Re-sleeve gastrectomy: weight loss, comorbidities and gerd evaluation in a large series with 5 years of follow-up

Increased staple line leak rates following re-sleeve: analysis comparing re-sleeve versus Roux-en-Y gastric bypass conversion and primary sleeve gastrectomy

BACKGROUND

Sleeve gastrectomy is the most common bariatric procedure and its long-term complications include inadequate weight loss, weight regain, and de novo GERD, often requiring revisional surgery. Revisions, notably re-sleeve and conversion to Roux-en-Y gastric bypass (RYGB), are frequently performed, but safety data is limited. Herein, we used the MBSAQIP database to compare 30 day outcomes of primary sleeve gastrectomy (SG) with re-sleeve (RS) and SG to RYGB conversion.

METHODS

Patients who underwent primary SG, RS, and SG to RYGB conversion within the MBSAQIP data registry from January 1, 2020 to December 31, 2022 were included in this study. Using Propensity Score Matching analysis, the cohorts were matched for 23 preoperative characteristics. We then compared 30 day postoperative outcomes and bariatric-specific complications between primary SG and RS (analysis 1) and between RS and SG to RYGB conversion (analysis 2).

RESULTS

A total of 302,961 were included. The matched cohorts in analysis 1 (n = 1630) and analysis 2 (n = 1633) had similar pre-operative characteristics. Propensity-matched outcomes in analysis 1 showed that patients in the RS group had significantly higher staple line leak (1.3% vs. 0.1%, p < 0.001) when compared to primary SG. Similarly, longer operative times (90.16 ± 51.90 min vs. 68.32 ± 37.54 min, p < 0.001) and higher rates of readmissions (5.5% vs. 2.1%, p < 0.001), reoperations (2.3% vs. 0.6%, p < 0.001), interventions (2.5% vs. 0.4%, p < 0.001) were found in those who underwent RS. In analysis 2, RS showed higher leak rates (1.3% vs. 0.5%, p = 0.015) when compared to conversion from SG to RYGB.

CONCLUSION

The RS group has a higher risk of staple line leaks compared to primary SG and conversion from SG to RYGB. In our study, there was a 2.6-fold increase in staple line leak after re-sleeve compared to RYGB conversion and a 13-fold increase compared to primary SG.

Safety of redo sleeve gastrectomy as a primary revisional procedure

BACKGROUND

Insufficient weight loss after primary laparoscopic sleeve gastrectomy (LSG) occasionally requires revisional surgery. A few single-institution studies have examined the safety of redo LSG (RSG) and have shown mixed results.

OBJECTIVES

The aim of this study was to evaluate the safety of RSG compared with LSG over a period of 30 days.

SETTING

University of Southern California, United States; Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.

METHODS

The 2020-2021 MBSAQIP registry was used to evaluate patients who underwent RSG. Thirty-day outcomes were evaluated using univariable analysis and multivariable logistic and linear regression.

RESULTS

A total of 226,029 patients were reviewed, of whom 1454 (.7%) underwent RSG and 224,575 (99.3%) underwent initial LSG. Patients who underwent RSG were older (45 versus 42 yr), predominantly female (86.2% versus 81.3%), had a lower body mass index (40.0 versus 43.4), fewer co-morbidities, and greater rates of gastroesophageal reflux (38.7% versus 25.1%). They demonstrated increased overall complications (3.6% versus 2.1%, P < .001) and a longer operative time (81 versus 62 min, P < .001), but there was no difference in mortality. On multivariable analysis, patients who underwent RSG were independently associated with an increased risk of overall postoperative complications (odds ratio [OR]: 1.493, P = .018), organ space infection (OR: 6.231, P < .001), staple line leak (OR: 12.838, P < .001), pneumonia (OR: 3.85, P = .013), ventilator requirement over 48 hours (OR: 6.404, P = .035), sepsis (OR: 4.397, P = .010), septic shock (OR: 8.669, P < .001), reoperation (OR: 1.808, P = .013), readmission (OR: 2.104, P < .001), reintervention (OR: 4.435, P < .001), and longer operative times (β = 12.790, P < .001).

CONCLUSIONS

In this national database study, RSG was associated with increased rates of postoperative complications and a longer operative time. Although these results are concerning, further studies are required to examine long-term outcomes.

Roux-en-Y Gastric Bypass after Laparoscopic Sleeve Gastrectomy Failure: Could the Number of Previous Operations Influence the Outcome?

After a failed laparoscopic adjustable gastric band (LAGB), laparoscopic sleeve gastrectomy (LSG) has been proposed as revisional surgery. Those patients that receive a second restrictive procedure fall into a small subgroup of patients with more than one restrictive procedure (MRP). If also the second restrictive procedure fails, the correct surgical strategy is a challenge for the surgeon. Roux-en-Y gastric bypass (RYGB) may be an option but there is no evidence in the literature on whether the procedure is effective in treating failures after MRP. This study aims to evaluate the influence of the previous number of restrictive interventions (MRP vs single LSG) in the results of RYGB as revisional surgery. We have retrospectively analyzed patients who underwent conversion from laparoscopic sleeve gastrectomy (LSG), or from multiple restrictive procedures (MRP), to RYGB for weight regain (WR) or insufficient weight loss (IWL) between 2009 and 2019. The number of patients analyzed was 69 with conversion to RYGB after LSG and 44 after MRP. The reduction of excess weight (%TWL) at 3, 6, 12, 24 RYGB postoperative months was respectively of 11.03%, 16.39%, 21.43%, and 24.22% in the MRP group, and of 10.97%, 16.4%, 21.22%, and 22.71% in the LSG group. No significant difference was found in %TWL terms after RYGB for the MRP group and the LSG group with an overall %TWL, which was 11.00 ± 6.03, 16.40 ± 8.08, 21.30 ± 9.43, and 23.30 ± 9.91 respectively at 3, 6, 12, and 24 months. The linear regression model highlighted a positive relationship between the %EWL post-bypass at 24 months and the time elapsed only between the LSG and RYGB in the MRP group patients (p < 0.001). RYGB has proved to be a reliable technique with good results in terms of weight loss after failed bariatric surgery both in patients who previously underwent MRP and in those who underwent exclusively LSG. RYGB showed better results in patients who experienced WR than in those who had IWL from previous techniques.

Endoscopic revision of one-anastomosis gastric bypass (ER-OAGB) for weight recurrence: a case series of 17 adults

Weight recurrence after one-anastomosis gastric bypass (OAGB), the third most common metabolic and bariatric surgery performed worldwide, is observed in a subset of patients due to the chronic, progressive nature of obesity. Endoscopic revision of the OAGB (ER-OAGB) through full-thickness suturing to reduce the gastrojejunal anastomosis and gastric pouch is a potential alternative to surgical revision. Here, we present a case series of ER-OAGB and long-term nutritional support at two international centers with expertise in bariatric endoscopy. Data were retrospectively evaluated from a prospectively maintained database. The primary outcome was total body weight loss (TBWL) at 12 months. Secondary outcomes included TBWL at 3, 6, and 15 months; excess weight loss (EWL) at 3, 6, 12, and 15 months; frequency of new/worsening symptoms of gastroesophageal reflux disease (GERD); and the frequency of serious adverse events. In this series, 17 adults (70.6% female, mean age 46.8 years, mean BMI 39.1 kg/m2) successfully underwent ER-OAGB an average of 8 years (range 2-21 years) after OAGB for a mean weight recurrence of 43.2% (range 10.9-86.9%). TBWL from ER-OAGB was 9.7 ± 1.8% at 3 months, 13.4 ± 3.5% at 6 months, 18.5 ± 2.1% at 12 months, and 18.1 ± 2.2% at 15 months. EWL from ER-OAGB was 30.5 ± 14.7% at 3 months, 42.6 ± 16.2% at 6 months, 54.2 ± 11.3% at 12 months, and 54.2 ± 11.7% at 15 months. There were no instances of new/worsening GERD symptoms or serious adverse events. In this small series of adults who experienced weight recurrence after OAGB, ER-OAGB facilitated safe and clinically meaningful weight loss, without new or worsening GERD symptoms, when performed by experienced bariatric endoscopists in concert with longitudinal nutritional support.