Surgical revision of loop (“mini”) gastric bypass procedure: multicenter review of complications and conversions to Roux-en-Y gastric bypass

Reoperation After Loop Duodenojejunal Bypass with Sleeve Gastrectomy: A 9-Year Experience

PURPOSE

Loop duodenojejunal bypass with sleeve gastrectomy (LDJBSG) is effective for weight loss and resolution of obesity-related associated medical problems. However, a description of the reoperative surgery following LDJBSG is lacking.

MATERIAL AND METHODS

In this retrospective study, we analyzed the surgical complications and reoperation (conversion or revision) following LDJBSG from 2011 to 2019 in a single institution.

RESULTS

A total of 337 patients underwent LDJBSG during this period. Reoperative surgery (RS) was required in 10LDJBSG patients (3%). The mean age and BMI before RS were 47 ± 9 years and 28.9 ± 3.6 kg/m2, respectively. The mean interval between primary surgery and RS for early (n = 5) and late (n = 5)complications was 8 ± 11 days and 32 ± 15.8 months, respectively. The conversion procedures were Roux-en-Y gastric bypass(n = 5), followed by Roux-en-Y duodenojejunal bypass (n = 2) and one-anastomosis gastric bypass (n = 1); other revision procedures were seromyotomy (n = 1) and re-laparoscopy (n = 1). Perioperative complications were observed in four patients after conversion surgery such as multiorgan failure (n = 1), re-laparoscopy (n = 1), marginal ulcer (n = 1), GERD (n = 1), and dumping syndrome (n = 1).

CONCLUSION

LDJBSG has low reoperative rates and conversion RYGB could effectively treat the early and late complications of LDJBSG. Because of its technical demands and risk of perioperative complications, conversion surgery should be reserved for a selected group of patients and performed by an experienced metabolic bariatric surgical team.

One-Anastomosis Gastric Bypass (OABG) vs. Single Anastomosis Duodeno-Ileal Bypass (SADI) as revisional procedure following Sleeve Gastrectomy: results of a multicenter study

PURPOSE

Sleeve Gastrectomy (SG) is the most performed bariatric surgery, but a considerable number of patients may require revisional procedures for suboptimal clinical response/recurrence of weight (SCR/RoW). Conversion options include One-Anastomosis Gastric Bypass (OAGB) and Single Anastomosis Duodeno-Ileal Bypass (SADI). The study aims to compare SADI vs. OAGB as revisional procedures in terms of early and mid-term complications, operative time, postoperative hospital stay and clinical outcomes.

METHODS

All patients who underwent OAGB or SADI as revisional procedures following SG for SCR/RoW at three high-volume bariatric centers between January 2014 and April 2021 were included. Propensity score matching (PSM) analysis was performed. Demographic, operative, and postoperative outcomes of the two groups were compared.

RESULTS

One hundred and sixty-eight patients were identified. After PSM, the two groups included 42 OAGB and 42 SADI patients. Early (≤ 30 days) postoperative complications rate did not differ significantly between OAGB and SADI groups (3 bleedings vs. 0, p = 0.241). Mid-term (within 2 years) complications rate was significantly higher in the OAGB group (21.4% vs. 2.4%, p = 0.007), mainly anastomotic complications and reflux disease (12% of OAGBs). Seven OAGB patients required conversion to another procedure (Roux-en-Y Gastric Bypass-RYGB) vs. none among the SADI patients (p = 0.006).

CONCLUSIONS

SADI and OAGB are both effective as revisional procedures for SCR/RoW after SG. OAGB is associated with a significantly higher rate of mid-term complications and a not negligible rate of conversion (RYGB). Larger studies are necessary to draw definitive conclusions.

American Society for Metabolic and Bariatric Surgery position statement on one-anastomosis gastric bypass

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.

Modified Hepatobiliary Scintigraphy for the Diagnosis of Bile Reflux in One-Anastomosis Gastric Bypass Surgery: a Prospective Multicenter Study

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.

Turnkey algorithmic approach for the evaluation of gastroesophageal reflux disease after bariatric surgery

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.

Management of leaks following one-anastomosis gastric bypass: an updated systematic review and meta-analysis of 44 318 patients

INTRODUCTION

One-anastomosis gastric bypass (OAGB) complication, such as leakage, can be dangerous and should be managed properly, yet little data exist in the literature regarding the management of leaks after OAGB, and there are no guidelines to date.

METHODS

The authors performed a systematic review and meta-analysis of the literature and 46 studies, examining 44 318 patients were included.

RESULTS

There were 410 leaks reported in 44 318 patients of OAGB published in the literature, which represents a prevalence of 1% of leaks after OAGB. The surgical strategy was very variable among all the different studies; 62.1% of patients with leaks had to undergo another surgery due to the leak. The most commonly performed procedure was peritoneal washout and drainage (with or without T-tube placement) in 30.8% of patients, followed by conversion to Roux-en-Y gastric bypass in 9.6% of patients. Medical treatment with antibiotics, with or without total parenteral nutrition alone, was conducted in 13.6% of patients. Among the patients with the leak, the mortality rate related to the leak was 1.95%, and the mortality due to the leak in the population of OAGB was 0.02%.

CONCLUSION

The management of leaks following OAGB requires a multidisciplinary approach. OAGB is a safe operation with a low leak risk rate, and the leaks can be managed successfully if detected in a timely fashion.

Efficacy and Safety of One Anastomosis Gastric Bypass Versus Roux-en-Y Gastric Bypass for Obesity: a Meta-analysis and Systematic Review

The objective of this review is to systematically review the efficacy and safety outcomes of one anastomosis gastric bypass (OAGB) with Roux-en-Y gastric bypass (RYGB). From inception to July 4, 2022, a systematic literature search was performed using PubMed, Embase, and Cochrane Library for randomized clinical trials comparing OAGB with RYGB in obesity. A meta-analysis performed using the RevMan 5.4.1 software evaluations was completed. We identified 1217 reports; after exclusions, eight trials with a total of 931 patients were eligible for analysis. Compared with RYGB, OAGB had multiple advantageous indexes. Examples include percent of excess weight loss (%EWL) at 12 months (P = 0.009), body mass index (BMI) at 2 years (P < 0.00001), early postoperative complication (P = 0.04), remission of dyslipidemia (P < 0.0001), and operative time (P < 0.00001). No significant statistical difference was observed in BMI at 6 months, %EWL at 6 months, BMI at 12 months, percent of excess body mass index loss (%EBMIL) at 2 years, BMI at 5 years, intraoperative complications, late postoperative complications, remission of type 2 diabetes mellitus, and dyslipidemia or gastroesophageal reflux disease remission between OAGB and RYGB. OAGB is no less effective than RYGB; no significant differences in weight loss efficacy were observed, and more large and long-term randomized controlled trials are needed to verify this. In addition, studies have shown that OAGB has a shorter operation time, fewer early postoperative complications, and a shorter learning curve, making it easier for young surgeons to perform.

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

Conversion of One Anastomosis Gastric Bypass to Roux-en-Y Gastric Bypass: Results of a Retrospective Multicenter Study

BACKGROUND

One anastomosis gastric bypass (OAGB) may expose the patient to certain specific complications. Here, we report the results of conversion of OAGB to Roux-en-Y gastric bypass (RYGB) in terms of outcomes and weight loss.

METHODS

Between January 2009 and January 2019, all patients undergoing conversion of OAGB to RYGB because of complications due to OAGB (n = 23) were included. The primary efficacy endpoint was the effectiveness of converting OAGB to RYGB. The secondary endpoints were overall mortality and morbidity during the first 3 postoperative months, specific morbidity, reoperation, length of hospitalization, weight loss, and progression of comorbidities related to obesity at 2-year follow-up.

RESULTS

Indications for conversion were bile reflux (n = 14; 60.9%), severe malnutrition (n = 3; 13%), gastro-gastric fistula (n = 4; 17.4%), and anastomotic leak (n = 2; 8.7%). The median time interval between OAGB and conversion to RYGB was 34 months (0-158). At the time of RYGB, median body mass index (BMI) was 28.0 kg/m² (18.2-50.7), representing a median BMI change of 14.0 (- 1.7-43.5). Fifteen surgeries (65.1%) were completed laparoscopically. Five complications (21.7%) were recorded, including 2 major ones (8.7%). Reoperation rate was 4.3% (n = 1). At 24 months of follow-up (n = 18; 78.3%), median BMI was 28.7 kg/m² (19.4-35.4), representing a median BMI change of 19.5 (12.2-43.1). No patient complained of bile reflux or persistent malnutrition.

CONCLUSION

RYGB performed as revisional surgery for complications after OAGB is an effective procedure with no major weight regain at 2 years of follow-up.

Conversion from one-anastomosis gastric bypass to Roux-en-Y gastric bypass: when and why-a single-center experience of all consecutive OAGB procedures

BACKGROUND

One-anastomosis gastric bypass (OAGB) is a well-established treatment method in patients with morbid obesity. Its long-term impact on de novo reflux, anastomotic complications, and malnutrition needs further evaluation. Roux-en-Y gastric bypass (RYGB) is a technically feasible procedure in revisional bariatric surgery. This study presents our institutional data on conversion from OAGB to RYGB.

OBJECTIVE

To determine the reasons for conversion, preoperative endoscopic findings, and feasibility of revisional bariatric surgery after OAGB.

SETTING

University hospital in Austria METHODS: Retrospective analysis of a prospectively fed database. All patients undergoing OAGB between January 2012 and December 2019 were included. Screening was carried out for all patients needing conversion to RYGB. Percent total weight loss, percent excess weight loss, time to conversion, postoperative complications, and reasons for conversion were assessed.

RESULTS

Eighty-two of 1,025 patients who underwent OAGB were converted laparoscopically to RYGB. Seven patients were converted early because of anastomotic/gastric tube leakage. Median time to late conversion was 29.1 ± 24.3 months, mean percent excess weight loss was 86.6% ± 33.1% and percent total weight loss was 35.1% ± 13.5%. Forty-two patients were converted because of reflux, 11 because of persistent marginal ulcers, 10 because of anastomotic stenosis, 9 because of malnutrition, and 3 because of weight regain. Seven patients showed Barrett's metaplasia in biopsies at the gastroesophageal junction before conversion.

CONCLUSION

Laparoscopic conversion from OAGB to RYGB is technically feasible with a moderate rate of postoperative complications. Severe (bile) reflux is a serious long-term complication after OAGB, with 4.1% of patients needing conversion to RYGB. Endoscopy after OAGB in patients showing clinical symptoms of gastroesophageal reflux disease is strongly advised to detect underlying pathologic changes.

Conversion of One-Anastomosis Gastric Bypass (OAGB) to Roux-en-Y Gastric Bypass (RYGB) is Effective in Dealing with Late Complications of OAGB: Experience from a Tertiary Bariatric Center and Literature Review

Purpose

Both primary and revisional bariatric surgery are on the rise due to global obesity pandemic. This study aimed to assess the indications for revision after one-anastomosis gastric bypass (OAGB) and the outcomes after laparoscopic conversion of OAGB to roux-en-y gastric bypass (RYGB).

Materials and Methods

Retrospective review on patients that had undergone conversion of OAGB to RYGB between June 2007-June 2019 in a tertiary bariatric center, followed by literature review.

Results

Out of 386 revisional bariatric surgery, a total of 14 patients underwent laparoscopic conversion of OAGB to RYGB. The mean age was 44.7 with 71% female. The mean pre-revision BMI was 29.2 kg/m². The primary indications for revision were bile reflux (n=7), marginal ulcer (n=3), inadequate weight loss or weight regain (IWL/WR) (n=3) and protein-calorie malnutrition (n=1). Conversion of OAGB to RYGB was completed laparoscopically in all cases. The mean length of stay was 4.1 days. There was no intraoperative or early post-operative complication. The mean total weight loss (rTWL%) after revision at year one, year three and year five post-revision were 11.5%, 18.1% and 29.1%, respectively. All patients achieved resolution of bile reflux and marginal ulcer. There was no mortality in this cohort.

Conclusion

Bile reflux, marginal ulcer, IWL/WR and malnutrition were the main indications for revision after OAGB in this study. In concordance with the available evidence, laparoscopic conversion of OAGB to RYGB was safe and effective in dealing with late complications of OAGB.

Bariatric Surgery After Previous Antireflux Surgery Without Takedown of the Previous Fundoplication: a Prospective Study

BACKGROUND

The increased prevalence of reflux disease in obese patients, combined with widespread availability of laparoscopic antireflux surgery, has increased the likelihood that more patients will seek bariatric surgery having previously undergone fundoplication.

OBJECTIVES

This study examined our series of laparoscopic bariatric surgery after previous antireflux surgery without takedown of the previous fundoplication. We discuss our results, our technique and the tips and tricks to avoid complication after this procedure.

SETTING

Private practice.

METHODS

We operated on patients suffering from obesity who had already undergone laparoscopic Nissen. The patients were eligible for bariatric surgery according to the French National Institute of Health's criteria for bariatric surgery. The pre-operative assessment involved gastroscopy with biopsies looking for Helicobacter pylori, oesophago-gastroduodenoscopy, investigation for sleep apnoea syndrome and a full laboratory assessment. The patients took part in their choice of surgery.

RESULTS

The patients' post-operative course was uncomplicated. No patients had symptoms of gastro-esophageal reflux late after surgery and good gastrointestinal comfort was achieved (no pain, no reflux). All of the patients were satisfied. Length of stay was 3 to 5 days. All patients exhibited significant weight loss.

CONCLUSION

Bariatric surgery is possible after fundoplication without taking down the fundoplication. It appears to be a viable alternative in patients seeking weight loss surgery after fundoplication, which is currently assumed contraindicated.

Areas of Non-Consensus Around One Anastomosis/Mini Gastric Bypass (OAGB/MGB): A Narrative Review

PURPOSE

One anastomosis/mini gastric bypass (OAGB/MGB) is now an established bariatric and metabolic surgical procedure with good outcomes. Despite two recent consensus statements around OAGB/MGB, there are some issues which are not accepted as consensus and need more long-term data and research.

MATERIAL AND METHODS

After identifying the topic of non-consensus from the two recent OAGB/MGB consensuses, PubMed, Scopus, and Cochrane were searched for articles published by November 2020.

RESULTS

In this study, we evaluated these non-consensus topics around OAGB/MGB and all related articles on these topics were assessed by authors to have an argument on these items.

CONCLUSION

There is enough evidence to include OAGB/MGB as an accepted standard bariatric and metabolic surgical procedure. However, long-term data and more research are needed to have a consensus in all aspects including these non-consensus topics.

The Effect of Bariatric Surgery and Endoscopic Procedures on Gastroesophageal Reflux Disease

Obesity is a global epidemic posing a significant burden on patients and healthcare systems. Gastroesophageal reflux disease is associated with obesity and its prevalence is also growing worldwide. Numerous bariatric surgeries and endoscopic procedures have arisen to assist with weight loss and management of obesity-related conditions. However, the effect of these interventions on reflux is variable and the evidence is often conflicting. To date, Roux-en-Y gastric bypass remains the gold-standard for attaining both reflux and weight loss management, however novel endoscopic techniques are quickly becoming more prevalent as an alternative to surgery. This review aims to summarize currently available endoscopic and surgical weight loss procedures and their impact on reflux symptoms while emphasizing areas requiring additional investigation.

Applying an Anti-reflux Suture in the One Anastomosis Gastric Bypass to Prevent Biliary Reflux: a Long-Term Observational Study

INTRODUCTION

The one anastomosis gastric bypass (OAGB) is an effective treatment to induce sustained weight loss in morbidly obese patients. Concerns remain regarding the development of reflux. The aim of this study was to investigate the effect of an "anti-reflux suture" as anti-reflux modification to prevent reflux.

METHOD

This is a single-center retrospective cohort study of patients who underwent a primary OAGB at the Center Obesity North-Netherlands (CON) between January 2015 and December 2016. Reflux was defined as symptoms of acid/bilious regurgitation or pyrosis. This was consequently asked and reported at each follow-up visit. Outcomes of patients with an anti-reflux suture were compared to those without.

RESULTS

In 414 (59%) of the 703 included patients, an anti-reflux suture was applied. Follow-up at 3 years was 74%. The incidence of reflux did not differ between patients with or without an anti-reflux suture (57 versus 56%, respectively; P = 0.9). The presence of an anti-reflux suture was significantly associated with a lower incidence of conversion to Roux-en-Y gastric bypass (RYGB) for reflux (OR 0.56, 95%CI 0.34-0.91). Patients preoperatively diagnosed with gastroesophageal reflux disease (GERD) were 5.2 times more likely to need a conversion to RYGB for reflux (95%CI 2.7-10.1).

CONCLUSION

The presence of preoperative GERD should be weighted heavily in the decision to perform an OAGB as this is a major risk factor for conversion surgery due to reflux. The anti-reflux suture might be a valuable addition to the procedure of the OAGB because it results in fewer conversion surgeries for reflux.

Revisional bariatric surgery to single-anastomosis gastric bypass: a large multi-institutional series

BACKGROUND

Reoperation is often required after bariatric procedures. Single-anastomosis gastric bypass (SAGB) is increasingly utilized as a primary bariatric procedure. Few series document SAGB as a revisional bariatric procedure.

OBJECTIVES

To describe our short-term experience with revisional SAGB, focusing on weight loss and reflux symptom outcomes.

SETTING

Three hospitals in Australia with both private and public (government funded) patients.

METHODS

We reviewed all revisional SAGB cases from 2012 to 2019 at. Complications were considered significant if they were Clavien-Dindo grade 3a or higher. A phone survey was conducted to assess weight loss outcomes, patient satisfaction, reflux symptoms, and other complications.

RESULTS

We identified 254 patients who had a revisional bariatric procedure to SAGB (21 previous sleeve gastrectomies and 233 previous adjustable bands), with a mean follow-up of 22 ± 15.6 months (range, 1-55 mo). The mean percentage of excess weight loss was 77% (183 patients, 72%), and the number of patients with follow-ups at 1 and 4 years was 184 (73%) and 35 patients (14%). Within 30 days, there were 29 patients (11%) who required reinterventions (21 endoscopies, 1 interventional radiology procedure, and 7 reoperations) with no deaths. Beyond 30 days, 27 patients (11%) required rerevision to Roux-en-Y gastric bypass for reflux symptoms and 10 (4%) required a laparotomy or laparoscopy for another reason (e.g., bowel obstruction). At a median follow-up of 36.6 months, 87 patients (34%) completed a phone survey, 45 (52%) of whom were taking proton pump inhibitors and 66 patients (76%) of whom were satisfied with their experience.

CONCLUSION

In our series, revision to SAGB was safe, with low short-term morbidity and favorable weight loss outcomes. However, beyond 1 year, a large proportion of patients experienced severe reflux symptoms and required rerevision.

Short-term outcomes of the conversion of one anastomosis gastric bypass to Roux-en-Y gastric bypass in symptomatic reflux patients without revising the size of the gastric pouch

Background:

Revising the size of the gastric pouch during the conversion of one anastomosis gastric bypass (OAGB)/mini-gastric bypass to Roux-en-Y gastric bypass (RYGB) is an important point. Even in patients undergoing RYGB, marginal ulcer is regarded as a known complication.

Materials and Methods:

In our Centre of Excellence in Bariatric and Metabolic Surgery, 2492 patients underwent OAGB from February 2012 to January 2019. Twelve of 2492 patients were enrolled in this clinical case series because of persistent gastroesophageal reflux-like symptoms which underwent conversional RYGB. All patients regularly received proton-pump inhibitors (PPIs) for 6 months after the surgery. After this period, the cases with symptomatic reflux were invited to be visited in the clinic by a bariatric surgeon and a gastroenterologist and received 6 months of PPI therapy until their symptoms disappeared. Twelve refractory reflux cases underwent conversional RYGB after 1 year. An enteroenterostomy was created in all the patients 75 cm distal to the gastrojejunostomy without resizing the gastric pouch, and the jejunal loop was cut just before the gastrojejunostomy.

Results:

Before conversional surgery, mean ± standard deviation (SD) body mass index (BMI) and gastroesophageal reflux disease (GERD)-Q score were found to be 26.45 ± 2.34 kg/m² and 10.08 ± 0.56, respectively. At 1 year after conversion, mean ± SD BMI in the patients was 28.12 ± 4.71, and GERD-Q score was 5.08 ± 1.5.

Conclusion:

It seems that resizing the gastric pouch is not necessary during the conversion of OAGB to RYGB.

Evaluation of reflux following sleeve gastrectomy and one anastomosis gastric bypass: 1-year results from a randomized open-label controlled trial

Background

Recent reports have demonstrated that de novo reflux and worsening of pre-existing symptoms occur after SG; concerns are still expressed about the risk of symptomatic biliary reflux gastritis and oesophagitis. The aim of our study was to investigate and compare the rate of postoperative acid and non-acid reflux following Mini-/One anastomosis gastric bypass (MGB/OAGB) and laparoscopic sleeve gastrectomy (LSG).

Study design

A prospective randomized open-label, controlled trial registered on clinicaltrial.gov (NCT number: NCT02987673) has been carried out to evaluate esophagogastric junction exposure to reflux in the first year after MGB/OAGB and LSG using high impedance manometry, endoscopy, and a validated questionnaire.

Results

A total of 58 individuals were eventually enrolled in this trial and represented the per-protocol population (n = 28 MGB/OAGB, n = 30 LSG). No difference was found between the two groups in terms of demographic characteristics, PAGI-SYM score, acid exposure time percent of the esophagus (AET%), esophagitis, and other HRiM and MII-pH data at baseline. Comparing MII-pH outcomes of the two groups, AET% resulted significantly higher after LSG at 12 months. Endoscopic findings showed a significant increase of esophagitis ≥ B in the LSG group after 1 year; postoperative esophagitis ≥ B resulted also significantly worsened after LSG when compared to MGB/OAGB.

Conclusion

Since AET% and rate of esophagitis are significantly higher after LSG when compared to MGB/OAGB, this procedure should be preferred in case of preoperative subclinical reflux or low grade (A) esophagitis.

Marginal ulcer causing delayed anastomotic perforation following one anastomosis gastric bypass (OAGB)

BACKGROUND

One anastomosis gastric bypass (OAGB) is gaining favor. Anastomotic perforation is a dreaded complication.

OBJECTIVES

To describe a series of patients presenting with delayed (> 90 days) perforation of a marginal ulcer (MU) following OAGB.

SETTING

Two university hospitals, Israel.

METHODS

A retrospective query identifying patients after OAGB admitted with delayed MU perforation. Demographic characteristics, time between OAGB to presentation, clinical, laboratory and imaging at presentation and management data were collected.

RESULTS

Between 1/2017-1/2020, 7 patients were identified. Mean body mass index (BMI) and time difference between OAGB and perforation were 14 kg/m² (range 7-23) and 13 months (range 4-23), respectively. All presented with upper abdominal pain, 4 had concomitant nausea and vomiting. One patient displayed tachycardia, none had fever and 3 exhibited leukocyte abnormalities. C-reactive protein ranged widely (2-311 mg/L). Mean albumin level was 2.9 g/dL (range 1.9-4). Pneumoperitoneum was demonstrated in half of plain abdominal films and all computed tomography (CT) scans. Management was tailored to clinical status. Four patients underwent laparoscopic primary repair with omentopexy. Two patients were initially managed nonoperatively, one eventually requiring conversion to Roux-en-Y gastric bypass (RYGB) while the other recovered without further intervention. One patient underwent exploratory laparotomy and "damage control" management with pouch gastrostomy and double-barrel jejunostomy. Risk factors for MU were present in 4 cases. Mean length of hospital stay was 18 days (range 3-79 days).

CONCLUSIONS

Perforation of MU may occur months to years after OAGB even without risk factors. Laboratory results are unreliable. The CT scan is diagnostic. A tailored approach can achieve good outcomes.

5-Year Results of Banded One-Anastomosis Gastric Bypass: a Pilot Study in Super-Obese Patients

BACKGROUND

The novel banded one-anastomosis gastric bypass (B-OAGB) procedure has not previously been reported in super-obese patients over the long term. In this pilot study, outcomes in patients with a mean baseline body mass index (BMI, kg/m²) of ≥ 50 who underwent B-OAGB were evaluated through 5-year follow-up.

PATIENTS AND METHODS

Total weight loss (TWL), excess weight loss (EWL), BMI evolution, and changes in type 2 diabetes biomarkers were analyzed prospectively in super-obese patients who underwent B-OAGB. Paired samples t tests were used to assess weight outcome change from baseline through 5-year follow-up and 95% CIs were calculated. The Bariatric Outcomes and Reporting System (BAROS) was used to assess surgical success at 3 time points.

RESULTS

Between October 2013 and February 2014, a 12-patient pilot cohort (mean baseline BMI 57.5 ± 6.3) underwent B-OAGB. No perioperative complications were observed within 30 days. Five-year mean BMI was 31.2 ± 5.4, a BMI loss of 25.9 (TWL 45.3 ± 7.5%; EWL 72.2 ± 12.8%). Between 11 and 24 months following surgery, 3 patients required band removal; each had one complication (1 stasis esophagitis and recurrent vomiting; 1 hypoalbuminemia; 1 anemia). There was no mortality. Long-term B-OAGB BAROS subscale and composite scores were comparable to other major bariatric procedures.

CONCLUSIONS

In a pilot study of super-obese patients who underwent B-OAGB, excellent durable BMI loss of 25.9 kg/m² (EWL 72.2%) at 5 years was achieved with an acceptable level of reoperation. More B-OAGB long-term follow-up studies are necessary to provide definitive conclusions regarding this combination bariatric procedure.

Revisional surgery after one anastomosis/mini gastric bypass: A narrative review

One anastomosis gastric bypass (OAGB)/mini gastric bypass is now considered to be a safe and efficient method for morbidly obese patients but has complications and adverse events such as other surgical procedures. The present paper outlines the need for and the nature of revisional surgery in the long-term following OAGB in accordance with the preferred reporting items for systematic reviews and meta-analysis guidelines. A literature search was carried out in PubMed. All articles on OAGB for which the authors described a patient needing revisional surgery in the long term after OAGB were examined.

Laparoscopic Roux-En-Y gastric bypass versus one anastomosis (loop) gastric bypass for obesity: A prospective comparative study of weight loss and complications

Introduction

Most Bariatric units perform Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) and One Anastomosis Gastric Bypass (OAGB) for weight loss and metabolic purposes with satisfactory results and low complication profile.

Objectives

This study compares LRYGB and OAGB outcomes in a high volume single bariatric unit.

Methods

Data was collected prospectively and analysed retrospectively for all LRYGB and OAGB performed between Jan 2014 to Dec 2016. The follow up period was for 2 years. Patients who were lost to follow up or had prior bariatric procedure were excluded. Excess weight loss percentage (EWL %), total weight loss percentage (TWL %) and post-operative complications were compared in both groups.

Results

1268 procedures performed. 113 patients were excluded. At 2 years, for LRYGB and OAGB groups mean TWL % was 31% and 35.4% respectively (P < 0.0001); and mean EWL % was 70.1% and 74.8% respectively (P = 0.0119). Gastroesophageal reflux symptoms were higher in OAGB group 17 (8.5%), with 7 patients needing further surgery, versus 26 (2.7%) in LRYGB (P = 0.0003). There was no difference in incidence of marginal ulcers between LRYGB and OAGB 2.7% vs 5% respectively (P = 0.1115). Internal hernia was seen only in LRYGB patients, 22 (2.2%). There was no significant difference in the re-operation rates following LRYGB 52 (5.4%) and OAGB 16 (8%) (P = 0.1824).

Conclusion

OAGB had superior short-term weight loss and low complications profile. Both procedures demonstrated no difference in either marginal ulcers or re-operation rates. Reflux symptoms have remained a major side effect of OAGB.

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One anastomosis gastric bypass has shown to have a safe operative profile and effective weight loss outcomes.

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No difference in marginal ulcerations or reoperation rate between One anastomosis gastric bypass and Laparoscopic Roux en y.

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We recommend strict selection criteria for patient undergoing OAGB.

Association between hiatal hernia and gastroesophageal reflux symptoms after one-anastomosis/mini gastric bypass

BACKGROUND

One-anastomosis gastric bypass (OAGB) is an accepted bariatric and metabolic surgery with certain important complications, such as postoperative gastroesophageal reflux disease (GERD) and bile reflux (BR), which are not well addressed in literature.

OBJECTIVES

The present study was conducted to determine the true incidence of postoperative de novo GERD and BR and their associations with a hiatal hernia (HH).

SETTING

The present research setting comprised the Center of Excellence of the European Branch of the International Federation for the Surgery of Obesity and Metabolic Disorders, Hazrat-e-Rasoul Hospital, Tehran, Iran.

METHODS

The present cohort study recruited 200 patients with morbid obesity undergoing OAGB/minigastric bypass from December 2016 to February 2018 without any preoperative GERD symptoms. These patients were followed up for 1 year after the surgery. The incidence of post-OAGB GERD and BR was determined in all the patients using the GERD symptom questionnaire, GerdQ.

RESULTS

The mean age of the patients was 41.0 ± 11.6 years. A hernia was observed in 56 (29.2%) cases and GERD in 37 (19.3%). Hernia was small in 44 (22.9%) cases, medium in 11 (5.7%), and large in 1 (.5%). HH was found to be significantly correlated with GERD (P = .012).

CONCLUSION

The important post-OAGB complications, such as GERD and BR, have not been adequately addressed in literature. The present study found moderate and large HHs to be important factors for de novo GERD and repairing a HH during OAGB may be essential for preventing GERD-like symptoms.

Short- and Mid-term Outcomes of 527 One Anastomosis Gastric Bypass/Mini-Gastric Bypass (OAGB/MGB) Operations: Retrospective Study

BACKGROUND

One anastomosis gastric bypass/mini-gastric bypass (OAGB/MGB) is considered an alternative option in metabolic and bariatric surgery. The aim of this study was to evaluate the safety, efficacy and postoperative challenges of OAGB/MGB as a new procedure.

METHODS

We performed 519 primary MGBs and 8 additional second-stage MGBs during 2014-2018. The data were collected from patients' notes as well as the surgeons' prospective data sheets. Two senior surgeons performed the operations. The ultimate primary measures were assessment of the safety and management of the complications. The secondary outcomes were excess weight loss and resolution of the comorbidities.

RESULTS

The type 2 diabetes mellitus (T2DM) remission rate was 83% and 70% over 1 and 3 years, respectively (HBA1C < 6.5%). Weight loss was 28-152 kg (SD 23.11). Excess weight loss ranged from 41 to 125%. Hypertension resolution was 61%, 58% and 58% in the first, second and third years, respectively. Ninety-nine per cent of sleep apnoea patients improved symptomatically and went off the continuous positive airway pressure (CPAP) machine. Two (0.37%) patients developed diarrhoea, cured by shortening the afferent biliopancreatic limb (BPL). Eight (1.5%) stomal ulcers were reported. Two patients (0.37%) developed deranged liver function, revised by shortening the BPL in one patient and a reversal in the second patient. The mean follow-up was 2.5 years. Mortality was zero.

CONCLUSIONS

This is the largest UK OAGB/MGB study to date showing safety and acceptable results for metabolic syndrome and obesity problems. OAGB/MGB revisional options are rectifying the morbidity and no mortality.

OAGB vs BGBP: A retrospective comparative study of a cohort of patients who had bariatric surgery in 2012 at one centre by a single surgeon

Two modifications of Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass (OAGB) and Roux-en-Y banded gastric bypass (BGBP), are gaining popularity in use because the OAGB is reported to be a simpler operation, and the BGBP is reported to have sustained weight loss compared to standard RYGB. A retrospective review and analysis of data comparing outcomes up to 5 years after BGBP and OAGB from a prospectively maintained database of all bariatric metabolic operations in 2012 was performed. Eighty-two patients underwent a BGBP and 90 an OAGB. The average age and body mass index were 44.12 and 43.97 and 43.57 and 45.79 in the BGBP and OAGB groups, respectively. Postoperative nutrient deficiencies were similar in both groups but were more prominent in the OAGB group. The % excess body weight loss (%EBWL) was 78% and 71.5% at 5 years in the OAGB and BGBP groups, respectively. The % total weight loss (%TWL) was also higher in OAGB compared to the BGBP group, 34.72% and 30.49%, respectively. Resolution of type 2 diabetes (T2DM) was significantly higher in the OAGB group, 79.16%, than in the BGBP group, 71.42%. The resolution of dyslipidaemia and hypertension were similar in both groups, but sleep apnoea resolution was higher in OAGB group. Both operations produced excellent weight loss in the intermediate term. The %EBWL and resolution of T2DM were significantly higher after the OAGB operation at the expense of increased incidence of nutrient deficiencies and hypoproteinemia. Quality of life improvement and patient satisfaction were high after both operations. Long-term follow up and multicentre prospective studies are needed to confirm these intermediate outcomes.

Retrospective cohort study of 925 OAGB procedures. The UK MGB/OAGB collaborative group

BACKGROUND

Mini-One Anastomosis Gastric Bypass is a new operation that provides comparable outcomes to the common bariatric procedures. Revisional surgery is still needed after a number of MGB-OAGB procedures. The aim of this study is to report the causes and management of these revisions.

METHODS

From 2010 to 2018, 925 MGB-OAGB operations were performed at 7 bariatric units across the United Kingdom and included in this retrospective cohort study. The data was retrospectively collected and analysed. The primary end point was the identification of the causes and management of revisions. Follow up ranged from 6 months to 3 years.

RESULTS

Twenty-two patients [2.3%] required revisional surgery after MGB-OAGB. Five patients [0.5%] developed severe diarrhoea managed by shortening the bilio-pancreatic limb to 150 cm. Four patients [0.4%] developed afferent loop syndrome and bile reflux was reported in another 3 [0.3%] cases; all were managed by either conversion to Roux en Y Gastric Bypass or a Braun anastomosis. Postoperative bleeding was controlled laparoscopically in 3 patients [0.3%]. Liver decompensation that was reported in 2 patients [0.2%] was treated by shortening the BPL in one patient and a reversal to normal anatomy in another. The liver failure resolved in both patients. Other indications for revision included two gastro-jejunal stenosis [0.2%], one perforated ulcer [0.1%], one patient [0.1%] with excessive weight loss and one case [0.1%] of protein malnutrition. None of the 22 patients undergoing revisional surgery after MGB-OAGB died. Lost to follow up rate was 0.2%.

CONCLUSION

Complications requiring revisional surgery after MGB-OAGB are uncommon [2.3%] and the majority can be managed by bilio-pancreatic limb shortening, the addition of a Braun side-to-side anastomosis or conversion to RYGB. Bilio-pancreatic limb length of 200 cm or more resulted in serious complications of liver failure, protein malnutrition, excessive weight loss and diarrhoea.

Outcomes of Long Pouch Gastric Bypass (LPGB): 4-Year Experience in Primary and Revision Cases

BACKGROUND

One of the most important complications of the one anastomosis gastric bypass (OAGB) is enterobilio acid reflux (EBAR). We report the concept of the long pouch Roux-en-Y gastric bypass (LPRYGB) meaning a Roux-en-Y with a long pouch and a 100-cm alimentary limb to avoid EBAR, with a long biliopancreatic limb to increase metabolic effects.

METHODS

A total of 300 LPRYGB cases in a 4-year period, with a 90% follow-up rate, were analysed. Anthropometric, technical feasibility, morbidity, weight loss and comorbidity outcomes were analysed.

RESULTS

The percentage total weight loss (%TWL) was 30.5% at 4 years of follow-up (32.3% in primary and 28.3% in revisions). Six intra-operative (2%) and 28 postoperative complications (9.3%) were seen. Out of this 28 complications, 11 (3.6%) were late complications. Reoperations were performed in 15 patients (5.0%). Clinically relevant EBAR was present in 3 cases only (1%) 4 years after the operation.

CONCLUSIONS

The LPRYGB combines the main advantages of the OAGB (light restriction and moderate malabsorption) with the anti-reflux effect from the Roux-en-Y diversion.

Adenocarcinoma of oesophagus involving gastro-oesophageal junction following mini-gastric bypass/one anastomosis gastric bypass

Mini-gastric bypass/one anastomosis gastric bypass (MGB/OAGB) is an emerging weight loss surgical procedure. There are serious concerns not only regarding the symptomatic biliary reflux into the stomach and the oesophagus but also the increased risk of malignancy after MGB/OAGB. A 54-year-old male, with a body mass index (BMI) of 46.1 kg/m², underwent Robotic MGB at another centre on 22^nd June 2016. His pre-operative upper gastrointestinal endoscopy was not done. He lost 58 kg within 18 months after the surgery and attained a BMI of 25.1 kg/m². However, 2-year post-MGB, the patient had rapid weight loss of 19 kg with a decrease in BMI to 18.3 kg/m² within a span of 2 months. He also developed progressive dysphagia and had recurrent episodes of non-bilious vomiting. His endoscopy showed eccentric ulcerated growth in lower oesophagus extending up to the gastro-oesophageal junction and biopsy reported adenocarcinoma of oesophagus. MGB/OAGB has a potential for bile reflux with increased chances of malignancy. Surveillance by endoscopy at regular intervals for all patients who have undergone MGB/OAGB might help in early detection of Barrett's oesophagus or carcinoma of oesophagus or stomach.

Cecal volvulus following mini gastric bypass: A case report and review of literature

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Cecal volvulus is one of the differential diagnosis of post Mini-gastric bypass acute intestinal obstruction. and pain.

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Urgent intervention in acute presentation post gastric bypass is the key to saving the patient life and lower morbidity.

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Conversion of Mini-gastric bypass to Roux-en-Y gastric bypass in any complication surgery is recommended when feasible.

Introduction: With the rising worldwide obesity epidemic, bariatric surgeries are gaining popularity as the most effective modality for achieving long term results in weight loss and reducing its metabolic sequels.

Case presentation: A 36-year-old female presented with a sudden onset of severe abdominal pain for 6 h. The patient underwent Mini gastric bypass (MGB) 2 years prior to presentation. Computed tomography (CT) scan revealed a 14-cm dilatation of the cecum occupying the left upper quadrant of the abdomen with the swirling appearance of the mesentery. These findings were confirmed through emergency exploratory laparotomy to be cecal volvulus. a right hemicolectomy and conversion of MGB to a conventional Roux-en-Y gastric bypass.

Discussion: a modification of the classical gastric bypass surgery the MGB considered by its advocates to be a safer, simpler, and more effective option. However, serious complications can take place especially in the early learning curve of the procedure.

Conclusions

We present a unexpected acute in top of chronic cecal volvulus in patient two years post MGB. The uncommon serious complication should be considered one of the differential diagnosis of acute surgical abdomen in those patients.

One-anastomosis gastric bypass as an alternative procedure of choice in morbidly obese patients

One-anastomosis gastric bypass is an attractive bariatric procedure. It is effective in weight loss and comorbidity resolution. It is a relatively simple and fast operation with low complication rates that make it a suitable option in super-obese individuals. Although not proven yet, there are some concerns about its long-term safety profile in terms of biliary reflux, marginal ulcer, and esophagogastric malignancy. In this article, we review the technique of this procedure and discuss about some practical surgical highlights. Furthermore, we overview studies performed about this procedure and compare it to some other well-established bariatric operations, while providing a detailed study about the facts related to its outcomes and complications.