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Cereser T, Heil J, Schöb O, Schlumpf R, Gantert WA, Infanger D, Böckmann M, Beissner P, Bach-Kliegel B, Potoczna N, Schiesser M. Long-term weight loss of distal gastric bypass is moderately superior compared to proximal gastric bypass in patients with a BMI of 37-44 Kg/m 2. Langenbecks Arch Surg 2024; 409:162. [PMID: 38771517 PMCID: PMC11108920 DOI: 10.1007/s00423-024-03348-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 05/07/2024] [Indexed: 05/22/2024]
Abstract
PURPOSE The laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the standard procedures in metabolic surgery. Different limb lengths have been proposed in the past to maximize weight loss (WL) and reduce metabolic complications. Distal gastric bypass surgery with a very short common channel (CC) (up to 100 cm) has been often criticized due to frequent side effects such as malnutrition, bone weakening and short-bowel syndrome. We introduced a modified version of a distal LRYGB with a 50-70 cm long biliopancreatic limb (BPL) and an intermediate short CC (120-150 cm). Our primary goal was to compare the long-term WL between distal and proximal LRYGB in two cohorts of patients. Secondary outcomes were weight regain (WR), insufficient weight loss (IWL), postoperative complications and metabolic changes 5 years after surgery. METHODS In this retrospective study we collected data from 160 patients operated between 2014 and 2015, with a BMI of 37-44 Kg/m2. 101 patients underwent a distal and 59 patients a proximal LRYGB in two bariatric centers. WL was calculated as percent of excess of BMI loss (%EBMIL), loss of body mass index (Delta-BMI), percent of excess weight loss (%EWL) and percent of total weight loss (%TWL). Data were collected 3, 6, 9, 12, 24, 48 and 60 months after surgery. RESULTS The distal LRYGB resulted in significantly better 5-year-WL compared to the proximal bypass in terms of %EBMIL (median at 5 years: 83% vs. 65%, p = 0.001), %TWL (median at 5 years: 32% vs. 26%, p = 0.017) and %EWL (median at 5 years: 65% vs. 51%, p = 0.029), with equal major complications and metabolic alterations. In addition, WR was significantly lower in patients with distal bypass (18% vs. 35%, p = 0.032). CONCLUSIONS Distal LYRGB with a 120-150 long CC results in better WL and WL-maintenance compared to proximal LRYGB without major side effects after five years.
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Affiliation(s)
- Teresa Cereser
- Chirurgisches Zentrum Zürich, Klinik Hirslanden, Zurich, Switzerland.
- Klinik für Viszeral- und Thoraxchirurgie, Kantonsspital Winterthur, Winterthur, Switzerland.
- University of Zurich (UZH), Zurich, Switzerland.
| | - Jan Heil
- Klinik für Allgemein-, Viszeral-, Transplantation- and Thoraxchirurgie, Goethe-Universität Frankfurt, Universitätsklinikum, Frankfurt am Main, Germany
| | - Othmar Schöb
- Chirurgisches Zentrum Zürich, Hirslanden Klinik, Zurich, Switzerland
| | - Rolf Schlumpf
- Chirurgisches Zentrum Zürich, Hirslanden Klinik, Zurich, Switzerland
| | - Walter A Gantert
- Chirurgie Zentrum Zentralschweiz Hirslanden Klinik St. Anna, Lucerne, Switzerland
| | - David Infanger
- Adipositas und Stoffwechselzentrum, Klinik Hirslanden, Zurich, Switzerland
| | - Michael Böckmann
- Adipositas und Stoffwechselzentrum, Klinik Hirslanden, Zurich, Switzerland
| | - Philippe Beissner
- Diabetes Adipositas Zentrum Zürich, Zollikerberg, Zurich, Switzerland
| | | | - Natascha Potoczna
- Stoffwechselpraxis Zentralschweiz AG, Hirslanden Klinik St. Anna, Lucerne, Switzerland
| | - Marc Schiesser
- Chirurgisches Zentrum Zürich, Hirslanden Klinik, Zurich, Switzerland
- Chirurgie Zentrum Zentralschweiz Hirslanden Klinik St. Anna, Lucerne, Switzerland
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Eagleston J, Nimeri A. Optimal Small Bowel Limb Lengths of Roux-en-Y Gastric Bypass. Curr Obes Rep 2023; 12:345-354. [PMID: 37466789 DOI: 10.1007/s13679-023-00513-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2023] [Indexed: 07/20/2023]
Abstract
PURPOSE OF REVIEW Gastric bypass and biliopancreatic diversion (BPD) have come full circle, from a loop configuration to a Roux-en-Y and finally back to a loop configuration as one anastomosis gastric bypass and single-anastomosis duodenal switch. Most surgeons performing Roux-en-Y gastric bypass (RYGB) do not measure the common channel (CC) length and most surgeons performing BPD do not measure the biliopancreatic limb length (BPL). RECENT FINDINGS The small bowel length in humans is variable from as short as < 400 cm to as long as > 1000 cm. The combination of these two facts means that even if surgeons keep the limb lengths constant, surgeons will get variable limb length due to the variability of small bowel length in patients. Hence, outcomes of weight loss, resolution of medical problems, or developing nutritional deficiencies which are related to limb length are variable. In this article, we evaluate the published literature related to the effect of varying the Roux limb, BPL, CC, and total alimentary limb lengths on the outcomes of RYGB. We have focused on historical and current randomized controlled trials as well as systematic reviews and meta-analysis to outline the current literature and our interpretation of this literature.
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Affiliation(s)
- Justin Eagleston
- Bariatric Surgery, Department of Surgery, Atrium Health, Charlotte, USA
| | - Abdelrahman Nimeri
- Wake Forest School of Medicine, Bariatric Surgery, Atrium Health, Charlotte, NC, USA.
- Director, of Bariatric Surgery, Brigham and Womens Hospital, Harvard Medical School, 75 Francis, MA, 02115, Boston, USA.
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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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Schneider R, Kraljević M, Peterli R, Rohm TV, Bosch AJ, Low AJ, Keller L, AlAsfoor S, Häfliger S, Yilmaz B, Peterson CJ, Lazaridis II, Vonaesch P, Delko T, Cavelti-Weder C. Roux-en-Y gastric bypass with a long compared to a short biliopancreatic limb improves weight loss and glycemic control in obese mice. Surg Obes Relat Dis 2022; 18:1286-1297. [DOI: 10.1016/j.soard.2022.06.286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 05/02/2022] [Accepted: 06/18/2022] [Indexed: 11/30/2022]
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Gadiot RPM, Biter LU, Feskens PG, Dunkelgrun M, Apers JA, van 't Hof G, Mannaerts GHH. Midterm Results from the Dutch Common Channel Trial (DUCATI): Superior Weight Loss Results of the Long Roux Limb Gastric Bypass in Comparison to the Standard Bypass at 3-Year Follow-Up. Obes Surg 2021; 31:5132-5140. [PMID: 34476726 DOI: 10.1007/s11695-021-05690-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 08/24/2021] [Accepted: 08/24/2021] [Indexed: 11/25/2022]
Abstract
In the multi-center Dutch Common Channel Trial (DUCATI), a very long Roux limb Roux-en-Y gastric bypass (VLRL-RYGB: BP-limb 60 cm, Roux limb variable, and common channel 100 cm) was compared to a standard Roux-en-Y gastric bypass (S-LRYGB: BP-limb 60 cm, Roux limb 150 cm, and common channel variable) in the treatment of morbidly obese patients. As all trial patients are beyond 3-year follow-up a midterm analysis was performed to investigate the effect of the VLRL-RYGB. METHODS A total of 444 patients were randomized (1:1) to receive either a VLRL-RYGB or a S-LRYGB. Follow-up results for weight loss, effect on obesity-related comorbid conditions, complications, reoperation, and malnutrition are investigated. RESULTS At 3-year follow-up a significant difference in %TWL (34.0% vs. 31.4%, p = 0.017) and %EWL (84.7% vs. 76.6%, p = 0.043) was observed in favor of VLRL-LRYGB group. Overall complication rate 3-years after surgery was 15.8% in the VLRL-LRYGB group vs. 9% in the S-LRYGB group (p = 0.031). Eight (3.6%) patients in the VLRL-LRYGB group versus 2 (0.9%) in the S-LRYGB group (p = 0.055) required revisional surgery for malabsorption. In the VLRL-LRYGB group 71.9% of patients had resolution of T2DM versus 48.9% in the S-LRYGB group (p = 0.044). CONCLUSION At midterm FU a considerable, significantly increased effect on weight loss of the VLRL-LRYGB was observed compared to the S-LRYGB, with a higher risk of overall complications, but no significant nutritional side effects. These results might impact the current view on the value of the Roux limb in the discussion on optimum limb lengths in Roux-en-Y gastric bypass surgery.
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Affiliation(s)
- Ralph P M Gadiot
- Department of Surgery, Franciscus Gasthuis & Vlietland, Kleiweg 500, Rotterdam, 3045 PM, the Netherlands.
| | - L Ulas Biter
- Department of Surgery, Franciscus Gasthuis & Vlietland, Kleiweg 500, Rotterdam, 3045 PM, the Netherlands
| | - Pierre G Feskens
- Department of Bariatric Surgery, Bariatric Center South-West Netherlands, Bravis Hospital, Bergen op Zoom, the Netherlands
| | - Martin Dunkelgrun
- Department of Surgery, Franciscus Gasthuis & Vlietland, Kleiweg 500, Rotterdam, 3045 PM, the Netherlands
| | - Jan A Apers
- Department of Surgery, Franciscus Gasthuis & Vlietland, Kleiweg 500, Rotterdam, 3045 PM, the Netherlands
| | - Gerhard van 't Hof
- Department of Bariatric Surgery, Bariatric Center South-West Netherlands, Bravis Hospital, Bergen op Zoom, the Netherlands
| | - Guido H H Mannaerts
- Department of Surgery, Tawam Hospital, Al Ain Abu Dhabi, United Arab Emirates
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Comparing a Short Biliopancreatic Limb to a Long Biliopancreatic Limb in Patients with a Roux-en-Y Gastric Bypass with 4 Years Follow-up. Obes Surg 2021; 31:4846-4852. [PMID: 34368902 DOI: 10.1007/s11695-021-05651-z] [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: 06/14/2021] [Revised: 07/30/2021] [Accepted: 07/30/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION In order to design the most effective weight loss procedure, the ideal biliopancreatic limb (BPL) and alimentary limb (AL) length in Roux-en-Y gastric bypass (RYGB) have been discussed extensively. Yet, no consensus has been reached. The aim of this study was to compare weight loss after a short and long BPL in patients who underwent a RYGB with a minimum of 4 years follow-up. METHODS This retrospective cohort study consisted of 574 patients who underwent a primary RYGB procedure between March 2015 and January 2017. Patients were divided in two groups based on the surgical procedure performed: a short BPL group (BPL of 50 cm with an AL of 150 cm) and long BPL group (BPL of 150 cm with an AL of 75 cm). The percentage total weight loss (%TWL) between groups was compared up to 4 years after surgery. Secondary outcomes were 30-day postoperative complications and health-related quality of life (RAND-36). RESULTS The short BPL group consisted of 286 patient and the long BPL group of 288 patients. Follow-up rates of both groups at the first, second, third, and fourth year after surgery were comparable. The long BPL group showed significantly more %TWL compared to the short BP limb group starting at 6 months (p = 0.004) until 4 years after surgery (p < 0.001). Thirty-day complications and health-related quality of life did not differ. CONCLUSION The results showed significantly more %TWL in patients receiving a long BPL compared to the short BPL up to 4 years after surgery.
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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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Käkelä P, Rantanen T, Virtanen KA. The Importance of Intestinal Length in Triglyceride Metabolism and in Predicting the Outcomes of Comorbidities in Laparoscopic Roux-en-Y Gastric Bypass-a Narrative Review. Obes Surg 2021; 31:3291-3295. [PMID: 33914241 PMCID: PMC8175306 DOI: 10.1007/s11695-021-05421-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/01/2021] [Accepted: 04/07/2021] [Indexed: 11/28/2022]
Abstract
In this narrative review, we will appraise if modification of the length of bypassed small intestine based on measured total small intestinal length could optimize the outcomes of the laparoscopic Roux-en-Y gastric bypass (LRYGB). We provide a summary of carefully selected studies to serve as examples and to draw tentative conclusions of the effects of LRYGB on remission of comorbidities. As the heterogeneity of the included studies varied in terms of outcomes, type of study, length of the bypassed small intestine, and the follow-up, a common endpoint could not be defined for this narrative article. To achieve efficient metabolic outcomes, it is important to carefully choose the small intestine length excluded from the food passage suited best to each individual patient. ![]()
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Affiliation(s)
- Pirjo Käkelä
- Department of Surgery, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland.
| | - Tuomo Rantanen
- Department of Surgery, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Kirsi A Virtanen
- Department of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland.,Department of Endocrinology and Clinical Nutrition, Kuopio University Hospital, Kuopio, Finland
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Petrucciani N, Etienne JH, Sebastianelli L, Iannelli A. Roux-en-Y gastric bypass as revisional surgery. Minerva Surg 2021; 76:8-16. [PMID: 33754587 DOI: 10.23736/s2724-5691.20.08493-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The Roux-en-Y gastric bypass (RYGB) is a worldwide-performed procedure as primary surgery, and as conversional procedure after complications and/or failure of other bariatric procedures. RYGB can be performed as revisional surgery after adjustable gastric banding, vertical banded gastroplasty, sleeve gastrectomy and one anastomosis gastric bypass. Each of these revisional procedures may be technically challenging, and accurate preoperative work-up and operative planning is required. If correctly performed, RYGB as revisional procedure is associated with satisfying outcomes and is indicated in the treatment of insufficient weight loss and postoperative complications of a primary bariatric procedure - such as chronic leak or gastroesophageal reflux after sleeve gastrectomy. The present article analyzes the most important indications, technical points and tips and tricks to safely perform RYGB as a secondary procedure.
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Affiliation(s)
- Niccolò Petrucciani
- Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, St. Andrea Hospital, Sapienza University, Rome, Italy
| | - Jean H Etienne
- Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, St. Andrea Hospital, Sapienza University, Rome, Italy.,Université Côte d'Azur, Nice, France
| | - Lionel Sebastianelli
- Department of Medical and Surgical Sciences and Translational Medicine, Faculty of Medicine and Psychology, St. Andrea Hospital, Sapienza University, Rome, Italy.,Université Côte d'Azur, Nice, France
| | - Antonio Iannelli
- Université Côte d'Azur, Nice, France - .,Unit of Digestive Surgery and Liver Transplantation, University Hospital of Nice, Nice, France.,Inserm U1065, Nice, France
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