undergoing primary bariatric surgery. The most common revisional procedures were Roux-en-Y gastric bypass (48.4%) and sleeve gastrectomy (32.5%). Revisional procedures had longer operative duration compared to primary procedures. Patients undergoing revisional procedures were more likely to experience readmission to hospital (4.8% revisional vs. 2.9% initial; p < 0.001) and require reoperation (2.4% revisional vs. 1.0% initial; p < 0.001) within 30 days of the procedure. Revisional procedures were independently associated with increased serious complications (OR 1.49, CI 1.36-1.64, p < 0.001) but were not a significant predictor of 30-day mortality (OR 0.74, CI 0.36-1.50, p = 0.409). CONCLUSIONS In comparison to primary bariatric surgery, patients undergoing revisional procedures have less metabolic comorbidities. Revisional procedures have worse perioperative outcomes and are independently associated with serious complications. These data help to contextualize outcomes for patients undergoing revisional bariatric procedures and to inform decision making in these patients.
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Affiliation(s)
- Steffane McLennan
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
| | - Kevin Verhoeff
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Valentin Mocanu
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Uzair Jogiat
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Daniel W Birch
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Shahzeer Karmali
- Centre for Advancement of Surgical Education and Simulation (CASES), Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Noah J Switzer
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
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13
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Failed Roux-en-Y Gastric Bypass-Long-Term Results of Distalization with Total Alimentary Limb Length of 250 or 300 cm. Obes Surg 2023; 33:293-302. [PMID: 36459358 PMCID: PMC9834116 DOI: 10.1007/s11695-022-06388-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/02/2022] [Accepted: 11/27/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Weight loss failure or weight regain may occur after Roux-en-Y gastric bypass (RYGB). Revisional surgery includes distalization. However, few studies have looked at the associations between the total alimentary limb length (TALL) and weight loss outcomes, none with long-term results. OBJECTIVES Peri- and postoperative outcomes were assessed after employing TALL of either 250 cm or 300 cm in the failed RYGB. METHODS This study is a retrospective cohort analysis of 90 patients that underwent laparoscopic distalization between January 2006 and January 2016 due to failed RYBG. The index RYGB was modified to TALL of 250 cm (n = 48) or of 300 cm (n = 42) which entailed elongating the bilio-pancreatic limb (BPL) and transposing the Roux limb (RL) to a common limb (CL) of 100 cm and 150 cm, respectively. Long-term weight loss outcomes along with nutritional and vitamin status were analyzed. RESULTS Preoperative BMI at distalization was 38.6 kg/m2. After 8 years, excess weight loss (EWL) was 61.8%. No differences between the two groups were seen in weight loss outcomes or early surgical complication rates (6.7%). However, more vitamin and nutritional deficiencies were present in the TALL 250-cm group (50.0% and 35.4%, respectively) versus the TALL 300-cm group (33.3% and 14.3% respectively), which led to laparoscopic revision in 27 patients by lengthening the TALL with 100 cm. Patients with weight regain after index RYGB had in average 59.9% higher EWL than patients with EWL failure. CONCLUSION Distalization of the failed RYGBP is safe and effective, but TALL should not be shorter than 300 cm (and CL 150 cm) due to high rates of malnutrition. Adequate supplementation and long-term follow-up are mandatory to prevent serious malnutrition.
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14
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Hort A, Cheng Q, Morosin T, Yoon P, Talbot M. Optimal common limb length in
Roux‐en‐Y
gastric bypass surgery: is it important for an ideal outcome? – a systematic review. ANZ J Surg 2022; 93:851-858. [PMID: 36480354 DOI: 10.1111/ans.18192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/07/2022] [Accepted: 11/27/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND In Roux-en-Y gastric bypass (RYGB) surgery the common limb length (CLL) is thought to significantly impact on nutritional and metabolic outcomes. However, there has been little focus on establishing routine standardized CLL measurements and its subsequent effect on weight loss and nutritional status. This review aimed to determine the effect of variations of CLL in RYGB surgery on post-operative outcomes, particularly nutritional status, while considering the need for routine CLL measurements in addition to measuring biliopancreatic limb and alimentary limb lengths. METHODS A systematic review was performed in accordance with the PRISMA guidelines. All English language articles addressing CLL and impact on weight loss, nutritional and metabolic outcomes were retrieved and reviewed. RESULTS Thirteen relevant studies were identified with CLLs varying from 76 to >600 cm. No significant difference in total body weight loss or excess weight loss was observed. Significant metabolic improvements occurred with shorter CLLs. Nutritional deficiencies were more severe when the CLL was <400 cm. CONCLUSION The data from this systematic review suggests that reasonable weight loss and positive impacts on metabolic outcomes can be achieved with CLLs of >400 cm.
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Affiliation(s)
- Amy Hort
- Department of Surgery Westmead Hospital Sydney New South Wales Australia
- Department of Surgery, The School of Medicine The University of Sydney Sydney New South Wales Australia
| | - Qiuye Cheng
- Department of Surgery Westmead Hospital Sydney New South Wales Australia
- UNSW St George and Sutherland Clinical School Sydney New South Wales Australia
| | - Tia Morosin
- Department of Surgery Westmead Hospital Sydney New South Wales Australia
| | - Peter Yoon
- Department of Surgery Westmead Hospital Sydney New South Wales Australia
| | - Michael Talbot
- UNSW St George and Sutherland Clinical School Sydney New South Wales Australia
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15
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Distal gastric bypass revision for weight recurrence or nonresponse to primary procedure: initial experience and outcomes in an academic practice. Surg Endosc 2022:10.1007/s00464-022-09719-4. [PMID: 36261645 DOI: 10.1007/s00464-022-09719-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 10/11/2022] [Indexed: 10/24/2022]
Abstract
BACKGROUND Considerable weight recurrence (WR) after Roux-en-Y gastric bypass (RYGB) may occur in nearly 20% of patients. While several nonoperative, endoscopic, and surgical interventions exist for this population, the optimal approach is unknown. This study reports our initial experience with distal bypass revision (DGB) and provides a comparison with patients after primary RYGB. METHODS Single-institution, retrospective review was conducted for patients who underwent DGB from 2018 to 2020. A Roux and common channel of 150 cm each were constructed (total alimentary limb 300 cm). A group of primary RYGB patients with similar demographics were selected as controls. Demographics, comorbidity resolution, surgical technique, complications, excess weight loss (EWL), total weight loss (TWL), BMI, and weight change data were compared. Patient postoperative weight loss (WL) was also compared after their primary and DGB operations. RESULTS Sixteen DGB patients, all female, were compared with 29 controls. DGB was performed on average 12.3 years after primary RYGB. In the DGB group, mean BMI was 53.7 before primary RYGB, 31.9 at nadir, and 44.1 prior to DGB. Post-DGB, mean BMI was 40.5, 37.4, 34.8, and 34.4, at 3-, 6-, 12-, and 24-months, respectively. Five patients (31.3%) experienced complications and were readmitted within 30 days, with two of them (12.5%) requiring reintervention and one (6.3%) undergoing reoperation. Mean EWL and TWL up to 2 years after DGB were lower than that after the patient's original RYGB (52.3 ± 18.6 vs. 67.2 ± 33.2; p = 0.126 and 19.6 ± 13.3 vs. 29.6 ± 11.8; p = 0.027, respectively). CONCLUSIONS DGB resulted in excellent WL up to 2 years after surgery but was associated with considerable postoperative complication rates. The magnitude of TWL was lower compared with the primary operation. Only a few patients experienced nutritional complications. Results of this study can help counsel patients pursuing DGB for WR or nonresponse to primary RYGB. The comparative effectiveness of this approach to other available options remains to be determined.
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16
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Hung WT, Hsu FC, Pan HM, Liao GS, Chen TW, Chan DC, Hsu KF. Case Report: Combined Laparoscopic Gastric Pouch Resizing with Fistula Resection and Distalization of the Roux Limb for a Patient with Weight Regain and a Gastro-Gastric Fistula After Roux-en-Y Gastric Bypass. Obes Surg 2022; 32:189-191. [PMID: 34302280 DOI: 10.1007/s11695-021-05595-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 07/08/2021] [Accepted: 07/14/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Wan-Ting Hung
- Division of General Surgery, Department of Surgery, Taichung Armed Forces General Hospital, Taichung, Taiwan
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Fang-Chin Hsu
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Department of General Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Hsin-Mei Pan
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Department of General Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Guo-Shiou Liao
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Teng-Wei Chen
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - De-Chuan Chan
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Kuo-Feng Hsu
- Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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17
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Dolan RD, Jirapinyo P, Thompson CC. Endoscopic versus surgical gastrojejunal revision for weight regain in Roux-en-Y gastric bypass patients: 5-year safety and efficacy comparison. Gastrointest Endosc 2021; 94:945-950. [PMID: 34126065 PMCID: PMC8908793 DOI: 10.1016/j.gie.2021.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 06/05/2021] [Indexed: 02/08/2023]
Abstract
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.
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18
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Almayouf M, Billa S, Alqahtani A. Candy cane syndrome at jejunojejunostomy causing small bowel obstruction following revisional laparoscopic gastric bypass: A case report and review of literature. Int J Surg Case Rep 2021; 86:106360. [PMID: 34482203 PMCID: PMC8426524 DOI: 10.1016/j.ijscr.2021.106360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 08/28/2021] [Accepted: 08/30/2021] [Indexed: 02/03/2023] Open
Abstract
Introduction and importance The literature described Candy cane syndrome (CCS) as causing various symptoms and affecting patients' quality of life. Most of the literature described this syndrome occurrence at gastrojejunostomy (GJ) anastomosis. The literature lacks data on this syndrome occurring at the jejunojejunostomy (JJ). Case presentation We describe a patient who underwent revision of laparoscopic gastric bypass (LGB) due to weight regain and presented three days after the procedure with small bowel obstruction (SBO). The patient was admitted as she demonstrated a picture of SBO. A complete workup and contrast study was done and showed dilated bowel loops. The patient was taken for exploratory laparoscopy, which revealed dilated 10–15 cm candy cane near the JJ, causing and obstruction. Resection of the elongated blind pouch was done, and the patient tolerated the surgery with improvement in her symptoms. Preoperative imaging, perioperative management, procedure videos, and follow-up were used to describe the case. Clinical discussion After reviewing the literature, eight papers reported CCS, 7 of those articles mentioned the syndrome located at the GJ. CCS located near the JJ can lead to symptoms including SBO. Management is mainly surgical, and prevention of occurrence can be achieved by limiting unnecessary elongated blind pouches. Conclusion CCS is a well-established condition occurring at the GJ following LGB, but it can manifest similarly if an elongated blind limb is left unresected at the JJ. Candy cane syndrome is an uncommon entity following laparoscopic gastric bypass. Most of literature mentioned this syndrome occurring at the gastrojejunostomy with vague unspecific symptoms. We report an unusual presentation of candy cane syndrome occurring at jejunojejunostomy causing small bowel obstruction.
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Affiliation(s)
- Mohammad Almayouf
- Prince Sattam bin Abdulaziz University, College of Medicine, Department of Surgery, Alkharj 11942, P.O.Box: 173, Saudi Arabia.
| | - Srikar Billa
- Dr. Sulaiman Al-Habib Hospitals, Takhassusi Road - Rahmaniya - Riyadh, P.O. Box: 2000, 11393 Riyadh, Saudi Arabia
| | - Awadh Alqahtani
- King Saud University, College of Medicine, Department of Surgery, P.BOX 145111, 4545 Riyadh, Saudi Arabia
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Hamed H, Ali M, Elmahdy Y. Types, Safety, and Efficacy of Limb Distalization for Inadequate Weight Loss After Roux-en-Y Gastric Bypass: A Systematic Review and Meta-analysis With a Call for Standardized Terminology. Ann Surg 2021; 274:271-280. [PMID: 32941271 DOI: 10.1097/sla.0000000000004485] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Comprehensive classification and evaluation of the outcome of limb distalization (LD) for inadequate weight loss after roux-en-y gastric bypass (RYGB). BACKGROUND Limb distalization is a revisional malabsorptive procedure for the management of inadequate weight loss after RYGB. Multiple studies with small sample sizes reported the outcome of LD. This meta-analysis aims to reach a higher level of evidence regarding the safety and efficacy of the procedure. METHODS A systematic search, including all studies on LD for management of inadequate weight loss after RYGB. The search engines included were PubMed, Embase, Web of Science, Cochrane Library, Scopus, and EBSCOhost. RESULTS Fourteen studies were included. The pooled estimates of the mid-term percentage of excess weight loss (%EWL), diabetic, and hypertension remission were 50.8%, 69.9%, and 59.8%, respectively. The rate of surgical revision for the management of protein-energy malnutrition (PEM) was 17.1%. The %EWL was significantly higher with older age and good response to index surgery (P = 0.01, 0.04, respectively). Less total alimentary limb length was not associated with better %EWL (P = 0.9), but it was significantly associated with severe PEM (P = 0.01). CONCLUSIONS LD has an encouraging rate of resolution of comorbidities. A judicious patient selection is essential for better weight loss after LD. Type I LD with total alimentary limb length ≥350 cm was associated with less risk of malnutrition. PEM is a life-threatening complication that may require revisional surgery years after LD. Future studies on LD, adopting standardized surgical practice and terminology, will allow a more conclusive assessment of the outcome of the procedure.
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Affiliation(s)
- Hosam Hamed
- Gastrointestinal surgical center (GISC), Faculty of Medicine, Mansoura University, Mansoura, Egypt
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20
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Wang A, Poliakin L, Sundaresan N, Vijayanagar V, Abdurakhmanov A, Thompson KJ, Mckillop IH, Barbat S, Bauman R, Gersin KS, Kuwada TS, Nimeri A. The Role of Total Alimentary Limb Length in Roux-En-Y Gastric Bypass – A Systematic Review. Surg Obes Relat Dis 2021; 18:555-563. [DOI: 10.1016/j.soard.2021.08.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/04/2021] [Accepted: 08/21/2021] [Indexed: 12/21/2022]
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21
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Kraljević M, Köstler T, Süsstrunk J, Lazaridis II, Taheri A, Zingg U, Delko T. Revisional Surgery for Insufficient Loss or Regain of Weight After Roux-en-Y Gastric Bypass: Biliopancreatic Limb Length Matters. Obes Surg 2021; 30:804-811. [PMID: 31863410 DOI: 10.1007/s11695-019-04348-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Weight regain after laparoscopic Roux-en-Y gastric bypass (RYGB) occurs in up to 35% of patients. Revisional surgery may be applied. Conversion from RYGB to a long biliopancreatic limb (BPL) RYGB is a potential option for revisional surgery and short-term results are promising. METHODS All patients who underwent conversion to long BPL RYGB due to weight loss failure, defined as excess weight loss (EWL) < 50% or body mass index (BMI) > 35 kg/m2, were assessed. Proximal RYGB or very very long limb RYGB (VVLL RYGB) was modified by shortening of the total alimentary limb length (TALL) to create a long BPL. RESULTS A total of 28 patients received revisional surgery from either PRYGB (n = 22) or VVLL RYGB (n = 6). Mean age at operation was 45.3 ± 10.4 years, with 78% females. Mean prerevisional BMI was 41.7 ± 4.4 kg/m2. Mean time to revision was 76.5 ± 38.5 months. Limb lengths were 150 cm (95% CI 133-156 cm) for RL and 100 cm (95% CI 97-113 cm) for CC, thus providing a total median alimentary limb length of 250 (95% CI 238-260 cm). Additional %EWL and TWL improved significantly in long-term. Five years postoperatively, all patients (n = 9) had an EWL% > 50%. Six patients (21.4%) required reoperation due to severe malnutrition during the postoperative course. CONCLUSION Conversion from RYGB to BPL RYGB leads to significant additional weight loss in the long term. However, the morbidity is relevant, especially severe protein malnutrition and the frequency of revisional surgery. Therefore, this type of surgery should not be done routinely.
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Affiliation(s)
- Marko Kraljević
- Department of General Surgery, Limmattal Hospital, 8952, Zurich-Schlieren, Switzerland
| | - Thomas Köstler
- Department of General Surgery, Limmattal Hospital, 8952, Zurich-Schlieren, Switzerland
| | - Julian Süsstrunk
- Department of General Surgery, Limmattal Hospital, 8952, Zurich-Schlieren, Switzerland
| | - Ioannis I Lazaridis
- Clarunis, University Center for Gastrointestinal and Liver Diseases, 4002, Basel, Switzerland
| | - Amy Taheri
- Institute of Clinical Chemistry, University Hospital Zurich, 8952, Zurich-Schlieren, Switzerland
| | - Urs Zingg
- Department of General Surgery, Limmattal Hospital, 8952, Zurich-Schlieren, Switzerland
| | - Tarik Delko
- Clarunis, University Center for Gastrointestinal and Liver Diseases, 4002, Basel, Switzerland.
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22
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Bariatric Surgery-How Much Malabsorption Do We Need?-A Review of Various Limb Lengths in Different Gastric Bypass Procedures. J Clin Med 2021; 10:jcm10040674. [PMID: 33578635 PMCID: PMC7916324 DOI: 10.3390/jcm10040674] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/06/2021] [Accepted: 02/07/2021] [Indexed: 12/18/2022] Open
Abstract
The number of obese individuals worldwide continues to increase every year, thus, the number of bariatric/metabolic operations performed is on a constant rise as well. Beside exclusively restrictive procedures, most of the bariatric operations have a more or less malabsorptive component. Several different bypass procedures exist alongside each other today and each type of bypass is performed using a distinct technique. Furthermore, the length of the bypassed intestine may differ as well. One might add that the operations are performed differently in different parts of the world and have been changing and evolving over time. This review evaluates the most frequently performed bariatric bypass procedures (and their variations) worldwide: Roux-en-Y Gastric Bypass, One-Anastomosis Gastric Bypass, Single-Anastomosis Duodeno-Ileal Bypass + Sleeve Gastrectomy, Biliopancreatic Diversion + Duodenal Switch and operations due to weight regain. The evaluation of the procedures and different limb lengths focusses on weight loss, remission of comorbidities and the risk of malnutrition and deficiencies. This narrative review does not aim at synthesizing quantitative data. Rather, it provides a summary of carefully selected, high-quality studies to serve as examples and to draw tentative conclusions on the effects of the bypass procedures mentioned above. In conclusion, it is important to carefully choose the procedure and small bowel length excluded from the food passage suited best to each individual patient. A balance has to be achieved between sufficient weight loss and remission of comorbidities, as well as a low risk of deficiencies and malnutrition. In any case, at least 300 cm of small bowel should always remain in the food stream to prevent the development of deficiencies and malnutrition.
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23
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A Step-by-Step Surgical Technique Video of Revision of Roux-en-Y Gastric Bypass with Limb Distalization. Obes Surg 2020; 31:464-466. [PMID: 33146870 DOI: 10.1007/s11695-020-04964-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/31/2020] [Accepted: 09/04/2020] [Indexed: 10/23/2022]
Abstract
The Roux-en-Y gastric bypass (RYGB) is the second most common bariatric procedure in the USA. Although the RYGB is an effective procedure, some patients will not achieve optimal weight loss or will experience significant weight regain. In this video report, we present a step-by-step surgical technique of RYGB limb distalization in a 49-year-old female patient for inadequate weight loss.
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24
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Almalki OM, Soong TC, Lee WJ, Chen JC, Wu CC, Lee YC. Variation in Small Bowel Length and Its Influence on the Outcomes of Sleeve Gastrectomy. Obes Surg 2020; 31:36-42. [PMID: 32914323 DOI: 10.1007/s11695-020-04958-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/28/2020] [Accepted: 09/02/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Small bowel length is drawing attention in the development of gastrointestinal bariatric/metabolic surgery, but the importance of the length of the small bowel in bariatric/metabolic is not clear. The present study was conducted to investigate variations in small bowel length and their clinical significance in patients undergoing laparoscopic sleeve gastrectomy (LSG). MATERIALS AND METHODS Small bowel length was measured in 620 patients diagnosed with obesity who underwent LSG between March 2014 and August 2018. Prospectively obtained demographic and clinical data were investigated, focusing on the association between small bowel length and weight loss. RESULTS Small bowel length varied widely among patients (mean 739.8 + 115.7 cm, range 380-1050 cm). Linear regression analysis revealed a significant association between small bowel length and body height, body weight, waist circumference, and serum levels of low-density lipoprotein cholesterol, hemoglobin, C-peptide, glycated hemoglobin (A1C), and gamma-glutamyl transferase (r-GT). Multivariate analysis confirmed that body height and serum A1C% levels independently predicted small bowel length in bariatric patients, strongly with body height (p < 0.001) but weakly with A1C%(p = 0.021). One-year follow-up rate was 75.3% (467/620), and small bowel length did not influence weight loss or the reduction of obesity related cardiovascular risk factors after LSG. CONCLUSION In this study, small bowel length varied widely among bariatric patients and was strongly associated with body height and weakly with serum A1C levels. Small bowel length has no significant role in weight loss or the resolution of cardiovascular risk factors after LSG.
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Affiliation(s)
- Owaid M Almalki
- Department of Surgery, College of Medicine, Taif University, Ta'if, Saudi Arabia.,Department of Surgery, Min-Sheng General Hospital, No. 168, Ching Kuo Road, Taoyuan, Taiwan
| | - Tien-Chou Soong
- Department of Weight Loss and Health Management Center, E-DA Dachang Hospital, Kaohsiung, Taiwan.,Department of Asia Obesity Medical Research Center, E-DA Hospital, Kaohsiung, Taiwan.,College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Wei-Jei Lee
- Department of Surgery, Min-Sheng General Hospital, No. 168, Ching Kuo Road, Taoyuan, Taiwan.
| | - Jung-Chien Chen
- Department of Surgery, Min-Sheng General Hospital, No. 168, Ching Kuo Road, Taoyuan, Taiwan
| | - Chun-Chi Wu
- Department of Surgery, Min-Sheng General Hospital, No. 168, Ching Kuo Road, Taoyuan, Taiwan
| | - Yi-Chih Lee
- Department of International Business, Chien Hsin University, Taoyuan, Taiwan
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25
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Brown AM, Spaniolas K. Distalization of Roux-en-Y Gastric Bypass: Lengthening the Biliopancreatic Limb. J Gastrointest Surg 2020; 24:2183-2184. [PMID: 32415657 DOI: 10.1007/s11605-020-04625-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 04/22/2020] [Indexed: 01/31/2023]
Abstract
Laparoscopic Roux-en-Y gastric bypass is an effective surgical procedure to manage obesity and associated comorbidities. Despite this, some patients experience suboptimal weight loss or weight regain. Several revisional options are available following gastric bypass. Distalization, by increasing the biliopancreatic limb and decreasing the common channel, has been previously shown to improve weight loss with low perioperative morbidity. The impact on weight and nutritional deficiencies is associated with lengths of the different intestinal limbs. Although gastric bypass distalization is an established procedure, in this video we present some technical tips and peals.
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Affiliation(s)
- Andrew M Brown
- Department of Surgery, Health Sciences Center, Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Health Sciences Center T18-040, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA
| | - Konstantinos Spaniolas
- Department of Surgery, Health Sciences Center, Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Health Sciences Center T18-040, Stony Brook Medicine, Stony Brook, NY, 11794-8191, USA.
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26
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Misra S, Nandhini BD, Christinajoice S, Kumar SS, Prabhakaran S, Palanivelu C, Raj PP. Is Laparoscopic Roux-en-Y Gastric Bypass Still the Gold Standard Procedure for Indians? Mid- to Long-Term Outcomes from a Tertiary Care Center. Obes Surg 2020; 30:4482-4493. [PMID: 32725594 DOI: 10.1007/s11695-020-04849-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/04/2020] [Accepted: 07/08/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Laparoscopic Roux-en-Y gastric bypass (RYGB) is the oldest and most widely performed bariatric surgery worldwide. There is, however, a scarcity of mid- to long-term data of RYGB, especially from the Indian subcontinent. MATERIALS AND METHODS The study was a single-center, retrospective analysis from patients who underwent RYGB between January 2009 and November 2014 from a tertiary care center in India. Percent of total weight loss (%TWL) was taken as the primary outcome of the study. Secondary outcomes included type 2 diabetes mellitus (T2DM) remission, comorbidity resolution, revisional surgeries, and complications related to RYGB at 1 year, at 3 years, and during the long term, following surgery. Postoperative visits took place at 1 and 3 years, while the long-term outcome was at median 8.3 years (range 5.4-11.2 years), with a follow-up of 92.4% (488/528), 80.5% (424/527) and 69.5% (363/522), respectively. RESULTS Out of 528 patients studied, 56% were females. The mean body mass index (BMI) was 40.6 ± 6.9 kg/m2. The %TWL in the long-term follow-up was 21.8 ± 11.3%. T2DM remission rates at 1 year, at 3 years, and during the long term were 84.5%, 70.0%, and 60.0%, respectively. Preoperative HBA1c (p = 0.002) and insulin usage (p = 0.016) had a significant predictive effect on T2DM remission. Gastroesophageal reflux disease (GERD) improved significantly (p < 0.001). Early (< 30 days) and late (> 30 days) complications were observed in 2.3% and 4.3% of the patients, respectively. CONCLUSION Weight loss during mid to long-term follow-up was maintained in the majority of the patients after RYGB. However, a small proportion had significant weight regain in the long term. T2DM, GERD, and other comorbidities were well improved after RYGB.
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Affiliation(s)
- Shivanshu Misra
- Department of Bariatric and Metabolic Surgery, GEM Hospital & Research Center, Coimbatore, Tamil Nadu, 641045, India
| | - B Deepa Nandhini
- Department of Bariatric and Metabolic Surgery, GEM Hospital & Research Center, Coimbatore, Tamil Nadu, 641045, India
| | - S Christinajoice
- Department of Bariatric and Metabolic Surgery, GEM Hospital & Research Center, Coimbatore, Tamil Nadu, 641045, India
| | - S Saravana Kumar
- Department of Bariatric and Metabolic Surgery, GEM Hospital & Research Center, Coimbatore, Tamil Nadu, 641045, India
| | - S Prabhakaran
- Department of Bariatric and Metabolic Surgery, GEM Hospital & Research Center, Coimbatore, Tamil Nadu, 641045, India
| | - C Palanivelu
- Department of Bariatric and Metabolic Surgery, GEM Hospital & Research Center, Coimbatore, Tamil Nadu, 641045, India
| | - P Praveen Raj
- Department of Bariatric and Metabolic Surgery, GEM Hospital & Research Center, Coimbatore, Tamil Nadu, 641045, India.
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27
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Ortega-Serrano J, Kraus-Fischer G, Alfonso-Ballester R, Cassinello-Fernández N. Shortening of the Common Channel as a Rescue Surgery After Gastric Bypass Failure. Obes Surg 2020; 30:4760-4767. [PMID: 32691399 DOI: 10.1007/s11695-020-04854-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND After Roux-en-Y gastric bypass (RYGB), up to 30% failures in weight loss have been reported. Among multiple solutions available, we report our experience with shortening of the common channel (SCC) by performing a limb distalization of the alimentary or the biliopancreatic limb. SETTINGS University Hospital. METHODS We reviewed data from 23 patients that underwent limb distalization between 2001 and 2019 due to inadequate weight loss after an initial RYGB in our center. All patients who failed to achieve an excess weight loss reduction of > 50% or maintained a body mass index (BMI) above 35 kg/m2 were included. Multiple variables were analyzed during the follow-up at five time points: initial, after RYGB, before SCC, after SCC, and current. RESULTS The mean BMI prior to the RYGB was 51.8 kg/m2, after RYGB was 37.6 kg/m2, before SCC was 43.6 kg/m2, after SCC was 36.1 kg/m2, and the final BMI was 36.3 kg/m2. No morbidity was seen after SCC. Long-term associated nutritional deficiencies were only identified in 3 patients which had iron deficiency and 1 patient with vitamin D deficiency. Patients with associated comorbidities significantly improved or were withdrawn from medications after the RYGB, with minor variations after SCC. CONCLUSIONS Limb distalization with SCC is a safe and effective technique for patients who failed to achieve an adequate weight loss after RYGB. There is a slight increase in excess of weight loss after the SCC compared with RYGB. In addition, no further weight regain was documented.
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Affiliation(s)
- Joaquin Ortega-Serrano
- Endocrine and Bariatric Surgery Unit, Hospital Clinico Universitario, Valencia, Spain. .,Department of Surgery, University of Valencia, Av. Blasco Ibanez, 17, 46010, Valencia, Spain.
| | - Gabriel Kraus-Fischer
- Endocrine and Bariatric Surgery Unit, Hospital Clinico Universitario, Valencia, Spain
| | - Raquel Alfonso-Ballester
- Endocrine and Bariatric Surgery Unit, Hospital Clinico Universitario, Valencia, Spain.,Department of Surgery, University of Valencia, Av. Blasco Ibanez, 17, 46010, Valencia, Spain
| | - Norberto Cassinello-Fernández
- Endocrine and Bariatric Surgery Unit, Hospital Clinico Universitario, Valencia, Spain.,Department of Surgery, University of Valencia, Av. Blasco Ibanez, 17, 46010, Valencia, Spain
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28
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Sun Y, Chu X, Shan X, Shi Y, Sun X. An Effective Way to Treat Hyperammonemic Encephalopathy Complicated Post-Distal Roux-en-Y Gastric Bypass Surgery. Obes Surg 2020; 30:3239-3241. [PMID: 32347520 DOI: 10.1007/s11695-020-04557-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Yuanyuan Sun
- Medical School of Southeast University, Nanjing, 210009, Jiangsu Province, People's Republic of China.,Medical School of Southeast University Nanjing Drum Tower Hospital, Nanjing, 210029, Jiangsu Province, People's Republic of China
| | - Xuehui Chu
- Nanjing Drum Tower Hospital, Nanjing, 210008, Jiangsu Province, People's Republic of China
| | - Xiaodong Shan
- Nanjing Drum Tower Hospital, Nanjing, 210008, Jiangsu Province, People's Republic of China
| | - Yuze Shi
- Medical School of Southeast University, Nanjing, 210009, Jiangsu Province, People's Republic of China.,Medical School of Southeast University Nanjing Drum Tower Hospital, Nanjing, 210029, Jiangsu Province, People's Republic of China
| | - Xitai Sun
- Medical School of Southeast University, Nanjing, 210009, Jiangsu Province, People's Republic of China. .,Medical School of Southeast University Nanjing Drum Tower Hospital, Nanjing, 210029, Jiangsu Province, People's Republic of China. .,Nanjing Drum Tower Hospital, Nanjing, 210008, Jiangsu Province, People's Republic of China. .,Department of Hepatobiliary Surgery, The Affiliated Drum Tower Hospital of Southeast University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu Province, China.
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29
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Debs T, Frey S, Petrucciani N, Fortier Beaulieu C, Lame F, Iannelli A, Sejor E, Amor IB, Gugenheim J. Combined Laparoscopic Revision of the Gastric Pouch and Distalization of the Roux Limb After Failure of Weight Loss Following Roux-en-Y Gastric Bypass. Obes Surg 2020; 30:2851-2853. [DOI: 10.1007/s11695-020-04476-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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30
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Moon RC, Bornstein A, Teixeira AF, Jawad MA. Short-term results of long biliopancreatic limb Roux-en-Y gastric bypass-is it superior? Surg Obes Relat Dis 2019; 16:492-496. [PMID: 31987734 DOI: 10.1016/j.soard.2019.12.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/06/2019] [Accepted: 12/17/2019] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To compare the short-term safety and effectiveness of long biliopancreatic limb Roux-en-Y gastric bypass (RYGB) to that of regular RYGB. SETTING Academic hospital, United States. METHODS A retrospective chart review was performed on 89 consecutive patients who underwent RYGB between February 4, 2014 and March 12, 2015. Of these, 43 underwent long biliopancreatic limb RYGB (150 versus 60 cm, with 100-cm Roux limb). RESULTS Baseline characteristics including sex, preoperative body mass index, and co-morbidities were similar between the long- and regular-limb RYGB patients. Long-limb patients were older than regular-limb patients. The median length of hospital stay was similar (2 d for both groups). In the long-limb RYGB group, the mean percentage of excess body mass index loss was 50.3%, 71.4%, 75.8%, and 80.5% at 6, 12, 24, and 36 months after the procedure, respectively. In the regular-limb RYGB group, the mean excess body mass index loss was 51.8%, 71.7%, 69.3%, and 68.5% during the same follow-up period. No significant difference in weight loss was observed between the 2 groups at any time point. Two patients in each group required 30-day readmission (4.7% and 4.3%). Two patients in each group required 30-day reoperation. One death occurred in the regular limb group due to a cerebrovascular accident after discharge. CONCLUSIONS Short-term results show that long biliopancreatic limb RYGB was not associated with a more significant weight loss after RYGB. The 2 procedures were similar in 30-day complications.
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Affiliation(s)
- Rena C Moon
- Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando Health, Orlando, Florida
| | - Aaron Bornstein
- Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando Health, Orlando, Florida
| | - Andre F Teixeira
- Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando Health, Orlando, Florida
| | - Muhammad A Jawad
- Department of Bariatric Surgery, Orlando Regional Medical Center, Orlando Health, Orlando, Florida.
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31
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van der Burgh Y, Boerboom A, de Boer H, Witteman B, Berends F, Hazebroek E. Weight loss and malnutrition after conversion of the primary Roux-en-Y gastric bypass to distal gastric bypass in patients with morbid obesity. Surg Obes Relat Dis 2019; 16:381-388. [PMID: 31948922 DOI: 10.1016/j.soard.2019.12.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 11/16/2019] [Accepted: 12/04/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND After Roux-en-Y gastric bypass (RYGB), 15% to 35% of patients fail to lose sufficient weight. Distalization of the limbs of the RYGB (D-RYGB) with shortening of the common channel (CC), has been used to induce additional weight loss. However, this may increase the risk of malnutrition. OBJECTIVE The aim of this study was to assess postoperative outcomes after D-RYGB with an alimentary limb of 250 to 300 cm and CC of 100 cm. SETTING General hospital, specialized in bariatric surgery. METHODS We retrospectively studied all patients who underwent revision of RYGB to D-RYGB between January 2014 and April 2018. Data were collected from medical records, including weight loss, nutritional deficiencies, and co-morbidities. Questionnaires on defecation pattern, quality of life, and patient satisfaction were obtained. RESULTS Forty-seven patients were included. Total weight loss (%TWL) increased significantly from 12% to 30% after D-RYGB. In 62% of patients %TWL >25% was achieved. Patients with %TWL <25% after primary RYGB, lost significantly more weight than initially reached after RYGB. Diabetes and hypertension remission occurred in 67% and 50%, respectively. Five patients (11%) needed subsequent lengthening of the CC to 250 cm due to protein malnutrition or debilitating defecation patterns. Nutritional deficiencies were present in 89% of patients after D-RYGB despite the prescription of specialized multivitamins. CONCLUSION Conversion of the primary RYGB to D-RYGB improves weight loss and co-morbidities in patients with insufficient weight loss after primary RYGB. After D-RYGB, nutritional complications and diarrhea are a risk. Based on this study, a modified D-RYGB with a longer CC of >200 cm will be considered.
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Affiliation(s)
- Yonta van der Burgh
- Department of Bariatric Surgery, Rijnstate Hospital/Vitalys Clinic, Arnhem, the Netherlands.
| | - Abel Boerboom
- Department of Bariatric Surgery, Rijnstate Hospital/Vitalys Clinic, Arnhem, the Netherlands
| | - Hans de Boer
- Department of Internal Medicine, Rijnstate Hospital, Arnhem, the Netherlands
| | - Bart Witteman
- Department of Bariatric Surgery, Rijnstate Hospital/Vitalys Clinic, Arnhem, the Netherlands
| | - Frits Berends
- Department of Bariatric Surgery, Rijnstate Hospital/Vitalys Clinic, Arnhem, the Netherlands
| | - Eric Hazebroek
- Department of Bariatric Surgery, Rijnstate Hospital/Vitalys Clinic, Arnhem, the Netherlands
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32
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Nimeri A. Comment on: Surgical therapy of weight regain following Roux-en-Y gastric bypass. Surg Obes Relat Dis 2019; 15:1729-1730. [PMID: 31427222 DOI: 10.1016/j.soard.2019.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 07/08/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Abdelrahman Nimeri
- Division of Bariatric Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina
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33
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Surgical therapy of weight regain after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2019; 15:1719-1728. [PMID: 31474525 DOI: 10.1016/j.soard.2019.07.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/28/2019] [Accepted: 07/03/2019] [Indexed: 12/26/2022]
Abstract
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.
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34
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Ribeiro R, Pouwels S, Parmar C, Pereira J, Manaças L, Guerra A, Borges N, Ribeiro J, Viveiros O. Outcomes of Long Pouch Gastric Bypass (LPGB): 4-Year Experience in Primary and Revision Cases. Obes Surg 2019; 29:3665-3671. [PMID: 31267476 DOI: 10.1007/s11695-019-04051-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND One of the most important complications of the one anastomosis gastric bypass (OAGB) is enterobilio acid reflux (EBAR). We report the concept of the long pouch Roux-en-Y gastric bypass (LPRYGB) meaning a Roux-en-Y with a long pouch and a 100-cm alimentary limb to avoid EBAR, with a long biliopancreatic limb to increase metabolic effects. METHODS A total of 300 LPRYGB cases in a 4-year period, with a 90% follow-up rate, were analysed. Anthropometric, technical feasibility, morbidity, weight loss and comorbidity outcomes were analysed. RESULTS The percentage total weight loss (%TWL) was 30.5% at 4 years of follow-up (32.3% in primary and 28.3% in revisions). Six intra-operative (2%) and 28 postoperative complications (9.3%) were seen. Out of this 28 complications, 11 (3.6%) were late complications. Reoperations were performed in 15 patients (5.0%). Clinically relevant EBAR was present in 3 cases only (1%) 4 years after the operation. CONCLUSIONS The LPRYGB combines the main advantages of the OAGB (light restriction and moderate malabsorption) with the anti-reflux effect from the Roux-en-Y diversion.
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Affiliation(s)
- Rui Ribeiro
- Clínica de Santo António, Metabolic Patient Multidisciplinary Centre, Reboleira, Lisbon, Portugal
| | - Sjaak Pouwels
- Department of Surgery, Haaglanden Medical Center, Lijnbaan 32, P.O. Box 432, 2501 CK, The Hague, The Netherlands.
| | | | - João Pereira
- Obesity and Endocrine Diseases Unit, Department of Surgery, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Leonor Manaças
- Obesity and Endocrine Diseases Unit, Department of Surgery, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Anabela Guerra
- Obesity and Endocrine Diseases Unit, Department of Surgery, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - Nuno Borges
- Obesity and Endocrine Diseases Unit, Department of Surgery, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
| | - João Ribeiro
- Clínica de Santo António, Metabolic Patient Multidisciplinary Centre, Reboleira, Lisbon, Portugal
| | - Octávio Viveiros
- Obesity and Endocrine Diseases Unit, Department of Surgery, Centro Hospitalar de Lisboa Central, Lisbon, Portugal
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