1
|
Bruinsma FFE, Nienhuijs SW, Liem RSL, Greve JWM, Marang-van de Mheen PJ. The Impact of Longer Biliopancreatic Limb Length on Weight Loss and Comorbidity Improvement at 5 Years After Primary Roux-en-Y Gastric Bypass Surgery: A Population-Based Matched Cohort Study. Obes Surg 2024:10.1007/s11695-024-07267-5. [PMID: 38981956 DOI: 10.1007/s11695-024-07267-5] [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: 10/20/2023] [Revised: 04/26/2024] [Accepted: 05/08/2024] [Indexed: 07/11/2024]
Abstract
INTRODUCTION Different limb lengths are used in Roux-en-Y gastric bypass (RYGB) surgery, as there is no consensus which limb length strategy has the best outcomes. The biliopancreatic limb (BPL) is thought to play an important role in achieving weight loss and associated comorbidity resolution. The objective of this study was to assess the impact of a longer BPL on weight loss and comorbidity improvement at 5 years after primary RYGB. METHODS All patients aged ≥ 18 years undergoing primary RYGB between 2014-2017 with registered follow-up 5 years after surgery were included. Long BPL was defined as BPL ≥ 100 cm and short BPL as BPL < 100 cm. The primary outcome was achieving at least 25% total weight loss (TWL) at 5 years. Secondary outcomes included absolute %TWL and improvement of comorbidities. A propensity score matched logistic and linear regression was used to estimate the difference in outcomes between patients with long and short BPL. RESULTS At 5 years, long BPL had higher odds to achieve ≥ 25% TWL (odds ratio (OR) 1.19, 95% confidence interval (CI) [1.01 - 1.41]) and was associated with 1.26% higher absolute TWL (β = 1.26, 95% CI [0.53 - 1.99]). Furthermore, long BPL was more likely to result in improved diabetes mellitus (OR = 2.17, 95% CI [1.31 - 3.60]) and hypertension (OR = 1.45, 95% CI [1.06 - 1.99]). CONCLUSION Patients undergoing RYGB with longer BPL achieved higher weight loss and were more likely to achieve improvement of comorbidities at 5 years.
Collapse
Affiliation(s)
- Floris F E Bruinsma
- Department of Surgery, Maastricht University Medical Centre, NUTRIM School for Nutrition and Translational Research in Metabolism, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands.
| | - Simon W Nienhuijs
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Ronald S L Liem
- Department of Surgery, Groene Hart Hospital, Gouda, The Netherlands
- Nederlandse Obesitas Kliniek, Gouda and The Hague, Gouda, The Netherlands
| | - Jan Willem M Greve
- Department of Surgery, Maastricht University Medical Centre, NUTRIM School for Nutrition and Translational Research in Metabolism, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- Department of Surgery, Zuyderland Medical Centre, Heerlen, The Netherlands
- Nederlandse Obesitas Kliniek, Heerlen, The Netherlands
| | - Perla J Marang-van de Mheen
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
- Safety & Security Science, Faculty of Technology, Policy and Management, Delft University of Technology, Delft, The Netherlands
| |
Collapse
|
2
|
Hage K, Sawma T, Jawhar N, Bartosiak K, Vargas EJ, Abu Dayyeh BK, Ghanem OM. Revisional Bariatric Surgery After Roux-en-Y Gastric Bypass for Bile Reflux: a Single-Center Long-Term Cohort Study. Obes Surg 2024; 34:2420-2430. [PMID: 38861123 DOI: 10.1007/s11695-024-07355-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 06/12/2024]
Abstract
PURPOSE Revisional bariatric surgery (RBS) after primary Roux-en-Y gastric bypass (RYGB) is indicated for the efficient management of specific complications such as bile reflux. Published literature on this topic remains scarce as we aim to evaluate the long-term outcomes (10 years) of RBS for bile reflux after RYGB. MATERIAL AND METHODS We conducted a single-center retrospective study of patients who underwent primary RYGB complicated by bile reflux and had RBS between 2008 and 2023. Our cohort was divided into two groups based on the etiology of bile reflux. Long-term surgical outcomes and nutritional status were reported and compared between the groups. RESULTS A total of 41 patients (100% primary RYGB; 90.2% female, 97.6% white) were included. 56.1% (n = 23) of patients underwent Roux limb lengthening and the remaining 43.9% (n = 18) had a gastrogastric fistula takedown, with no significant differences in terms of intraoperative complications, estimated blood loss (p = 0.616), length of hospital stay (p = 0.099), and postoperative complications between the two groups. Long-term resolution of obesity-related medical conditions was demonstrated for all the evaluated comorbidities. Lastly, there was no reported mortality, bile reflux recurrence, or micro- and macro-nutrient deficiencies over the total follow-up period of 10 years. CONCLUSION In our cohort, RBS after a primary RYGB for bile reflux management demonstrated safe and efficient short- and long-term surgical outcomes without any reported bile reflux recurrence or mortality. Adequate supplementation and close patient follow-up remain essential to decrease the morbidity and mortality associated with RBS as further studies are required to support our findings.
Collapse
Affiliation(s)
- Karl Hage
- Metabolic and Abdominal Wall Reconstructive Surgery, Department of Surgery, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN, 55905, USA
| | - Tedy Sawma
- Metabolic and Abdominal Wall Reconstructive Surgery, Department of Surgery, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN, 55905, USA
| | - Noura Jawhar
- Metabolic and Abdominal Wall Reconstructive Surgery, Department of Surgery, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN, 55905, USA
| | - Katarzyna Bartosiak
- Metabolic and Abdominal Wall Reconstructive Surgery, Department of Surgery, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN, 55905, USA
- Department of General, Oncological, Metabolic and Thoracic Surgery, Military Institute of Medicine, National Research Institute, 04-141, Warsaw, Poland
| | - Eric J Vargas
- Department of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, MN, 55905, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, MN, 55905, USA
| | - Omar M Ghanem
- Metabolic and Abdominal Wall Reconstructive Surgery, Department of Surgery, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN, 55905, USA.
| |
Collapse
|
3
|
Qin X, Mao Z, Lee WJ, Zhang M, Wu G, Zhou X. Pathological and immunohistochemical analysis of gastric mucosa after one anastomosis gastric bypass surgery. Asian J Endosc Surg 2024; 17:e13324. [PMID: 38804100 DOI: 10.1111/ases.13324] [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] [Received: 03/27/2024] [Revised: 04/19/2024] [Accepted: 05/03/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND One anastomosis gastric bypass (OAGB) is now the third most common bariatric surgery worldwide. This procedure is garnering increasing attention, but its complication of bile reflux and the associated risk of gastric carcinogenesis remains controversial. OBJECTIVE The study aims to assess the impact of bile reflux on the gastric mucosa by comparing pathological and immunohistochemical results of gastric mucosa before and 2 years after OAGB surgery. METHODS This retrospective study analyzed gastric lesions observed in gastroscopy before and after OAGB surgery. Pathological examinations were conducted on mucosal samples from proximal, middle and distal part of stomach, with a particular focus on the expression of Ki-67, P53, and CDX2 in immunohistochemistry. Ki-67 indicates cellular proliferation, P53 is a tumor suppressor protein, and CDX2 is a marker for intestinal differentiation. RESULTS A total of 16 patients completed the follow-up. Regarding gastritis, presurgery nonerosive gastritis was found in two cases (12.5%), and postsurgery in six cases (37.5%). Erosive gastritis increased from one case (6.2%) presurgery to three cases (18.7%) postsurgery, totaling an increase from three to nine cases (p = .028). Bile reflux in the stomach increased from one case (6.2%) presurgery to three cases (18.7%) postsurgery. Most lesions in the proximal, middle, and distal part of stomach were relatively mild, with normal tissue states being predominant. Mild inflammation was found in all three areas, whereas moderate inflammation, intestinal metaplasia, and glandular atrophy were less common. No cases of severe inflammation were noted. The expression of gastric biomarkers CDX-2, Ki67, and P53 showed no significant statistical variation in different areas. CONCLUSION Bile reflux does occur after OAGB, but its incidence is not high. Based on the immunohistochemical and pathological results of the gastric mucosa 2 years post-OAGB, there seems to be no significant causal relationship between OAGB and oncogenic inflammation around the gastric tube.
Collapse
Affiliation(s)
- Xiaoguang Qin
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Bariatric/Metabolic Surgical Center, Ben Q Hospital, Suzhou, China
| | - Zhongqi Mao
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Bariatric/Metabolic Surgical Center, Ben Q Hospital, Suzhou, China
| | - Wei-Jei Lee
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Medical Weight Loss Center, China Medical University Hsinchu Hospital, Zhubei, Taiwan
| | - Min Zhang
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Bariatric/Metabolic Surgical Center, Ben Q Hospital, Suzhou, China
| | - Guoqiang Wu
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
- Bariatric/Metabolic Surgical Center, Ben Q Hospital, Suzhou, China
| | - Xiaoqing Zhou
- Department of General Surgery, The First Affiliated Hospital of Soochow University, Suzhou, China
| |
Collapse
|
4
|
Hany M, Zidan A, Aboelsoud MR, Torensma B. Laparoscopic sleeve gastrectomy vs one-anastomosis gastric bypass 5-year follow-up: a single-blinded randomized controlled trial. J Gastrointest Surg 2024; 28:621-633. [PMID: 38704199 DOI: 10.1016/j.gassur.2024.01.038] [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] [Received: 11/19/2023] [Revised: 01/15/2024] [Accepted: 01/27/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is the most performed bariatric procedure worldwide, whereas one-anastomosis gastric bypass (OAGB) is the third most performed procedure. Both procedures have reported good weight loss (WL) and low complications. However, should both have differences in the durability of WL and malnutrition? METHODS A single-blinded, randomized controlled trial of 300 patients was conducted to compare the outcomes of LSG and OAGB over a 5-year follow-up. The primary endpoint was WL in percentages of total WL (%TWL) and excess WL (%EWL). The secondary endpoints were complications, gastroesophageal reflux disease (GERD), associated medical problems, bariatric analysis and reporting outcome system (BAROS) assessment, and weight recurrence (WR). RESULTS Overall, 201 patients (96 in the LSG group and 105 in the OAGB group) completed 5 years of follow-up. OAGB had significantly higher %TWL and %EWL than those of LSG throughout the follow-up. LSG had significantly higher WR and GERD. Both procedures had significant improvement in associated medical problems and BAROS scores compared with baseline, with no significant difference. WR was associated with higher relapse of associated medical conditions after initial remission and with lower BAROS scores regarding WL scores. CONCLUSION OAGB had significantly higher WL, less WR, and less GERD. However, it had a higher incidence of bile reflux. Both procedures had comparable complication rates, excellent remissions in associated medical problems, and improved quality of life. WR was associated with significantly more relapse of associated medical problems and significantly lower BAROS scores.
Collapse
Affiliation(s)
- Mohamed Hany
- Department of Surgery, Medical Research Institute, Alexandria University, Alexandria, Egypt; Madina Women Hospital, Alexandria, Egypt.
| | - Ahmed Zidan
- Department of Surgery, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Moustafa R Aboelsoud
- Department of Surgery, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Bart Torensma
- Clinical Epidemioloigist, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
5
|
Ghiassi S, Nimeri A, Aleassa EM, Grover BT, Eisenberg D, Carter J. American Society for Metabolic and Bariatric Surgery position statement on one-anastomosis gastric bypass. Surg Obes Relat Dis 2024; 20:319-335. [PMID: 38272786 DOI: 10.1016/j.soard.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 11/04/2023] [Indexed: 01/27/2024]
Abstract
The following position statement is issued by the American Society for Metabolic and Bariatric Surgery in response to inquiries made to the society by patients, physicians, society members, hospitals, health insurance payors, and others regarding one-anastomosis gastric bypass as a treatment for obesity and metabolic disease. This statement is based on current clinical knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. The statement may be revised in the future as more information becomes available.
Collapse
Affiliation(s)
- Saber Ghiassi
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
| | - Abdelrahman Nimeri
- Department of Surgery, Brigham and Women's Hospital, Harvard School of Medicine, Boston, Massachusetts
| | - Essa M Aleassa
- Digestive Disease Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Brandon T Grover
- Department of Surgery, Gundersen Health System, La Crosse, Wisconsin
| | - Dan Eisenberg
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Jonathan Carter
- Department of Surgery, University of California, San Francisco, California
| |
Collapse
|
6
|
Jain M, Tantia O, Goyal G, Chaudhuri T, Khanna S, Majumdar K, Gupta S. LSG vs OAGB: 7-Year Follow-up Data of a Randomised Control Trial and Comparative Outcome Based on BAROS Score. Obes Surg 2024; 34:1295-1305. [PMID: 38427149 DOI: 10.1007/s11695-024-07114-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 02/08/2024] [Accepted: 02/15/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND This study aims to evaluate and compare long-term results of laparoscopic sleeve gastrectomy (LSG) and one anastomosis gastric bypass (OAGB) based on bariatric analysis reporting and outcome system (BAROS) score. MATERIALS AND METHODS Patients operated for morbid obesity between 2013 and 2015 were randomised to LSG and OAGB groups. Based on inclusion and exclusion criteria, 201 patients (100 LSG and 101 OAGB) were analysed for changes in total body weight (TBW), body mass index (BMI), percent excess weight loss (%EWL), percent total weight loss (%TWL), QoL (quality of life) scores, comorbidity resolution and outcome based on BAROS at 7 years. RESULTS Sixty-six LSG and 64 OAGB patients were followed up at 7 years. Mean pre-operative TBW and BMI were 119 ± 28.2 and 44.87 ± 7.71 for LSG group and 113.25 ± 23.74 and 44.71 ± 8.75 for OAGB group respectively. At 7 years after surgery, there was significant drop in mean TBW and BMI in both groups. Mean %EWL for LSG and OAGB patients was 50.78 ± 28.48 and 59.99 ± 23.32 and mean %TWL for LSG and OAGB patients was 23.22 ± 12.66 and 27.71 ± 12.27 respectively. Mean QoL scores at 7 years were significantly higher than the pre-operative scores and most of the patients in both groups had remission or improvement in their comorbidities. 68.76% OAGB patients had very good or excellent outcome on BAROS score while only 36.37% LSG patients had similar outcome. CONCLUSIONS LSG and OAGB are successful bariatric procedures over the long term. OAGB outperforms LSG and has significantly higher %EWL and %TWL over the long term.
Collapse
Affiliation(s)
- Mayank Jain
- Department of Minimal Access & Bariatric Surgery, Synergyplus Hospital, NH2, Near Guru Ka Taal, Agra, 282007, Uttar Pradesh, India
| | - Om Tantia
- Department of Minimal Access & Bariatric Surgery, ILS Hospitals, DD-6, Sector 1, Salt Lake City, Kolkata, 700064, West Bengal, India.
| | - Ghanshyam Goyal
- Department of Minimal Access & Bariatric Surgery, ILS Hospitals, DD-6, Sector 1, Salt Lake City, Kolkata, 700064, West Bengal, India
| | - Tamonas Chaudhuri
- Department of Minimal Access & Bariatric Surgery, ILS Hospitals, DD-6, Sector 1, Salt Lake City, Kolkata, 700064, West Bengal, India
| | - Shashi Khanna
- Department of Minimal Access & Bariatric Surgery, ILS Hospitals, DD-6, Sector 1, Salt Lake City, Kolkata, 700064, West Bengal, India
| | - Kajari Majumdar
- Department of Minimal Access & Bariatric Surgery, ILS Hospitals, DD-6, Sector 1, Salt Lake City, Kolkata, 700064, West Bengal, India
| | - Sonam Gupta
- Department of Minimal Access & Bariatric Surgery, ILS Hospitals, DD-6, Sector 1, Salt Lake City, Kolkata, 700064, West Bengal, India
| |
Collapse
|
7
|
Monrabal Lezama M, Bras Harriott C, Herbella FAM, Schlottmann F. Gastroesophageal Reflux Disease After Roux-en-Y Gastric Bypass: Pathophysiology and Management. J Laparoendosc Adv Surg Tech A 2024; 34:167-172. [PMID: 38153398 DOI: 10.1089/lap.2023.0289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
Introduction: Patients with obesity are often affected by gastroesophageal reflux disease (GERD). Roux-en-Y gastric bypass (RYGB) is considered the ideal operation for patients with severe obesity and GERD. Although the majority of patients improve their reflux with the operation, some might persist symptomatic and others can even develop de novo GERD. The aim of this study was to determine pathophysiologic factors involved in the development of GERD after RYGB surgery and define potential treatments for this condition. Materials and Methods: Studies including patients with GERD before and after RYGB and/or analyzing possible GERD therapies were analyzed by the authors. Searches were conducted in PubMed, Cochrane Library, and Embase databases. Results: GERD can persist, worsen, or develop after RYGB. There are certain technical elements of the operation identified as potential risk factors for GERD. Medical therapy is effective in the majority of patients. Both endoscopic and surgical procedures can also help resolving GERD after RYGB. Conclusions: Although the majority of patients with GERD after RYGB can be effectively managed with medical therapy, some may require endoscopic or surgical treatment. Critical technical elements of RYGB should be considered to reduce the risk of postoperative GERD.
Collapse
Affiliation(s)
| | | | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Francisco Schlottmann
- Department of Surgery, Hospital Alemán of Buenos Aires, Buenos Aires, Argentina
- Department of Surgery, University of Illinois, Chicago, Illinois, USA
| |
Collapse
|
8
|
Esparham A, Ahmadyar S, Zandbaf T, Dalili A, Rezapanah A, Rutledge R, Khorgami Z. Does One-Anastomosis Gastric Bypass Expose Patients to Gastroesophageal Reflux: a Systematic Review and Meta-analysis. Obes Surg 2023; 33:4080-4102. [PMID: 37880462 DOI: 10.1007/s11695-023-06866-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 09/23/2023] [Accepted: 09/25/2023] [Indexed: 10/27/2023]
Abstract
This systematic review and meta-analysis aimed to investigate the incidence of new-onset gastroesophageal reflux, reflux change, esophagitis, Barrett's esophagus, and revision due to reflux, gastritis, and marginal ulcer after one-anastomosis gastric bypass (OAGB). We performed subgroup analyses based on primary and revisional OAGB and time of follow-up. Meta-analysis of 87 studies with 27,775 patients showed a 6% rate of new-onset reflux after OAGB. Preoperative reflux status did not change significantly after OAGB. The rate of esophagitis and Barrett's esophagus was 15% and 1%, respectively. The new-onset reflux rate after OAGB was significantly higher than gastric bypass but not different with sleeve gastrectomy. The current study showed a relatively low rate of reflux and its complications after OAGB, but it was significantly higher than Roux-en-Y gastric bypass.
Collapse
Affiliation(s)
- Ali Esparham
- Student Research Committee, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Soheil Ahmadyar
- Student Research Committee, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Tooraj Zandbaf
- Department of General Surgery, Faculty of Medicine, Mashhad Medical Sciences, Islamic Azad University, Mashhad, Iran
| | - Amin Dalili
- Department of General Surgery, School of Medicine, Surgical Oncology Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Alireza Rezapanah
- Department of General Surgery, School of Medicine, Surgical Oncology Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Robert Rutledge
- Center for Laparoscopic Obesity Surgery, 6240 N Durango Dr STE 120, Las Vegas, NV, 89149, USA
| | - Zhamak Khorgami
- Department of Surgery, University of Oklahoma School of Community Medicine, 1919 S. Wheeling Avenue, Suite 600, Tulsa, OK, 74104-5638, USA.
- Harold Hamm Diabetes Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| |
Collapse
|
9
|
Dolores Frutos Bernal M. Bile reflux after bariatric surgery. Cir Esp 2023; 101 Suppl 4:S63-S68. [PMID: 37979939 DOI: 10.1016/j.cireng.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 02/12/2023] [Indexed: 11/20/2023]
Abstract
The growing epidemic of obesity and the increase in weight loss surgery has led to a resurgence of interest in biliary reflux because anatomical alterations may be refluxogenic. HIDA scan is the least invasive scan with good patient tolerability, sensitivity and reproducibility for the diagnosis of biliary reflux. Patients with more advanced oesophageal lesions have a higher degree of duodenal reflux. It has been shown in animal models and in vitro that there is more Barrett's and dysplasia with duodenal reflux. There are two cases of post-OAGB malignancy reported in 20 years, both without correlation with a biliary aetiology, so the carcinogenic risk probably remains theoretical. Prospective trials on OAGB should include endoscopy preoperatively and at 5-year intervals, to have data on the real effects of bile exposure on the gastric reservoir and oesophagus.
Collapse
Affiliation(s)
- M Dolores Frutos Bernal
- Cirugía Bariátrica y Laparoscópica, Departamento de Cirugía General, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.
| |
Collapse
|
10
|
Arnon-Sheleg E, Farraj M, Michael S, Mari A, Khoury T, Sbeit W. Modified Hepatobiliary Scintigraphy for the Diagnosis of Bile Reflux in One-Anastomosis Gastric Bypass Surgery: a Prospective Multicenter Study. Obes Surg 2023; 33:1997-2004. [PMID: 37184825 DOI: 10.1007/s11695-023-06632-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/27/2023] [Accepted: 05/04/2023] [Indexed: 05/16/2023]
Abstract
PURPOSE One-anastomosis gastric bypass (OAGB) is a relatively simple surgical procedure for those afflicted with severe obesity. Studies reported symptomatic biliary reflux gastritis and esophagitis as predominant complications. Hepatobiliary scintigraphy (HIDA) is the least invasive test for the diagnosis of bile reflux, with good sensitivity, patient tolerability, and reproducibility. The aim of this study was to define an optimized HIDA scintigraphy protocol for demonstrating bile reflux in post-OAGB patients. MATERIAL AND METHODS We conducted a prospective multicenter study. Patients after OAGB with dyspeptic complaints were included. All patients underwent HIDA scan with a dedicated protocol for demonstrating bile reflux; prevalence and severity were reported. RESULTS Nineteen patients were included, 18 females and one male, with mean age of 41.8 years and mean time of 22.4 months from operation to the scan. Bile reflux into the gastric pouch was documented in 11 patients (53%). Reflux to the stomach pouch was severe in three patients (27%), moderate in two patients (18%), and mild in six patients (55%). Bile reflux into the esophagus was documented in four patients (21%), severe reflux in one patient (25%), and mild in the other three (75%). A correlation was found between complaints of vomiting, heartburn and regurgitation, and findings of esophagitis on gastroscopy in patients with vs. without reflux. CONCLUSIONS The tailored HIDA scan protocol detected bile reflux in more than half of the post-OAGB patients included in the study, with a high diagnostic sensitivity.
Collapse
Affiliation(s)
- Elite Arnon-Sheleg
- Nuclear Medicine Department, Galilee Medical Center, 2210001, Nahariya, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Moaad Farraj
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Department of Surgery, The Baruch Padeh Medical Center, 1528001, Tiberias, Israel
| | - Samar Michael
- Radiology Department, Galilee Medical Center, 2210001, Nahariya, Israel
| | - Amir Mari
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Gastroenterology Department, Nazareth Hospital, 16100, Nazareth, Israel
| | - Tawfik Khoury
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel.
- Department of Gastroenterology, Galilee Medical Center, 2210001, Nahariya, Israel.
| | - Wisam Sbeit
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
- Department of Gastroenterology, Galilee Medical Center, 2210001, Nahariya, Israel
| |
Collapse
|
11
|
Askari A, Jambulingam P, Gurprashad R, Al-Taan O, Adil T, Munasinghe A, Jain V, Rashid F, Whitelaw D. The surgical management of obesity. Clin Med (Lond) 2023; 23:330-336. [PMID: 38614646 PMCID: PMC10541046 DOI: 10.7861/clinmed.2023-0189] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
Obesity has reached pandemic levels globally. Surgical management of obesity aims to establish metabolic control, weight loss and resolution of multiple health conditions and to improve quality of life. Here, we examine the role of surgery in the management of obesity within the context of a multidisciplinary team involving a variety of healthcare professionals. We highlight the importance of patient selection, perioperative care, the various types of bariatric surgery currently available as well as emerging procedures. In addition to clarifying the different types of procedure, we also examine the potential complications and issues of weight regain and failure to lose weight. Ultimately, bariatric surgery remains comparatively safe and with generally excellent results in terms of control of existing obesity-related conditions; with the ever-increasing number of patients living with obesity, the scope of bariatric surgery is thus likely to increase.
Collapse
Affiliation(s)
- Alan Askari
- Luton & Dunstable Hospital, Lewsey Road, Luton, UK
| | | | | | - Omer Al-Taan
- Luton & Dunstable Hospital, Lewsey Road, Luton, UK
| | - Tanveer Adil
- Luton & Dunstable Hospital, Lewsey Road, Luton, UK
| | | | - Vigyan Jain
- Luton & Dunstable Hospital, Lewsey Road, Luton, UK
| | | | | |
Collapse
|
12
|
Ghanem OM, Ghazi R, Abdul Razzak F, Bazerbachi F, Ravi K, Khaitan L, Kothari SN, Abu Dayyeh BK. Turnkey algorithmic approach for the evaluation of gastroesophageal reflux disease after bariatric surgery. Gastroenterol Rep (Oxf) 2023; 11:goad028. [PMID: 37304555 PMCID: PMC10256627 DOI: 10.1093/gastro/goad028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/12/2022] [Accepted: 02/01/2023] [Indexed: 06/13/2023] Open
Abstract
Bariatric surgeries are often complicated by de-novo gastroesophageal reflux disease (GERD) or worsening of pre-existing GERD. The growing rates of obesity and bariatric surgeries worldwide are paralleled by an increase in the number of patients requiring post-surgical GERD evaluation. However, there is currently no standardized approach for the assessment of GERD in these patients. In this review, we delineate the relationship between GERD and the most common bariatric surgeries: sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), with a focus on pathophysiology, objective assessment, and underlying anatomical and motility disturbances. We suggest a stepwise algorithm to help diagnose GERD after SG and RYGB, determine the underlying cause, and guide the management and treatment.
Collapse
Affiliation(s)
- Omar M Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rabih Ghazi
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Fateh Bazerbachi
- CentraCare, Interventional Endoscopy Program, St Cloud Hospital, St Cloud, MN, USA
| | - Karthik Ravi
- Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Leena Khaitan
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA
| | | | - Barham K Abu Dayyeh
- Corresponding author. Division of Gastroenterology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA. Tel: +1-507-284-2511; Fax: +1-507-284-0538;
| |
Collapse
|
13
|
Orlow R, Herbella FAM, Katayama RC, Patti MG. Insights into the Paradox of the Weak Association Between Sleeve Gastrectomy and Barrett's Esophagus. Obes Surg 2023:10.1007/s11695-023-06599-y. [PMID: 37059866 DOI: 10.1007/s11695-023-06599-y] [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: 02/16/2023] [Revised: 04/06/2023] [Accepted: 04/10/2023] [Indexed: 04/16/2023]
Abstract
Sleeve gastrectomy (SG) is deemed a refluxogenic operation but with a low incidence of postoperative Barrett´s esophagus (BE). We aimed to shed some light on the potential paradox of the weak association between SG, BE and esophageal adenocarcinoma (EAC). The high incidence of GERD after SG is not followed by an increased rate of BE and EAC, as these rates are similar to the general population. We hypothesized that this paradox may occur due to a difference in the gastro-esophageal reflux composition secondary to a lower content of bile, to a decrease in inflammation due to weight loss and hormonal changes, and to acquisition of healthier habits such as exercise, smoking cessation, and better eating behavior.
Collapse
Affiliation(s)
- Rafaella Orlow
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil.
| | - Rafael C Katayama
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil
| | - Marco G Patti
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| |
Collapse
|
14
|
Reicher R, Cohen NA, Fishman S, Shnell M. Endoscopic Transoral Outlet Reduction for the Treatment of Biliary Reflux Symptoms in Patients After One-Anastomosis Gastric Bypass-a Case Series. Obes Surg 2023; 33:870-878. [PMID: 36689142 DOI: 10.1007/s11695-023-06463-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: 10/03/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 01/24/2023]
Abstract
PURPOSE OAGB is the third most common bariatric surgery. Biliary reflux (BR) is an inherent complication of this unique anatomy, although there is still controversy regarding its significance and long-term risks including carcinogenesis. To date, there is no effective treatment for BR with conversion to RYGB reserved for refractory patients. TORe is an effective treatment for weight-regain and dumping syndrome after RYGB. We hypothesized that narrowing the anastomosis would decrease the amount of bile refluxate entering the stomach and esophagus in patients with BR symptoms after OAGB and alleviate symptoms. The purpose of this study is to evaluate the efficacy of TORe for the treatment of BR symptoms after OAGB. MATERIALS AND METHODS BR was diagnosed clinically in patients after OAGB using the gastroesophageal reflux disease health-related quality of life (GERD-HRQL) instrument after treatment with high-dose proton pump inhibitor (PPI) excluded possible acid reflux. TORe was carried out using a suture pattern that narrowed and elongated the anastomosis. All patients were prospectively followed. RESULTS Twelve patients, post-OAGB, underwent TORe for BR. Symptoms resolved in 9 (75%) patients. GERD-HRQL score at 6 months declined from an average of 33.7 (SD 1.9) before the procedure to 16.1 (SD 10, p < 0.001). In one case, a small perforation was identified during the procedure and was immediately sutured with no further sequela. DISCUSSION TORe appears a safe and effective treatment for BR symptoms after OAGB, at least in the short term. Accurate tools for BR diagnosis, a larger cohort, and longer follow-up periods are needed to better show the effectiveness and durability of this treatment option.
Collapse
Affiliation(s)
- Relly Reicher
- Tel Aviv Sourasky Medical Center, Bariatric Endoscopy Unit, Department of Gastroenterology and Liver Diseases, Affiliated to Tel Aviv University, Tel Aviv, Israel.
| | - Nathaniel A Cohen
- Tel Aviv Sourasky Medical Center, Bariatric Endoscopy Unit, Department of Gastroenterology and Liver Diseases, Affiliated to Tel Aviv University, Tel Aviv, Israel
| | - Sigal Fishman
- Tel Aviv Sourasky Medical Center, Bariatric Endoscopy Unit, Department of Gastroenterology and Liver Diseases, Affiliated to Tel Aviv University, Tel Aviv, Israel
| | - Mati Shnell
- Tel Aviv Sourasky Medical Center, Bariatric Endoscopy Unit, Department of Gastroenterology and Liver Diseases, Affiliated to Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
15
|
Felsenreich DM, Zach ML, Vock N, Jedamzik J, Eichelter J, Mairinger M, Gensthaler L, Nixdorf L, Richwien P, Bichler C, Kristo I, Langer FB, Prager G. Esophageal function and non-acid reflux evaluated by impedance-24 h-pH-metry, high-resolution manometry, and gastroscopy after one-anastomosis gastric bypass-outcomes of a prospective mid-term study. Surg Endosc 2023; 37:3832-3841. [PMID: 36693919 PMCID: PMC10156623 DOI: 10.1007/s00464-022-09857-9] [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: 09/29/2022] [Accepted: 12/27/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND One-Anastomosis Gastric Bypass (OAGB) is the third most common bariatric operation for patients with obesity worldwide. One concern about OAGB is the presence of acid and non-acid reflux in a mid- and long-term follow-up. The aim of this study was to objectively evaluate reflux and esophagus motility by comparing preoperative and postoperative mid-term outcomes. SETTING Cross-sectional study; University-hospital based. METHODS This study includes primary OAGB patients (preoperative gastroscopy, high-resolution manometry (HRM), and impedance-24 h-pH-metry) operated at Medical University of Vienna before 31st December 2017. After a mean follow-up of 5.1 ± 2.3 years, these examinations were repeated. In addition, history of weight, remission of associated medical problems (AMP), and quality of life (QOL) were evaluated. RESULTS A total of 21 patients were included in this study and went through all examinations. Preoperative weight was 124.4 ± 17.3 kg with a BMI of 44.7 ± 5.6 kg/m2, total weight loss after 5.1 ± 2.3 years was 34.4 ± 8.3%. In addition, remission of AMP and QOL outcomes were very satisfactory in this study. In gastroscopy, anastomositis, esophagitis, Barrett´s esophagus, and bile in the pouch were found in: 38.1%, 28.3%, 9.5%, and 42.9%. Results of HRM of the lower esophageal sphincter pressure were 28.0 ± 15.6 mmHg, which are unchanged compared to preoperative values. Nevertheless, in the impedance-24 h-pH-metry, acid exposure time and DeMeester score decreased significantly to 1.2 ± 1.2% (p = 0.004) and 7.5 ± 8.9 (p = 0.017). Further, the total number of refluxes were equal to preoperative; however, the decreased acid refluxes were replaced by non-acid refluxes. CONCLUSION This study has shown decreased rates of acid reflux and increased non-acid reflux after a mid-term outcome of primary OAGB patients. Gastroscopy showed signs of chronic irritation of the gastrojejunostomy, pouch, and distal esophagus, even in asymptomatic patients. Follow-up gastroscopies in OAGB patients after 5 years may be considered.
Collapse
Affiliation(s)
- D M Felsenreich
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - M L Zach
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - N Vock
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - J Jedamzik
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - J Eichelter
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - M Mairinger
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - L Gensthaler
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - L Nixdorf
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - P Richwien
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - C Bichler
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - I Kristo
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - F B Langer
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - G Prager
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria.
| |
Collapse
|
16
|
Sewefy AM, Atyia AM, Mohammed MM, Kayed TH, Hamza HM. Single anastomosis sleeve jejunal (SAS-J) bypass as a treatment for morbid obesity, technique and review of 1986 cases and 6 Years follow-up. Retrospective cohort. Int J Surg 2022; 102:106662. [PMID: 35568310 DOI: 10.1016/j.ijsu.2022.106662] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/16/2022] [Accepted: 05/01/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Santoro's operation is a sleeve gastrectomy with transit bipartition. The operation aims to maintain passage to the duodenum to minimize nutritional deficiency. This procedure is rapidly changed to single anastomosis sleeve ileal (SASI) bypass. SAS-J bypass is a modification of SASI with a short biliary limb. MATERIAL AND METHODS This study is a retrospective study of prospectively collected data. The study includes a comprehensive review of 1986 patients who underwent SAS-J bypass over 6 years. The total number is used to evaluate the perioperative data. One- and two-year follow-up was used to evaluate weight loss and comorbidities; follow-up of more than 5 years was used to obtain long-term results. RESULTS In this study, 70.4% of patients were female and 29.6% were male. The mean body mass index (BMI) was 44.7. The mean age was 42 years. Regarding comorbidities, 25.8% of the patients had type 2 diabetes, 31% were hypertensive, 14.2% had sleep apnea syndrome, 6.6% had gastroesophageal reflux disease (GERD), and 39.6% had hyperlipidemia. Of the 1294 patients who complete one-year follow up, %EWL reached 87%. Blood glucose levels were normalized in 98.5% of patients, hypertension remitted in 93%, hyperlipidemia improved in 97%, SAS is improved in all cases, and GERD improved in 89% of patients. After 5 years, 94 patients' BMI decreased from 44.3 to 28.3 without significant nutritional deficiency. CONCLUSIONS Laparoscopic SAS-J bypass is an effective and simple alternative bariatric procedure at short- and long-term follow-up.
Collapse
Affiliation(s)
- Alaa M Sewefy
- Department of Surgery, Minia University Hospital, Egypt.
| | - Ahmed M Atyia
- Department of Surgery, Minia University Hospital, Egypt
| | | | - Taha H Kayed
- Department of Surgery, Minia University Hospital, Egypt
| | - Hosam M Hamza
- Department of Surgery, Minia University Hospital, Egypt
| |
Collapse
|