Revisional One-Anastomosis Gastric Bypass After Restrictive Index Surgery-a Metaanalysis and Comparison with Revisional Roux-en-Y Gastric Bypass

Revisional one-anastomosis gastric bypass for failed laparoscopic sleeve gastrectomy

The study aimed to evaluate the mid-term weight loss outcomes and complications of revisional one-anastomosis gastric bypass (OAGB) following failed laparoscopic sleeve gastrectomy (LSG). A total of 586 patients underwent LSG from January 2010 to February 2018. Revisional OAGB (rOAGB) was performed in 22 (3.8%) patients. A retrospective analysis of prospectively collected data from 20 patients with at least 12 months of follow-up after the revisional OAGB was carried out. The indications for revisional surgery were as follows: insufficient weight loss-4 (20%), weight regain-13 (65%), weight regain and symptoms of gastroesophageal reflux disease (GERD)-2 (10%), and dysphagia with gastroesophageal reflux-1 (5%). The mean interval between the LSG and rOAGB was 35.3 ± 15.4 months (range 4-64). The mean follow-up time after rOAGB was 45.5 ± 17.1 months (range 12-54). At the end of the follow-up after rOAGB, %TWL was 26.4 ± 8.9%, and %EWL was 58.5 ± 21.6%, based on pre-LSG body weight. In all three patients with intractable GERD, the clinical symptoms of reflux retreated after revisional OAGB. The overall complication rate was 20%. In conclusion, the main indications for revision after LSG are weight regain, insufficient weight loss, and intractable GERD. Revisional OAGB emerges as a viable surgical alternative for unsuccessful LSG, presenting notable weight loss outcomes; however, it may be linked to an increased incidence of complications.

ReSleeve or revisional one anastomosis gastric bypass for failed primary sleeve gastrectomy with dilated gastric tube: a retrospective study

BACKGROUND

Revisional bariatric surgery (RBS) has been increasingly performed due to weight loss failure (WLF). Many revisional procedures have been proposed after primary laparoscopic sleeve gastrectomy (pLSG) failure, including ReSleeve gastrectomy (ReLSG), and laparoscopic one anastomosis gastric bypass (LOAGB). Choosing the RBS post-pLSG failure represents a challenge. WLF without gastric tube (GT) dilation is undoubtedly converted to a malabsorptive procedure, but the presence of GT dilation makes it more difficult to select a RBS. This study aimed to compare two relatively simple revisional procedures after pLSG failure with dilated GT to help decision making on which procedure better done to which patient.

METHODS

Data of 52 patients who completed one year follow-up (FU) after their RBS (ReLSG: 27 or LOAGB: 25) for their failed pLSG were collected, assessed, correlated to weight loss (WL) and compared.

RESULTS

Mean operative time was 97 ± 18.4 min. with revisional LOAGB (RLOAGB) and 62 ± 11 min. with ReLSG. Six patients (11.5%) had seven postoperative procedure-specific complications. Significant hemorrhage occurred in three patients. Two cases of leakage were encountered with each procedure. LOAGB Patients had lower mean final weight (76.2 ± 10.5 vs 85.3 ± 13), lower mean Final BMI (26.4 ± 2.5 vs 29.7 ± 2.9) and higher mean percentage of excess weight loss (EWL%) (83.6 ± 13.5% vs 60.29 ± 14.6%). All RLOAGB patients and 77.8% of ReLSG patients had EWL% > 50%. RLOAGB patients had higher EWL% compared to ReLSG (p < 0.001). Insufficient WL (IWL) patients had higher EWL% compared to weight regain (WR) patients (p = 0.034).

CONCLUSION

Both procedures (RLOAGB and ReLSG) were relatively safe and effective in terms of WL. RLOAGB led to higher WL compared to ReLSG in all types of patients despite higher Caloric intake. IWL patients had more WL compared to WR patients. WL was not related to GT dilation type. Large-scale longer-FU studies are still needed.

TRIAL REGISTRATION

PACTR202310644487566 (retrospectively registered).

Two-Year Results of the Banded Versus Non-banded Re-sleeve Gastrectomy as a Secondary Weight Loss Procedure After the Failure of Primary Sleeve Gastrectomy: a Randomized Controlled Trial

BACKGROUND

Insufficient weight loss or weight regain has been reported in up to 30% of patients after laparoscopic sleeve gastrectomy (LSG). Approximately 4.5% of patients who undergo LSG need revisional surgery for a dilated sleeve.

METHODS

This randomized controlled trial compared the outcomes between banded (BLSG) and non-banded re-LSG (NBLSG) after weight regain. Percentage excess body weight loss (%EWL), percentage total weight loss (%TWL), associated medical problems, gastric volume measurement, and endoscopy were measured preoperatively and 1 and 2 years postoperatively.

RESULTS

Both groups (25 patients each) achieved similar % EWL and %TWL at six months, one year, and two years postoperatively (%EWL 46.9 vs. 43.6, 83.7 vs. 86.3, and 85.7 vs. 83.9) (p= > 0.151) (%TWL 23.9 vs. 21.8, 43.1 vs .43.3, 44.2 vs. 42.2) (p=>0.342), respectively. However, the body mass index was significantly lower with BLSG (24.9 vs. NBLSG, 26.9). Both groups showed a significant reduction in stomach volume after two years (BLSG -248.4 mL vs. NBLSG -215.8 mL). Food tolerance (FT) scores were significantly reduced in both groups, whereby BSLG had significantly lower FT with an average of -1.1 point. No significant differences were observed regarding improvement of the associated medical problems after the first and two years after revisional LSG or the postoperative complications between both groups.

CONCLUSION

Laparoscopic re-LSG is feasible and safe with satisfactory outcomes in patients with weight regain after LSG who have gastric dilatation without reflux esophagitis. Both groups had comparable significant weight loss effects and improvement of associated medical problems. The BLSG tends to have a more stable weight loss after two years with a significantly lower BMI, lower stomach volume, and less weight regain. Food tolerance decreased in both groups but reduced more in the BLSG group. After a 2-year follow-up, we may regard both procedures are safe, with no significant differences in the occurrence of complications and nutritional deficits.

Comparison of early post-operative complications in primary and revisional laparoscopic sleeve gastrectomy, gastric bypass, and duodenal switch MBSAQIP-reported cases from 2015 to 2019

BACKGROUND

Sleeve gastrectomy (SG) is now the most performed bariatric surgery, though gastric bypass (GB) and duodenal switch (DS) remain common, especially as conversion/revision (C/R) procedures. This analysis compared early postoperative outcomes of primary and C/R laparoscopic SG to DS and GB; and primary procedures of each vs C/R counterparts.

METHODS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) dataset was queried for SG, GB, and DS cases from 2015 to 2019. Multivariable logistic regression calculated crude and adjusted odds ratios for surgical site infection (SSI), reoperation, and readmission at 30 days in two initial comparisons: (1) primary SG vs DS or GB and (2) C/R SG vs DS or GB. A secondary analysis compared primary GS, GB, or DS with C/R counterparts. Models were adjusted for confounding demographics and comorbidities.

RESULTS

Of 755,968 primary cases, most were SG (72.8%), followed by GB (26.3%), then DS (0.9%). Compared to SG, GB and DS demonstrated higher odds of SSI (aOR 3.02 [2.84, 3.2]), readmission (aOR 1.97 [1.92, 2.03]), and reoperation (aOR 2.74 [2.62, 2.86]), respectively. Of 68,716 C/R cases, SG was most common (43.2%), followed by GB (37.5%), then DS (19.2%). C/R GB and DS demonstrated greater risk of SSI (aOR 2.28 [1.98, 2.62]), readmission (aOR 2.10 [1.94, 2.27]), and reoperation (aOR 2.3 [2.04, 2.59]) vs SG, respectively. C/R SG and DS demonstrated greater risk of SSI (OR 2.09 [1.66, 2.63]; 1.63 [1.24, 2.14), readmission (OR 1.13 [1.02, 1.26]), and reoperation (OR 1.27 [1.06, 1.52]; 1.58 [1.24, 2.0]), vs primary procedures. C/R DS demonstrated greater risk of SSI (OR 1.23 [1.66, 2.63]).

CONCLUSIONS

Early complications are comparable between GB and DS, and greater than SG. In C/R procedures, GB and DS demonstrate greater risk than SG. Overall, C/R procedures demonstrate greater risk of most, but not all, early postoperative complications.

[Therapeutic Options for Regaining Weight after Bariatric Surgery]

PURPOSE

The purpose of this article is to create an overview of diagnostic and therapeutic options for weight regain (WR) and insufficient weight loss (IWL) after bariatric surgery (BS). With increasing popularity of BS, WR is becoming more relevant.

METHODS

We combined recent literature on WR and IWL with personal experience to suggest possible proceedings if WR or IWL is diagnosed.

RESULTS

If an anatomical-pathological cause can be detected, surgical therapy is the most effective. If WR or IWL is idiopathic, a multimodal therapeutic concept is necessary for sufficient therapeutic success. Depending on the initial BS, a combination of lifestyle intervention, medication and surgical therapy seems most effective.

CONCLUSIONS

Extensive diagnostic testing is necessary prior to any surgical intervention. In idiopathic WR after Roux-en-Y Gastric Bypass (RYGB), we suggest lengthening the biliopancreatic limb and shortening the common channel. After Sleeve-Gastrectomy (SG), we currently see RYGB as most effective in patients with gastroesophageal reflux disease (GERD) and SADI-S as a feasible option if no GERD is present.

Revisional Roux-en-Y Gastric Bypass Versus Revisional One-Anastomosis Gastric Bypass After Failed Sleeve Gastrectomy: a Randomized Controlled Trial

Background

High rates of revision surgery have been reported for laparoscopic sleeve gastrectomy (LSG), with weight regain (WR) as the most frequently reported cause. Roux-en-Y gastric bypass (RYGB) is the most commonly performed revision procedure, whereas one-anastomosis gastric bypass (OAGB) is a less popular approach.

Methods

A single-blinded randomized controlled trial was conducted. One hundred seventy-six patients were enrolled and randomized. After loss to follow-up, 80 patients for RYGB and 80 patients for OAGB were analyzed, with a 2-year follow-up. Patients with grade B or higher gastroesophageal reflux disease (GERD) were excluded. Early and late postoperative complications were recorded. Body mass index (BMI), percentage of excess BMI loss (%EBMIL), nutritional laboratory test results, and the resolution of associated medical problems were assessed after revision surgery.

Results

After 2 years, both groups achieved significantly lower BMI than their post-LSG nadir BMI (p < 0.001). The %EBMIL changes showed significantly faster weight loss in the OAGB group than in the RYGB at the 6-month follow-up (mean difference: 8.5%, 95% confidence interval [CI]: 0.2 to 16.9%). However, at 1-year and 2-year follow-ups, the differences were statistically insignificant (p > 0.05). Early and late complications were similar between two groups. Both groups showed improvement or resolution of associated medical problems, with no statistically significant differences after 2 years (p = 1.00).

Conclusion

Both revisional RYGB and OAGB have comparable significant weight loss effects when performed for WR after LSG. After a 2-year follow-up, both procedures were safe, with no significant differences in the occurrence of complications and nutritional deficits.

Graphical abstract

Bariatric Surgery Conversions in MBSAQIP Centers: Current Indications and Outcomes

BACKGROUND

The demand for revisional bariatric surgery has increased, and bariatric conversions (BC) to a different procedure represent most of the revisional cases. The 2020 Metabolic and Bariatric Surgery Accreditfnation and Quality Improvement Program (MBSAQIP) database was expanded to include additional variables on BC. This study aims to analyze the indications and outcomes of BC.

METHODS

A retrospective analysis of the 2020 MBSAQIP database was performed. Patients who underwent BC were included in the analysis. Index procedures, rates, and indications for BC of the different bariatric operations were described. Outcomes of the most frequent BC were analyzed.

RESULTS

A total of 168,548 bariatric surgeries were done; 20,387 (12.1%) were revisional, and from those 15,031 (73.7%) were BC. The most converted index operations were sleeve gastrectomy (SG) (49.3%) and adjustable gastric banding (AGB) (45.9%). The most frequent conversions were SG to Roux-en-Y gastric bypass (RYGB) (40.3%) for gastroesophageal reflux disease (GERD) (54.2%) and weight loss failure (WLF) (35.8%), AGB to SG (27%) or RYGB (16.2%) for WLF (67% and 61.3%, respectively), and SG to biliopancreatic diversion with duodenal switch (3.2%) or single anastomosis duodeno-ileal bypass (2%) for WLF (91.2% and 92.4%, respectively). Postoperative overall morbidity, serious morbidity, reoperation, and mortality rates ranged from 5.3 to 20.8%, 2.3 to 19.2%, 1.5 to 10%, and 0 to 0.8%, respectively.

CONCLUSIONS

BC represents the most frequent revisional bariatric procedure. GERD and WLF are the main causes for BC. Further research is needed to define the ideal BC according to the index procedure and indication.

Roux-en-Y Versus One Anastomosis Gastric Bypass as Redo-Operations Following Sleeve Gastrectomy: A Retrospective Study

BACKGROUND

Aim of this study was to improve knowledge about the best conversional bariatric procedure following sleeve gastrectomy (SG).

METHODS

Data of conversional Roux-en-Y gastric bypass (RYGB) and of one anastomosis gastric bypass (OAGB) after SG were collected prospectively and analyzed retrospectively. Weight loss parameters, gastroesophageal reflux disease (GERD) and comorbidities outcomes were recorded.

RESULTS

Total of 123 patients (90 female, mean age 44 ± 0.9 years, mean body mass index (BMI) 42 ± 0.8 kg/m²) had either RYGB (n = 68) or OAGB (n = 55). Perioperative mortality was zero. Mean surgery time was significantly shorter for OAGB (168 ± 7.2 vs. 201 ± 6.8 min). Perioperative complication rates were not significantly (ns) different between RYGB and OAGB. Total body weight loss (TBWL) in RYGB and OAGB was 18 ± 2.2% and 18 ± 1.9% (12 months) and 18 ± 3.0% and 23 ± 2.6% (24 months; ns), respectively. Length of (individualized) biliopancreatic limb (BPL) correlated significantly with weight loss. Remission rates after 12 months of RYGB and OAGB for arterial hypertension (aHt) were 89% and 92%, for obstructive sleep apnea (OSAS) 56% and 82%, for Type 2 diabetes mellitus (T2DM) 100% and 92%, for osteoarthritis 64% and 85% and for GERD 89% versus 87% (ns), respectively. Nutritional deficiencies were comparable in RYGB (n = 11) and OAGB (n = 14) group (ns).

CONCLUSION

Both RYGB and OAGB are effective conversional procedures after SG, leading to comparable TBWL, BMI-loss and high remission rates of comorbidities including GERD. Significantly shorter operation times were in favor of OAGB. BPL, which was longer in OAGB was significantly related to higher %TBWL and %BMI-loss compared to RYGB.

Association of metabolic-bariatric surgery with long-term survival in adults with and without diabetes: a one-stage meta-analysis of matched cohort and prospective controlled studies with 174 772 participants

BACKGROUND

Metabolic-bariatric surgery delivers substantial weight loss and can induce remission or improvement of obesity-related risks and complications. However, more robust estimates of its effect on long-term mortality and life expectancy-especially stratified by pre-existing diabetes status-are needed to guide policy and facilitate patient counselling. We compared long-term survival outcomes of severely obese patients who received metabolic-bariatric surgery versus usual care.

METHODS

We did a prespecified one-stage meta-analysis using patient-level survival data reconstructed from prospective controlled trials and high-quality matched cohort studies. We searched PubMed, Scopus, and MEDLINE (via Ovid) for randomised trials, prospective controlled studies, and matched cohort studies comparing all-cause mortality after metabolic-bariatric surgery versus non-surgical management of obesity published between inception and Feb 3, 2021. We also searched grey literature by reviewing bibliographies of included studies as well as review articles. Shared-frailty (ie, random-effects) and stratified Cox models were fitted to compare all-cause mortality of adults with obesity who underwent metabolic-bariatric surgery compared with matched controls who received usual care, taking into account clustering of participants at the study level. We also computed numbers needed to treat, and extrapolated life expectancy using Gompertz proportional-hazards modelling. The study protocol is prospectively registered on PROSPERO, number CRD42020218472.

FINDINGS

Among 1470 articles identified, 16 matched cohort studies and one prospective controlled trial were included in the analysis. 7712 deaths occurred during 1·2 million patient-years. In the overall population consisting 174 772 participants, metabolic-bariatric surgery was associated with a reduction in hazard rate of death of 49·2% (95% CI 46·3-51·9, p<0·0001) and median life expectancy was 6·1 years (95% CI 5·2-6·9) longer than usual care. In subgroup analyses, both individuals with (hazard ratio 0·409, 95% CI 0·370-0·453, p<0·0001) or without (0·704, 0·588-0·843, p<0·0001) baseline diabetes who underwent metabolic-bariatric surgery had lower rates of all-cause mortality, but the treatment effect was considerably greater for those with diabetes (between-subgroup I² 95·7%, p<0·0001). Median life expectancy was 9·3 years (95% CI 7·1-11·8) longer for patients with diabetes in the surgery group than the non-surgical group, whereas the life expectancy gain was 5·1 years (2·0-9·3) for patients without diabetes. The numbers needed to treat to prevent one additional death over a 10-year time frame were 8·4 (95% CI 7·8-9·1) for adults with diabetes and 29·8 (21·2-56·8) for those without diabetes. Treatment effects did not appear to differ between gastric bypass, banding, and sleeve gastrectomy (I² 3·4%, p=0·36). By leveraging the results of this meta-analysis and other published data, we estimated that every 1·0% increase in metabolic-bariatric surgery utilisation rates among the global pool of metabolic-bariatric candidates with and without diabetes could yield 5·1 million and 6·6 million potential life-years, respectively.

INTERPRETATION

Among adults with obesity, metabolic-bariatric surgery is associated with substantially lower all-cause mortality rates and longer life expectancy than usual obesity management. Survival benefits are much more pronounced for people with pre-existing diabetes than those without.

FUNDING

None.