Laparoscopic Fundoplication Using the Excluded Stomach as a Novel Management Option for Refractory Bile Reflux Following One Anastomosis Gastric Bypass (OAGB)

Revision/Conversion Surgeries After One Anastomosis Gastric Bypass-An Experts' Modified Delphi Consensus

PURPOSE

There is a lack of evidence for treatment of some conditions including complication management, suboptimal initial weight loss, recurrent weight gain, or worsening of a significant obesity complication after one anastomosis gastric bypass (OAGB). This study was designed to respond to the existing lack of agreement and to provide a valuable resource for clinicians by employing an expert-modified Delphi consensus method.

METHODS

Forty-eight recognized bariatric surgeons from 28 countries participated in the modified Delphi consensus to vote on 64 statements in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was regarded to indicate a consensus.

RESULTS

A consensus was achieved for 46 statements. For recurrent weight gain or worsening of a significant obesity complication after OAGB, more than 85% of experts reached a consensus that elongation of the biliopancreatic limb (BPL) is an acceptable option and the total bowel length measurement is mandatory during BPL elongation to preserve at least 300-400 cm of common channel limb length to avoid nutritional deficiencies. Also, more than 85% of experts reached a consensus on conversion to Roux-en-Y gastric bypass (RYGB) with or without pouch downsizing as an acceptable option for the treatment of persistent bile reflux after OAGB and recommend detecting and repairing any size of hiatal hernia during conversion to RYGB.

CONCLUSION

While the experts reached a consensus on several aspects regarding revision/conversion surgeries after OAGB, there are still lingering areas of disagreement. This highlights the importance of conducting further studies in the future to address these unresolved issues.

Conversion of one-anastomosis gastric bypass (OAGB) to Roux-en-Y gastric bypass (RYGB) for gastroesophageal reflux disease (GERD): who is more at risk? A multicenter study

BACKGROUND

Although gastroesophageal reflux disease (GERD) affects 0.6% to 10% of patients operated on for one-anastomosis gastric bypass (OAGB), only about 1% require surgery to convert to Roux-en-Y gastric bypass (RYGB) [3-5]. The aim of the present study was to analyze the characteristics of OAGB patients converted to RYGB for GERD not responding to medical treatment.

METHODS

This retrospective multicenter study included patients who underwent conversion from OAGB to RYGB for severe GERD. The conversion was performed with resection of the previous gastro-jejunal anastomosis and the use of the afferent loop as a new biliary loop.

RESULTS

A total of 126 patients were included in the study. Of these patients, 66 (52.6%) had a past medical history of bariatric restrictive surgery (gastric banding, sleeve gastrectomy). A hiatal hernia (HH) was present in 56 patients (44.7%). The association between previous restrictive surgery and HH was recorded in 33 (26.2%) patients. Three-dimensional gastric computed tomography showed an average gastric pouch volume of 242.4 ± 55.1 cm3. Conversion to RYGB was performed on average 60 ± 35.6 months after OAGB. Seven patients (5.5%) experienced an early postoperative complication (4 patients grade IIIb and 3 grade IIb), and 3 (2.4%) a late complication. Patients showed further weight loss after RYGB conversion and an average of 24.8 ± 21.7 months after surgery, with a mean % of total weight loss (%TWL) of 6.9 ± 13.6 kg. From a clinical point of view, the problem of GERD was definitively solved in more than 90% of patients.

CONCLUSIONS

Situations that weaken the esogastric junction appear to be highly frequent in patients operated on for OAGB and converted to RYGB for severe reflux. Similarly, the correct creation of the gastric pouch could play an important role in reducing the risk of conversion to RYGB for GERD.

Anti-reflux mucosal resection for treatment of refractory gastro-oesophageal reflux disease: Efficacy and impact on perioperative indicators

BACKGROUND

Refractory gastroesophageal reflux disease (RGERD) is difficult to treat and recurrent. For such patients, anti-reflux mucosal resection (ARMS) is the main clinical treatment, but its advantages and disadvantages remain unclear.

AIM

To investigate the efficacy of endoscopic ARMS in the treatment of RGERD and its impact on perioperative indicators.

METHODS

A total of 102 patients with RGERD were selected from January 2019 to December 2021 and divided into either a control group or an observation group using the random number table method, with 51 cases in each group. The control group underwent laparoscopic Nissen fundoplication, and the observation group underwent ARMS treatment. The operation conditions, postoperative recovery, GerdQ score before and after surgery, extraesophageal symptom score, high-resolution esophageal manometry parameters [abdominal lower esophageal sphincter (LES) length, LES resting pressure (LESP), upper esophageal sphincter resting pressure (UESP), and distal systolic integral (DCI)], 24 h pH-impedance monitoring indexes (DeMeester score and the number of episodes of acid reflux, weak acid reflux, fluid reflux, gas reflux, and mixed reflux), gastric dynamics indicators [serum motilin (MTL) and gastrin (GAS)], and complications were compared between the two groups.

RESULTS

In the observation group, the operation time was shorter than that of the control group (P < 0.05), and the intraoperative blood loss was less than that of the control group (P < 0.05), but the difference in hospitalization time between the two groups was not statistically significant (P > 0.05). The GerdQ score and extraesophageal symptom score decreased in both groups at 1 and 6 months after surgery compared with those before surgery (P < 0.05), and these scores were lower in the observation group than in the control group (P < 0.05). At 1 and 6 months after surgery, the length of the LES in the abdominal segment was longer in both groups than that before surgery (P < 0.05), and longer in the observation group than in the control group (P < 0.05), while LESP, UESP, and DCI were higher than those before surgery (P < 0.05), and higher in the observation group than in the control group (P < 0.05). DeMeester score and the number of episodes of acid reflux, weak acid reflux, liquid reflux, gas reflux, and mixed reflux were lower in both groups at 1 and 6 months after surgery compared with those before surgery, and lower in the observation group than in the control group (P < 0.05). Serum MTL and GAS were higher in the two groups at 1 and 6 months after surgery than those before surgery, and were higher in the observation group than in the control group (P < 0.05). The incidence of complications was lower in the observation group than in the control group (P < 0.05).

CONCLUSION

ARMS for treatment of RGERD can significantly optimize the surgical situation, promote clinical symptom regression, improve esophageal and gastric dynamics, reduce gastric reflux events, and reduce the incidence of complications.

Anti-reflux mucosal resection for treatment of refractory gastro-oesophageal reflux disease: Efficacy and impact on perioperative indicators

BACKGROUND

Refractory gastroesophageal reflux disease (RGERD) is difficult to treat and recurrent. For such patients, anti-reflux mucosal resection (ARMS) is the main clinical treatment, but its advantages and disadvantages remain unclear.

AIM

To investigate the efficacy of endoscopic ARMS in the treatment of RGERD and its impact on perioperative indicators.

METHODS

A total of 102 patients with RGERD were selected from January 2019 to December 2021 and divided into either a control group or an observation group using the random number table method, with 51 cases in each group. The control group underwent laparoscopic Nissen fundoplication, and the observation group underwent ARMS treatment. The operation conditions, postoperative recovery, GerdQ score before and after surgery, extraesophageal symptom score, high-resolution esophageal manometry parameters [abdominal lower esophageal sphincter (LES) length, LES resting pressure (LESP), upper esophageal sphincter resting pressure (UESP), and distal systolic integral (DCI)], 24 h pH-impedance monitoring indexes (DeMeester score and the number of episodes of acid reflux, weak acid reflux, fluid reflux, gas reflux, and mixed reflux), gastric dynamics indicators [serum motilin (MTL) and gastrin (GAS)], and complications were compared between the two groups.

RESULTS

In the observation group, the operation time was shorter than that of the control group (P < 0.05), and the intraoperative blood loss was less than that of the control group (P < 0.05), but the difference in hospitalization time between the two groups was not statistically significant (P > 0.05). The GerdQ score and extraesophageal symptom score decreased in both groups at 1 and 6 months after surgery compared with those before surgery (P < 0.05), and these scores were lower in the observation group than in the control group (P < 0.05). At 1 and 6 months after surgery, the length of the LES in the abdominal segment was longer in both groups than that before surgery (P < 0.05), and longer in the observation group than in the control group (P < 0.05), while LESP, UESP, and DCI were higher than those before surgery (P < 0.05), and higher in the observation group than in the control group (P < 0.05). DeMeester score and the number of episodes of acid reflux, weak acid reflux, liquid reflux, gas reflux, and mixed reflux were lower in both groups at 1 and 6 months after surgery compared with those before surgery, and lower in the observation group than in the control group (P < 0.05). Serum MTL and GAS were higher in the two groups at 1 and 6 months after surgery than those before surgery, and were higher in the observation group than in the control group (P < 0.05). The incidence of complications was lower in the observation group than in the control group (P < 0.05).

CONCLUSION

ARMS for treatment of RGERD can significantly optimize the surgical situation, promote clinical symptom regression, improve esophageal and gastric dynamics, reduce gastric reflux events, and reduce the incidence of complications.

The Surgical Technique of Primary Modified Fundoplication Using the Excluded Stomach with Simultaneous Gastric Bypass

PURPOSE

The aim of this work is to demonstrate a new concept of the surgical technique "FundoRing" for the prevention of acid and bile reflux esophagitis after gastric bypass.

MATERIALS AND METHODS

A laparoscopic surgical technique of gastric bypass simultaneous with combined upper total and lower left partial fundoplication. This described case is a participant in an ongoing randomized clinical trial.

RESULTS

The patient was without complications and was discharged on the third postoperative day. Delta BMI was 14 kg/m² (38-24) at the 1-year follow-up. The patient did not have heartburn or bile reflux esophagitis after surgery. Evaluation of the mucosa of the esophagus by upper endoscopy after each of the 3 follow-up visits demonstrated that reflux esophagitis had resolved. Intraoperative fluorescence imaging technologies (NIR/ICG) (IMAGE1 S™ Rubina®) were to determine the quality of blood supply-no violation of the blood supply to the fundoplication wrap of the gastric pouch was detected. A CT scan clearly shows a fundoplication ring around the esophagus (two-thirds) and the upper part of the gastric pouch (one-third).

CONCLUSION

The surgical technique of primary modified fundoplication using the excluded stomach with simultaneous gastric bypass is feasible.

Ten-year outcome of one-anastomosis gastric bypass with a biliopancreatic limb of 150 cm versus Roux-en-Y gastric bypass: a single-institution series of 940 patients

BACKGROUND

Long-term outcomes of one-anastomosis gastric bypass (OAGB) need to be compared with those of Roux-en-Y gastric bypass (RYGB).

OBJECTIVE

The present study evaluates the long-term outcomes at 10-year follow-up of OAGB with a biliopancreatic limb of 150 cm versus RYGB.

SETTING

Private practice, France.

METHODS

Data of patients who underwent OAGB or RYGB as primary or secondary procedures between 2010 and 2011 at a referral center were collected prospectively and analyzed retrospectively.

RESULTS

A total of 940 patients underwent OAGB (n = 405) or RYGB (n = 535). Operative time was significantly shorter in the OAGB group. Postoperative morbidity occurred in 17.2% of patients after RYGB versus 8.1% after OAGB (P ≤ .0001). Patients in the RYGB group had a significantly higher rate of kinking of the jejuno-jejunal anastomosis, stenosis of the gastrojejunal anastomosis, and dysphagia for early ulcers. At long term, no differences were found in the rate of severe malnutrition. Cumulated morbidity was significantly higher after RYGB, with higher incidence of internal hernia, anastomotic ulcer, blind-loop syndrome, and hypoglycemia. Conversion to RYGB and laparoscopic exploration for chronic pain were more frequent after OAGB. Surgery for weight regain was significantly more frequent after RYGB. Patients in the OAGB group had significantly lower weight, body mass index, and greater percentage excess, and total weight losses at 120 months. No significant differences were detected in co-morbidity outcomes.

CONCLUSION

After 10 years, both RYGB and OAGB are effective procedures. However, OAGB is associated with shorter operative times and better results in short- and long-term morbidity and weight loss outcomes.