A Retrospective Comparative Study of Primary Versus Revisional Roux-en-Y Gastric Bypass: Long-Term Results

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Medium and Long-Term Weight Loss After Revisional Bariatric Surgery: A Systematic Review and Meta-Analysis

Despite the current increase in revisional bariatric surgery (RBS), data on the sustainability of weight loss remain unclear. A systematic review and meta-analysis were performed to assess weight loss outcomes in adult patients undergoing RBS with follow-up > 2 years. Twenty-eight observational studies (n = 2213 patients) were included. The %TWL was 27.2 (95%CI = 23.7 to 30.6), and there was a drop in BMI of 10.2 kg/m2 (95%CI =  - 11.6 to - 8.7). The %EWL was 54.8 (95%CI = 47.2 to 62.4) but with a high risk of publication bias (Egger's test = 0.003). The overall quality of evidence was very low. Our data reinforce that current evidence on RBS is mainly based on low-quality observational studies, and further higher-quality studies are needed to support evidence-based practice.

Gastric mucocele after conversion of open butterfly gastroplasty to Roux-En-Y gastric bypass - A case report with a review of the literature

INTRODUCTION

There has been a significant increase in the prevalence of morbid obesity across the globe. Various non-surgical weight loss options have shown limited long-term efficacy, leading to the popularity of surgical treatment alternatives with long-term efficacy.

PRESENTATION OF CASE

This case report describes the development of a gastric mucocele in a 51-year-old female patient. The patient initially underwent open butterfly gastroplasty in August 2016. Seven years later, she presented with severe symptoms of gastroesophageal reflux disease (GERD). After further diagnostic evaluations, laparoscopic Roux-en-Y bypass surgery was performed. However, the patient experienced complications including fever, abdominal pain, and fluid collection around the stomach. Conservative management initially helped, but persistent symptoms led to laparoscopic exploration, which revealed a distended remnant stomach forming a gastric mucocele. Severe adhesions hindered attempts to remove the remnant stomach, resulting in the need for gastro-gastric anastomosis. Following the surgery, the patient had no symptoms, could eat solid food, and was discharged in good condition.

DISCUSSION

Although various non-surgical weight loss options such as diet modifications, lifestyle changes, and drug therapy have been used for weight loss, they have demonstrated limited long-term efficacy. Surgical treatment has demonstrated long-term efficacy in such patient groups. In recent years, there has been an increased popularity of Roux-en-Y gastric bypass (RYGBP) due to long-term weight loss. However, in some cases, complications have also been reported.

CONCLUSION

This case emphasizes the challenges in managing complications from open butterfly gastroplasty and Roux-en-Y gastric bypass. Surgeons should be aware of the possibility of gastric mucocele development and consider appropriate management strategies.

Outcome comparison between primary and revisional bariatric surgery: A propensity-matched analysis

BACKGROUND

Revisional bariatric procedures for weight recurrence are rising but are considered higher risk and less effective than primary bariatric procedures. This study aimed to compare clinical outcomes between primary and revisional bariatric surgery for weight recurrence.

METHODS

Prospectively collected data from adult patients who underwent revisional or primary bariatric surgery from 2016 to 2020 in an academic institution were reviewed. Roux-en-Y gastric bypass and sleeve gastrectomy were performed primarily or as conversion procedures after laparoscopic adjustable gastric band, vertical banded gastroplasty, and sleeve gastrectomy. 1:1 propensity score matching was performed between revisional bariatric surgery and primary bariatric surgery, and logistic regression analysis was used to compare up to 2-year weight loss and comorbidity resolution outcomes.

RESULTS

A total of172 cases (86 revisional bariatric surgery versus 86 primary bariatric surgery) were included. Groups were matched for age, sex, preoperative body mass index, bariatric procedure, diabetes, hypertension, and obstructive sleep apnea. Procedure duration (203 ± 78 vs 154 ± 69 minutes; P < .001) and length of stay (2.3 ± 2.1 vs 1.7 ± 1 days; P = .02) were longer for revisional bariatric surgery versus primary bariatric surgery, respectively. Total weight loss was less in revisional bariatric surgery compared with primary bariatric surgery at 1 year (23 ± 10% vs 32 ± 9%; P < .001) and 2 years (21 ± 12.% vs 32 ± 10%; P < .001) of follow-up; however, no differences were detected in postoperative occurrences, emergency department visits, readmissions, reintervention and reoperation rates, and comorbidity resolution.

CONCLUSION

Although revisional bariatric surgery was associated with longer operation times, prolonged hospitalization, and lower weight loss than primary bariatric surgery, it was accomplished safely and led to substantial weight loss and comorbidity resolution. This information can guide patient counseling before revisional surgery for weight recurrence.

Laparoscopic sleeve gastrectomy to Roux-en-Y gastric bypass conversion versus primary Roux-en-Y gastric bypass: a propensity score matching analysis

BACKGROUND

Secondary bariatric surgery rates have increased, accounting for approximately 19% of the total bariatric cases in the last years, most commonly conversion of sleeve gastrectomy to gastric bypass. Using the MBSAQIP, we evaluate the outcomes of this procedure compared to the primary RYGB surgery.

METHODS

The new variable, conversion of sleeve gastrectomy to RYGB in the 2020 and 2021 MBSAQIP database was analyzed. Patients who underwent primary laparoscopic RYGB and those who underwent laparoscopic sleeve gastrectomy to RYGB conversion were identified. Using Propensity Score Matching analysis, the cohorts were matched for 21 preoperative characteristics. We then compared 30-day outcomes and bariatric-specific complications between primary RYGB and conversion from sleeve gastrectomy to RYGB.

RESULTS

There were 43,253 primary RYGB procedures performed and 6,833 conversions from sleeve gastrectomy to RYGB. The matched cohorts (n = 5912) for the two groups have similar pre-operative characteristics. Propensity-matched outcomes showed that conversion from sleeve gastrectomy to RYGB was associated with more readmissions (6.9% vs 5.0%, p < 0.001), interventions (2.6% vs 1.7%, p < 0.001), conversion to open (0.7% vs 0.2%, p < 0.001), length of stay (1.79 ± 1.77 days vs 1.62 ± 1.66 days, p < 0.001), and operative time (119.16 ± 56.82 min vs 138.27 ± 66.00, p < 0.001). There were no significant differences in mortality (0.1% vs 0.1%, p = 0.405), and bariatric-specific complications such as anastomotic leak (0.5% vs 0.4%, p = 0.585), intestinal obstruction (0.1% vs 0.2%, p = 0.808), internal hernia (0.2% vs 0.1%, p = 0.285) or anastomotic ulcer (0.3% vs 0.3%, p = 0.731) rates.

CONCLUSION

Conversion from sleeve gastrectomy to RYGB is a safe and feasible operation with reasonable outcomes compared with primary RYGB.

Distalization of Standard Roux-en-Y Gastric Bypass: Indications, Technique, and Long-Term Results

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.

Predictors of morbidity in revisional bariatric surgery and bariatric emergencies at an MBSAQIP-accredited community hospital

Introduction

Bariatric surgery revisions and emergencies are associated with higher morbidity and mortality compared to primary bariatric surgery. No formal outcome benchmarks exist that distinguish MBSAQIP-accredited centers in the community from unaccredited institutions.

Methods

A retrospective chart review was conducted on 53 bariatric surgery revisions and 61 bariatric surgical emergencies by a single surgeon at a high-volume community hospital accredited program from 2018 to 2020. Primary outcomes were complications or deaths occurring within 30-days of the index procedure. Secondary outcomes included operative time, leaks, surgical site occurrences (SSOs), and deep surgical site infections.

Results

There were no significant differences in the demographic characteristics of the study groups. Mean operative time was significantly longer for revisions as compared to emergency operations (149.5 vs. 89.4 min). Emergencies had higher surgical site infection (5.7% vs. 21.3%, p < 0.05) and surgical site occurrence (SSO) (1.9% vs. 29.5%, p < 0.05) rates compared to revisions. Logistic regression analysis identified several factors to be predictive of increased risk of morbidity: pre-operative albumin < 3.5 g/dL (p < 0.05), recent bariatric procedure within the last 30 days (p < 0.05), prior revisional bariatric surgery (p < 0.05), prior duodenal switch (p < 0.05), and pre-operative COPD (p < 0.05).

Conclusion

Bariatric surgery revisions and emergencies have similar morbidity and mortality, far exceeding those of the primary operation. Outcomes comparable to those reported by urban academic centers can be achieved in community hospital MBSAQIP-accredited centers.

One-Stage Versus Two-Stage Gastric Bypass as Redo Surgery After Failed Adjustable Gastric Banding-Observation Comparative Multicenter Study

BACKGROUND

This study investigates the outcome of one-stage and two-stage Roux-Y gastric bypass (RYGB) as a revision procedure after failed adjustable gastric banding (AGB).

MATERIAL AND METHODS

Data of patients who underwent a one-stage RYGB (OS-RYGB) or a two-stage RYGB (TS-RYGB) revision procedure after failing AGB between 2005 and 2019 were analyzed. Outcome criteria were perioperative complications, operating time, change in weight and BMI, and remission of comorbidities at 1-year follow-up.

RESULTS

Data from 230 patients after OS-RYGB and 197 after TS-RYGB were analyzed. The total perioperative complication rates were not significantly different between the two groups (overall p > 5%). In the category of other complications, there was a significant difference between the two groups, with a lower rate in TS-RYGB than in OS-RYGB (p = 0.020). Wound infections occurred more frequently after TS-RYGB than after OS-RYGB (p = 0.015). Mean operating time differed significantly between the two groups (OS-RYGB (149.9 min) and TS-RYGB 191 min; p < 0.001). The change in hypertension was significantly higher in OS-RYGB (37.9 vs. 21.1%; p = 0.007). Other comorbidities showed no significant change within 1 year after surgery. Regarding the change in BMI, %TWL, and %EWL, there were no significant benefits for either group (p = 0.574, 0.762, and 0.378, respectively).

CONCLUSION

Removing a failed AGB using the OS- or TS-RYGB is safe and feasible. The decision between OS- and TS-RYGB is still individual and depends on the patient's general condition, the desired goal of the procedure, and the personal competence of the surgeon. Further studies are needed to clarify long-term outcome and effect of both procedures.

Can responsive deep brain stimulation be a cost-effective treatment for severe obesity?

OBJECTIVE

A first-in-human responsive deep brain stimulation (rDBS) trial (NCT03868670) for obesity is under way, which is based on promising preclinical evidence. Given the upfront costs of rDBS, it is prudent to examine the success threshold for cost-effectiveness compared with laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

Efficacy and safety data on LRYGB and safety data on rDBS were collected for established indications through a literature search. The success threshold was defined as minimum BMI reduction. Treatment costs were calculated via Medicare national reimbursement data.

RESULTS

LRYGB had a mean BMI reduction of 13.75 kg/m² . Based on adverse events, LRYGB was a less-preferred health state (overall adverse event utility of 0.96 [0.02]) than rDBS (0.98 [0.01]), but LRYGB ($14,366 [$6,410]) had a significantly lower treatment cost than rDBS ($29,951 [$4,490]; p < 0.0001). Therefore, for rDBS to be cost-effective compared with LRYGB, the multiple models yielded a success threshold range of 13.7 to 15.2 kg/m² .

CONCLUSIONS

This study established a preliminary efficacy success threshold for rDBS to be cost-effective for severe obesity, and results from randomized controlled trials are needed. This analysis allows for interpretation of the economic impact of advancing rDBS for obesity in light of ongoing trial results and suggests an attainable threshold is needed for cost-effectiveness.

Primary Roux-en-Y Gastric Bypass Results in Greater Weight Loss at 15-Year Follow-Up Compared with Secondary Roux-en-Y Gastric Bypass After Failure of Gastric Band or Mason McLean Vertical Gastroplasty

PURPOSE

The aim of the study is to compare the outcomes of patients treated with secondary Roux-en-Y gastric bypass (RYGB) after adjustable gastric banding (AGB) or vertical banded gastroplasty (VBG) with those of patients having primary RYGB.

MATERIALS AND METHODS

Patients undergoing secondary RYGB after AGB or VBG between 1997 and 2004 with a minimal follow-up of 15 years were matched using a propensity score (according to gender, age, BMI, duration of follow-up) with comparable patients who underwent primary RYGB.

RESULTS

The mean follow-up was 16.50 years in the secondary RYGB group (N = 32) versus 16.33 years in the primary RYGB group (N = 32). Early postoperative complications rate was 6.25% in the secondary RYGBs versus 9.38% in the primary RYGBs (P = 1). Late postoperative complications and additional surgical procedures were 56.25% and 37.5% in the secondary and primary RYGB group, respectively (P = 0.21). Long-term (at 16-20 years) %TWL and %EWL were significantly lower (P < 0.01 and P = 0.013, respectively) after secondary RYGB (%TWL = 7.56%; %EWL = 17.15%) than after primary RYGB (%TWL = 24.51%; %EWL = 55.61%). Remission of obesity-related comorbidities was comparable (P > 0.05). Gastroesophageal reflux was more frequent after secondary RGYB-43.75% versus 25%, P < 0.05. Quality of life-Morehead-Ardelt II score (0.02 in secondary RYGB versus 0.69 in primary RYGB, P = 0.13), general self-assessment of health status and weight satisfaction were comparable.

CONCLUSION

Secondary RYGB after AGB or VBG is less efficient at weight loss, GERD remission and energy expenditure at 15 years after conversion. However, it is as effective for improvement/resolution of obesity-related comorbidities and is associated with similar QoL scores.

Revisional Bariatric Surgery

Revisional bariatric surgery is a growing subset of all bariatric procedures. Although revisions can be associated with higher morbidity rates and less optimal outcomes than those seen with primary procedures, they can be safely performed, with excellent outcomes and improved quality of life for patients. Facility and familiarity with revisional principles and techniques are necessary components of bariatric surgical practice.

Laparoscopic Roux-en-Y Gastric Bypass After Failed Vertical Banded Gastroplasty: 2-Year Follow-up of 102 Patients

BACKGROUND

Vertical banded gastroplasty (VBG) is now discarded from being a restrictive procedure for morbid obesity due to its many drawbacks, doubtful efficacy, and lots of post-operative complications. Roux-en-Y gastric bypass (RYGB) is the most commonly performed procedure for VBG revision. So we aimed at reporting our experience in conversional RYGB for a failed VBG.

MATERIAL AND METHODS

Analyzing follow-up records of 102 patients who underwent revisional RYGB after failed VBG in the period from April 2014 to January 2018.

RESULTS

A total of 102 laparoscopic revisions of failed VBGs to RYGB were performed. The mean operating time was 161.9 min ±29.2 and the mean length of the hospital stay was 1.5 days ±1.2. Fourteen patients (13%) developed early post-operative complications (gastrojejunostomy leak 5; bleeding 9). Four patients (4.7%) developed late complications (Port site hernia 2; internal hernia 1; Stomal ulcer 1). The mean BMI pre-RYGB was 46.6 ± 5.9 kg/m², and the mean %EBWL (percent excess body weight lost) of the patients at 12 and 24 months post-revision were 56.2% and 64.3%, respectively. Our patients had immediate post-revision resolution of VBG-related complications like dysphagia and vomiting. We also report improvement in all obesity-related health problems with (75.7%) complete remission rate and (24.3%) partial remission or improvement rate of diabetes mellitus.

CONCLUSION

Conversion of VBG to RYGB is a feasible procedure and is associated with acceptable early morbidity rates and reduced lengths of hospitalization also it provides acceptable weight loss and improvement in obesity-related health problems. Graphical Abstract.

Weight Loss After Sleeve Gastrectomy: Does Type 2 Diabetes Status Impact Weight and Body Composition Trajectories?

INTRODUCTION/ PURPOSE

Sleeve gastrectomy (SG), the most frequently performed bariatric procedure, induces marked weight-loss, but with high inter-individual variability. Since type 2 diabetes (T2D) negatively impacts weight-loss outcomes after Roux-en-Y gastric bypass (RYGB), we herein aimed to evaluate whether and how T2D status may influence weight-loss and body composition changes in individuals with or without T2D after SG.

MATERIAL AND METHODS

We retrospectively included individuals with obesity operated from SG and prospectively followed at our center: 373 patients including 152 with T2D (40%). All subjects' clinical characteristics were collected before and during 4 years of follow-up post-SG. Linear mixed models were applied to analyze weight-loss trajectories post-surgery.

RESULTS

Compared to individuals with obesity but no T2D, those with T2D before SG displayed lower weight-loss at 1 year (21 vs. 27% from baseline, p < 10^-3). This difference was accentuated in patients with poorer glucose control (HbA1c > 7%) at baseline. Furthermore, patients with T2D underwent less favorable body composition changes at 1-year post-SG compared to individuals without T2D (% fat mass reduction: 28 vs. 37%, p < 10^-3 respectively).

CONCLUSION

When undergoing SG, subjects with obesity and T2D who have poor pre-operative glycemic control display reduced weight-loss and less improvement in body composition compared to patients with obesity but without T2D. This result suggests that glycemic control prior to surgery is important to take into account for the outcome of bariatric surgery.