Role of Primary Use of Mega Stents Alone and Combined with Other Endoscopic Procedures for Early Leak and Stenosis After Bariatric Surgery, Single-Institution Experience

Endoluminal Vacuum Therapy as Effective Treatment for Patients with Postoperative Leakage After Metabolic Bariatric Surgery-A Single-Center Experience

BACKGROUND

Metabolic bariatric surgery (MBS) is standardized and safe. Nevertheless, complications such as anastomotic leakage (AL) or staple-line leakage (SLL) can occur. In upper GI or colorectal surgery, endoluminal vacuum therapy (EVT) offers a therapeutic alternative to revisional surgery. Data on EVT in patients with leakage after MBS remain scarce. The aim of this study is to evaluate the efficacy of EVT and its potential as endoscopic alternative to revisional surgery.

MATERIAL AND METHODS

All patients treated for AL or SLL with EVT after MBS between 01/2016 and 08/2023 at the Department for General Surgery, Medical University Vienna, were included in this retrospective, single-center study. Therapeutic value of EVT as management option for acute postoperative leakage after MBS in daily practice was evaluated. Statistical analyses were performed descriptively.

RESULTS

Twenty-one patients were treated with EVT within the observational period of 7 years. In 11 cases (52.4%), the index surgery was a primary bariatric intervention; in 10 cases (47.6%), a secondary surgery after initial MBS was performed. Favored approach was a combination of revisional surgery and EVT (n = 18; 85.7%), intermediate self-expanding metal stent (SEMS) in 16 (76.2%) cases. EVT was changed six times (0-33) every 3-4 days. Mean EVT time was 25.1 days (3-97). No severe associated complications were detected and EVT showed an efficacy of 95.2%.

CONCLUSION

This small case series supports the trend to establish EVT in daily clinical practice when revisional surgery after MBS is needed, thus preventing further reoperation and reducing associated morbidity and mortality in critically ill patients.

Outcomes of primary versus conversional Roux-En-Y gastric bypass after laparoscopic sleeve gastrectomy: a retrospective propensity score-matched cohort study

BACKGROUND

Conversional surgery is common after laparoscopic sleeve gastrectomy (LSG) because of suboptimal weight loss (SWL) or poor responders and gastroesophageal reflux disease (GERD). Roux-en-Y gastric bypass (RYGB) is the most common conversional procedure after LSG.

METHODS

A retrospective cohort study analyzed patients who underwent primary RYGB (PRYGB) or conversional RYGB (CRYGB) at three specialized bariatric centers between 2008 and 2019 and tested for weight loss, resolution of GERD, food tolerance (FT), early and late complications, and the resolution of associated medical problems. This was analyzed by propensity score matching (PSM).

RESULTS

In total, 558 (PRYGB) and 155 (CRYGB) completed at least 2 years of follow-up. After PSM, both cohorts significantly decreased BMI from baseline (p < 0.001). The CRYGB group had an initially more significant mean BMI decrease of 6.095 kg/m2 at 6 months of follow-up (p < 0.001), while the PRYGB group had a more significant mean BMI decrease of 5.890 kg/m2 and 8.626 kg/m2 at 1 and 2 years, respectively (p < 0.001). Food tolerance (FT) improved significantly in the CRYGB group (p < 0.001), while CRYGB had better FT than PRYGB at 2 years (p < 0.001). A GERD resolution rate of 92.6% was recorded in the CRYGB (p < 0.001). Both cohorts had comparable rates of early complications (p = 0.584), late complications (p = 0.495), and reoperations (p = 0.398). Associated medical problems at 2 years significantly improved in both cohorts (p < 0.001).

CONCLUSIONS

CRYGB is a safe and efficient option in non- or poor responders after LSG, with significant weight loss and improvement in GERD. Moreover, PRYGB and CRYGB had comparable complications, reoperations, and associated medical problem resolution rates.

Management of Leak by Intraoperative Megastent Insertion During Revisional Bariatric Metabolic Surgery: a Case Report

We describe gastric tube continuity restoration (gastrogastrostomy) in a patient who underwent revisional laparoscopic one-anastomosis gastric bypass (OAGB) due to weight recurrence after laparoscopic sleeve gastrectomy (SG). The patient sought restoration to SG due to poor quality of life. A postoperative 11-mm leak at the site of the gastrogastrostomy, attributed to adhesions and edema from a marginal ulcer, complicated the procedure. As a result, laparoscopic exploration was performed, followed by insertion of a megastent. We hereby present video documentation of this case report as well as megastent insertion technique for the treatment of such complications.

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

Endoscopic Self-Expanding Metallic Stent Placement in the Management of Post Laparoscopic Sleeve Gastrectomy Complications

Introduction Endoscopic treatments have become popular by providing the best solution for healing complications while allowing oral nutrition. In this study, we aim to evaluate outcomes of the endoscopic-covered stents for staple line complications following bariatric surgery.

Methods A prospective evaluation was performed for all patients treated for staple line complications after bariatric surgery. Bariatric patients with acute leaks, chronic gastrocutaneous fistulas, and anastomotic strictures refractory to endoscopic dilation after sleeve gastrectomy were included in this survey.

Results From January 2019 to June 2020, 41 patients (12 with acute leaks, 16 with chronic fistulas, and 13 with strictures) were treated with endoscopic silicone-covered stents (polyester or nitinol). The mean follow-up was 3.5 months. Immediate symptomatic improvement occurred in 95.2% (91.7% of acute leaks, 81.2% of fistulas, and 92.3% of strictures). In addition, 87.8% of patients initiated oral feeding immediately after stenting. There was no mortality case in this population.

Conclusion Although stent migration rarely occurs in subjects, the endoscopic silicone-covered stents strategy is one of the best treatments for anastomotic complications after bariatric surgery, providing rapid healing while simultaneously allowing for oral nutrition.

Comparison of 5-Year Follow-up Outcomes Between Primary and Revision Roux-en-Y Gastric Bypasses After Open Vertical Banded Gastroplasty: an Inverse Propensity Score-Weighted Analysis

INTRODUCTION

Vertical banded gastroplasty (VBG) is associated with high weight regain; Roux-en-Y gastric bypass (RYGB) is used as a revision procedure in patients with VBG experiencing weight regain. This study compared the 5-year follow-up outcomes of primary (PRYGB) and revision RYGB after VBG (RRYGB).

METHODS

Patients who underwent PRYGB or RRYGB after VBG from 2008 to 2016 were enrolled. Data on weight regain, weight loss (WL), food tolerance (FT), early and late complications, and resolution or improvement in associated medical conditions were analyzed.

RESULTS

PRYGB and RRYGB groups had 558 and 156 patients, respectively, after exclusion of the lost to follow-up patients. PRYGB group showed significantly lower mean body mass index (over the entire follow-up period), early complications, reintervention rates for late complications, and overall reintervention rates than that of the RRYGB group. On the other hand, FT scores, odds of late complications, and improvements (in the fifth year) in associated medical conditions were comparable between the two groups.

CONCLUSION

RRYGB in patients with VBG who regained weight showed comparable safety and resolution of associated diseases to that of PRYGB over the 5-year follow-up period. The WL in the RRYGB group was acceptable despite being less than that of the PRYGB group. FT was better after RRYGB than that of PRYGB in the first year; however, both were comparable at the fifth year follow-up. Patients with VBG undergoing RYGB should receive attentive treatment and evaluation of associated factors.